In November, 2009, a rancorous argument about screening mammography for women aged 40-49 was touched off by the publication of updated guidelines(1), supported by a systematic literature review(2) by the US Preventive Services Task Force (USPSTF). The guidelines suggested that yearly mammographic screening for women in that age group should not be automatic, but a decision made for individual patients after discussion between the patients and their doctors. This was based on a critical review of the best available data which suggested that the benefits of screening acrue to only a few patients. 1904 women would have to start screening and continue for multiple rounds to prevent one cancer death over 11-20 years of follow-up. These benefits had to be balanced against a number of potential risks, including the risks of treatment of cancers that might never behave malignantly, and the at least theoretical risk of generating new cancers through radiation exposure from mammography.
These seemingly reasonable recommendations generated heated responses. The debate, to be charitable, seemed to be at its core about how one should weigh benefits and harms in making individual and health policy decisions. Since different people value different outcomes differently, I was not sure at the time how to make a meaningful contribution to this debate, or whether the debate had to do with the issues we usually discuss on Health Care Renewal.
I should note that the USPSTF guidelines never said "do not screen" women under age 50, or that the government should not pay for such screening. They did say "the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take pateint context into account, including the patient's values regarding specific benefits and harms." It is hard to see how anyone could argue with that as an expression empowering patients' choices and values. (For further discussion about how the recommendations were actually modest and reasonable, see Partridge and Winer.)(3)
Now that the dust has settled, it may be useful to reflect further on this. Doing so suggests that the rancorous US debate mainly obscured rather than illuminated the major issues regarding mammography screening, particularly about our lack of clear evidence from clinical research needed to make the best individual and policy decisions about mammography.
It seems to me that the main questions one must answer to make an individual or policy decision about screening mammography are:
Does it improve longevity?
This is not the same as asking whether mammography reduces mortality from breast cancer. It is theoretically possible that while decreasing mortality due to breast cancer, screening and its downstream consequences increases mortality from other causes. At least in theory, screening may detect small tumors that would never grow or metastasize. Treating such tumors could sometimes lead to premature death due to complications of surgery, radiation, or chemotherapy. Furthermore, screening also involves periodically exposing large numbers of women to radiation, which may sometimes cause new tumors. So reducing breast cancer mortality does not automatically mean that overall longevity would be improved.
There have been eight major trials of breast cancer screening which included women younger than 50. (See reference 2.) None demonstrated a statistically significant increase in overall survival (that is, an increase unlikely to have been due to chance alone) due to screening.
Does it reduce suffering, improve functioning or generally improve quality of life?
To my knowledge, no major trial attempted to answer this question. No such data is mentioned in the USPSTF systematic review.
Do the above benefits outweigh all its potential harms and risks?
So we cannot answer this question, because the benefits that might be most meaningful to patients (overall survival, symptom reduction, functional improvement, overall quality of life improvement) have not been clearly measured.
A Lack of Relevant Evidence
So the USPSTF guidelines, like other relevant guidelines, were based on the evidence that is available. Since the evidence did not directly answer the most important questions, the guideline writers were left doing the best they could with evidence that only indirectly addressed the main issues. No wonder they ended up unable to make a clear recommendation, and leaving the decisions to individual discussions, and individual discussions that would necessarily hinge on guesses about the unknown.
One would think that a big point of discussion about breast cancer screening would be why after eight trials enrolling a total of about 350,000 patients reported over 20 years we still cannot answer the big clinical questions. A related point for discussion in the US is why only one, and the earliest trial was conducted here. If we here in the US think breast cancer screening is such a major concern (and we should think so), why have we been unable to mount a single important trial of it since the HIP trial conducted more than 30 years ago?
Instead, the rancorous debate in the US included...
Anecdotes, Some Irrelevant
The press found a number of women who said they would not be alive were it not for screening mammography before age 50. With all due respect, one cannot tell whether an individual whose tumor was found on screening mammography would still have been diagnosed early enough for succesful treatment in the absence of screening mammography. (And also with all due respect, we have no idea whether there also are cases of women who died as a result of treatments of tumors that never would have progressed, or cases of women who died of tumors caused by radiation from multiple mammograms.) Reasoning from single cases when people, diseases, and treatment results vary so much is likely to mislead.
It is somewhat ironic that some of the cases cited were of women who had breast cancer diagnosed before age 40, even though the debate was supposedly about screening from ages 40-49. For example, in an inflammatory article that suggested that some "oncologists" might want the USPSTF sent to the prison at Guantanamo Bay, Washington Post editorialist Dana Milbank cited cancer activist Nancy Brinker, who mentioned her sister "whose breast cancer was found with a mammogram at age 37," (and apparently who tragically is no longer alive).(4)
Going Well Beyond the Evidence
As noted above, no trial has shown that screening mammography for women under 50 increases overall longevity. We all hope it does, but so far, there is no clear evidence that it does.
Yet multiple media reports included assertions that screening mammography saves lives. For example, the breast cancer activist mentioned above said, "mammography saves lives," apparently including mammography under age 50.(4) An op-ed column by Dr Alan Kaye, chairman of radiology at Bridgeport Hospital, asserted "large, multinational research studies have shown that mammography saves lives in all age groups covered by the current guidelines."(5) I would challenge him to show me a single such study that found a statistically significant increase in overall survival for patients under 50. A Texas radiologist stated, "I diagnosed a 40-year old woman with breast cancer last week. If she had waited 10 years, with pre-menopause breast cancer she would have been dead."(6) Unfortunately, since she was just diagnosed, how can he be certain that she will survive any given amount of time? How could he know that the cancer might not have become manifest, absent that single mammogram, later while still treatable?
I do not want to be too hard on patients who do not appreciate that the outcomes of testing and treatment for breast cancer are not certain. However, one would hope that physicians would be able to deal with this uncertainty.
Conflicted Opinions
Some of the more strident discourse came from those who may have had financial vested interests in promoting screening mammography. Fugh-Berman and Bell pointed out numerous "fact-free emotionally charged statements" made by people who appeared to "reading from the same script-book."(7) They identified that many of the loudest critics of the USPSTF guidelines were affiliated with not-for-profit organizations with impressive names, but also with substantial financial support from corporations that make products used in mammography. Also, some had personal financial relationships with such corporations.
An op-ed article by former US Food and Drug Agency (FDA) commissioner Dr Andrew von Eschenbach and Ms Nancy Desmond distorted the USPSTF guidelines to mean "most women should delay screening until they are 50," and claimed that was based on cost concerns, not clinical evidence.(8). Desmond is the CEO of and von Eschenbach is now a senior advisor to the Center for Health Transformation. The Center's members include numerous pharmaceutical and device manufacturing corporations, including several that make mammography equipment (e.g., GE Healthcare and Siemens).
Summary
Cancer, especially breast cancer, has major emotional connotations, and can be a difficult issue to deal with from many people. The conflicting emotions cancer brings out in many patients may understandably affect their physicians, as well as friends and family. Nonetheless, physicians, other health policy professionals, and health policy experts can serve patients better if they do not allow the patients' understandable affective responses cloud their understanding of the clinical and scientific issues.
Yet the late 2009 debate in the US about screening mammography included many responses in which emotion seemed to overwhelm reason. It may also be that some such responses came from people who had vested interests, or whose employers had vested interests that supported the emotional, rather than the reasoned approach. Meanwhile, no one seemed to acknowledge that a big reason we are still debating this topic is that we have not made the effort or expended the resources to do good trials of sufficient size to answer the questions that need answering. Of course, such trials might provide answers that would upset some people, or threaten others' incomes. (As one news article pointed out, mammography is now a $5 billion a year industry in the US.)(6)
So my end of annus horribilis 2009 message on Health Care Renewal is to better serve our patients, from 2010 onward we health care professionals need to try harder to put evidence and logic ahead of our own emotions, and certainly ahead of our financial self-interest.
Note that numerous bloggers have taken on this topic, so see posts on Respectful Insolence, GoozNews, Health Care Organizational Ethics, and the Evidence in Medicine blog.
References
1. US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151: 716-726. [link here]
2. Nelson HD, Tyne K, Naik A et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151: 727-737. [link here]
3. Partridge AH, Winer EP. On mammography - more agreement than disagreement. N Engl J Med 2009; 361: 2499-2501. [link here]
4. Milbank D. Feeling farther from the finish. Washington Post, Nov 24, 2009. [link here]
5. Kaye A. An alarming retreat on early detection. Hartford Courant, Nov 25, 2009 [link here]
6. Jacobson SJ. Dallas-area clinics ignore proposed rules, still push for mammograms. Dallas News, Nov 27, 2009. [link here]
7. Fugh-Berman A, Bell A. Mammography and the corporate breast. Bioethics Forum, Nov 24, 2009. [link here]
8. von Eschenbach A, Desmond N. Government panels can't put price on human life. Associated Press, Nov 24, 2009. [link here]
Thursday, December 31, 2009
What the November, 2009, Breast Cancer Screening Argument Obscured
In November, 2009, a rancorous argument about screening mammography for women aged 40-49 was touched off by the publication of updated guidelines(1), supported by a systematic literature review(2) by the US Preventive Services Task Force (USPSTF). The guidelines suggested that yearly mammographic screening for women in that age group should not be automatic, but a decision made for individual patients after discussion between the patients and their doctors. This was based on a critical review of the best available data which suggested that the benefits of screening acrue to only a few patients. 1904 women would have to start screening and continue for multiple rounds to prevent one cancer death over 11-20 years of follow-up. These benefits had to be balanced against a number of potential risks, including the risks of treatment of cancers that might never behave malignantly, and the at least theoretical risk of generating new cancers through radiation exposure from mammography.
These seemingly reasonable recommendations generated heated responses. The debate, to be charitable, seemed to be at its core about how one should weigh benefits and harms in making individual and health policy decisions. Since different people value different outcomes differently, I was not sure at the time how to make a meaningful contribution to this debate, or whether the debate had to do with the issues we usually discuss on Health Care Renewal.
I should note that the USPSTF guidelines never said "do not screen" women under age 50, or that the government should not pay for such screening. They did say "the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take pateint context into account, including the patient's values regarding specific benefits and harms." It is hard to see how anyone could argue with that as an expression empowering patients' choices and values. (For further discussion about how the recommendations were actually modest and reasonable, see Partridge and Winer.)(3)
Now that the dust has settled, it may be useful to reflect further on this. Doing so suggests that the rancorous US debate mainly obscured rather than illuminated the major issues regarding mammography screening, particularly about our lack of clear evidence from clinical research needed to make the best individual and policy decisions about mammography.
It seems to me that the main questions one must answer to make an individual or policy decision about screening mammography are:
Does it improve longevity?
This is not the same as asking whether mammography reduces mortality from breast cancer. It is theoretically possible that while decreasing mortality due to breast cancer, screening and its downstream consequences increases mortality from other causes. At least in theory, screening may detect small tumors that would never grow or metastasize. Treating such tumors could sometimes lead to premature death due to complications of surgery, radiation, or chemotherapy. Furthermore, screening also involves periodically exposing large numbers of women to radiation, which may sometimes cause new tumors. So reducing breast cancer mortality does not automatically mean that overall longevity would be improved.
There have been eight major trials of breast cancer screening which included women younger than 50. (See reference 2.) None demonstrated a statistically significant increase in overall survival (that is, an increase unlikely to have been due to chance alone) due to screening.
Does it reduce suffering, improve functioning or generally improve quality of life?
To my knowledge, no major trial attempted to answer this question. No such data is mentioned in the USPSTF systematic review.
Do the above benefits outweigh all its potential harms and risks?
So we cannot answer this question, because the benefits that might be most meaningful to patients (overall survival, symptom reduction, functional improvement, overall quality of life improvement) have not been clearly measured.
A Lack of Relevant Evidence
So the USPSTF guidelines, like other relevant guidelines, were based on the evidence that is available. Since the evidence did not directly answer the most important questions, the guideline writers were left doing the best they could with evidence that only indirectly addressed the main issues. No wonder they ended up unable to make a clear recommendation, and leaving the decisions to individual discussions, and individual discussions that would necessarily hinge on guesses about the unknown.
One would think that a big point of discussion about breast cancer screening would be why after eight trials enrolling a total of about 350,000 patients reported over 20 years we still cannot answer the big clinical questions. A related point for discussion in the US is why only one, and the earliest trial was conducted here. If we here in the US think breast cancer screening is such a major concern (and we should think so), why have we been unable to mount a single important trial of it since the HIP trial conducted more than 30 years ago?
Instead, the rancorous debate in the US included...
Anecdotes, Some Irrelevant
The press found a number of women who said they would not be alive were it not for screening mammography before age 50. With all due respect, one cannot tell whether an individual whose tumor was found on screening mammography would still have been diagnosed early enough for succesful treatment in the absence of screening mammography. (And also with all due respect, we have no idea whether there also are cases of women who died as a result of treatments of tumors that never would have progressed, or cases of women who died of tumors caused by radiation from multiple mammograms.) Reasoning from single cases when people, diseases, and treatment results vary so much is likely to mislead.
It is somewhat ironic that some of the cases cited were of women who had breast cancer diagnosed before age 40, even though the debate was supposedly about screening from ages 40-49. For example, in an inflammatory article that suggested that some "oncologists" might want the USPSTF sent to the prison at Guantanamo Bay, Washington Post editorialist Dana Milbank cited cancer activist Nancy Brinker, who mentioned her sister "whose breast cancer was found with a mammogram at age 37," (and apparently who tragically is no longer alive).(4)
Going Well Beyond the Evidence
As noted above, no trial has shown that screening mammography for women under 50 increases overall longevity. We all hope it does, but so far, there is no clear evidence that it does.
Yet multiple media reports included assertions that screening mammography saves lives. For example, the breast cancer activist mentioned above said, "mammography saves lives," apparently including mammography under age 50.(4) An op-ed column by Dr Alan Kaye, chairman of radiology at Bridgeport Hospital, asserted "large, multinational research studies have shown that mammography saves lives in all age groups covered by the current guidelines."(5) I would challenge him to show me a single such study that found a statistically significant increase in overall survival for patients under 50. A Texas radiologist stated, "I diagnosed a 40-year old woman with breast cancer last week. If she had waited 10 years, with pre-menopause breast cancer she would have been dead."(6) Unfortunately, since she was just diagnosed, how can he be certain that she will survive any given amount of time? How could he know that the cancer might not have become manifest, absent that single mammogram, later while still treatable?
I do not want to be too hard on patients who do not appreciate that the outcomes of testing and treatment for breast cancer are not certain. However, one would hope that physicians would be able to deal with this uncertainty.
Conflicted Opinions
Some of the more strident discourse came from those who may have had financial vested interests in promoting screening mammography. Fugh-Berman and Bell pointed out numerous "fact-free emotionally charged statements" made by people who appeared to "reading from the same script-book."(7) They identified that many of the loudest critics of the USPSTF guidelines were affiliated with not-for-profit organizations with impressive names, but also with substantial financial support from corporations that make products used in mammography. Also, some had personal financial relationships with such corporations.
An op-ed article by former US Food and Drug Agency (FDA) commissioner Dr Andrew von Eschenbach and Ms Nancy Desmond distorted the USPSTF guidelines to mean "most women should delay screening until they are 50," and claimed that was based on cost concerns, not clinical evidence.(8). Desmond is the CEO of and von Eschenbach is now a senior advisor to the Center for Health Transformation. The Center's members include numerous pharmaceutical and device manufacturing corporations, including several that make mammography equipment (e.g., GE Healthcare and Siemens).
Summary
Cancer, especially breast cancer, has major emotional connotations, and can be a difficult issue to deal with from many people. The conflicting emotions cancer brings out in many patients may understandably affect their physicians, as well as friends and family. Nonetheless, physicians, other health policy professionals, and health policy experts can serve patients better if they do not allow the patients' understandable affective responses cloud their understanding of the clinical and scientific issues.
Yet the late 2009 debate in the US about screening mammography included many responses in which emotion seemed to overwhelm reason. It may also be that some such responses came from people who had vested interests, or whose employers had vested interests that supported the emotional, rather than the reasoned approach. Meanwhile, no one seemed to acknowledge that a big reason we are still debating this topic is that we have not made the effort or expended the resources to do good trials of sufficient size to answer the questions that need answering. Of course, such trials might provide answers that would upset some people, or threaten others' incomes. (As one news article pointed out, mammography is now a $5 billion a year industry in the US.)(6)
So my end of annus horribilis 2009 message on Health Care Renewal is to better serve our patients, from 2010 onward we health care professionals need to try harder to put evidence and logic ahead of our own emotions, and certainly ahead of our financial self-interest.
Note that numerous bloggers have taken on this topic, so see posts on Respectful Insolence, GoozNews, Health Care Organizational Ethics, and the Evidence in Medicine blog.
References
1. US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151: 716-726. [link here]
2. Nelson HD, Tyne K, Naik A et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151: 727-737. [link here]
3. Partridge AH, Winer EP. On mammography - more agreement than disagreement. N Engl J Med 2009; 361: 2499-2501. [link here]
4. Milbank D. Feeling farther from the finish. Washington Post, Nov 24, 2009. [link here]
5. Kaye A. An alarming retreat on early detection. Hartford Courant, Nov 25, 2009 [link here]
6. Jacobson SJ. Dallas-area clinics ignore proposed rules, still push for mammograms. Dallas News, Nov 27, 2009. [link here]
7. Fugh-Berman A, Bell A. Mammography and the corporate breast. Bioethics Forum, Nov 24, 2009. [link here]
8. von Eschenbach A, Desmond N. Government panels can't put price on human life. Associated Press, Nov 24, 2009. [link here]
These seemingly reasonable recommendations generated heated responses. The debate, to be charitable, seemed to be at its core about how one should weigh benefits and harms in making individual and health policy decisions. Since different people value different outcomes differently, I was not sure at the time how to make a meaningful contribution to this debate, or whether the debate had to do with the issues we usually discuss on Health Care Renewal.
I should note that the USPSTF guidelines never said "do not screen" women under age 50, or that the government should not pay for such screening. They did say "the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take pateint context into account, including the patient's values regarding specific benefits and harms." It is hard to see how anyone could argue with that as an expression empowering patients' choices and values. (For further discussion about how the recommendations were actually modest and reasonable, see Partridge and Winer.)(3)
Now that the dust has settled, it may be useful to reflect further on this. Doing so suggests that the rancorous US debate mainly obscured rather than illuminated the major issues regarding mammography screening, particularly about our lack of clear evidence from clinical research needed to make the best individual and policy decisions about mammography.
It seems to me that the main questions one must answer to make an individual or policy decision about screening mammography are:
Does it improve longevity?
This is not the same as asking whether mammography reduces mortality from breast cancer. It is theoretically possible that while decreasing mortality due to breast cancer, screening and its downstream consequences increases mortality from other causes. At least in theory, screening may detect small tumors that would never grow or metastasize. Treating such tumors could sometimes lead to premature death due to complications of surgery, radiation, or chemotherapy. Furthermore, screening also involves periodically exposing large numbers of women to radiation, which may sometimes cause new tumors. So reducing breast cancer mortality does not automatically mean that overall longevity would be improved.
There have been eight major trials of breast cancer screening which included women younger than 50. (See reference 2.) None demonstrated a statistically significant increase in overall survival (that is, an increase unlikely to have been due to chance alone) due to screening.
Does it reduce suffering, improve functioning or generally improve quality of life?
To my knowledge, no major trial attempted to answer this question. No such data is mentioned in the USPSTF systematic review.
Do the above benefits outweigh all its potential harms and risks?
So we cannot answer this question, because the benefits that might be most meaningful to patients (overall survival, symptom reduction, functional improvement, overall quality of life improvement) have not been clearly measured.
A Lack of Relevant Evidence
So the USPSTF guidelines, like other relevant guidelines, were based on the evidence that is available. Since the evidence did not directly answer the most important questions, the guideline writers were left doing the best they could with evidence that only indirectly addressed the main issues. No wonder they ended up unable to make a clear recommendation, and leaving the decisions to individual discussions, and individual discussions that would necessarily hinge on guesses about the unknown.
One would think that a big point of discussion about breast cancer screening would be why after eight trials enrolling a total of about 350,000 patients reported over 20 years we still cannot answer the big clinical questions. A related point for discussion in the US is why only one, and the earliest trial was conducted here. If we here in the US think breast cancer screening is such a major concern (and we should think so), why have we been unable to mount a single important trial of it since the HIP trial conducted more than 30 years ago?
Instead, the rancorous debate in the US included...
Anecdotes, Some Irrelevant
The press found a number of women who said they would not be alive were it not for screening mammography before age 50. With all due respect, one cannot tell whether an individual whose tumor was found on screening mammography would still have been diagnosed early enough for succesful treatment in the absence of screening mammography. (And also with all due respect, we have no idea whether there also are cases of women who died as a result of treatments of tumors that never would have progressed, or cases of women who died of tumors caused by radiation from multiple mammograms.) Reasoning from single cases when people, diseases, and treatment results vary so much is likely to mislead.
It is somewhat ironic that some of the cases cited were of women who had breast cancer diagnosed before age 40, even though the debate was supposedly about screening from ages 40-49. For example, in an inflammatory article that suggested that some "oncologists" might want the USPSTF sent to the prison at Guantanamo Bay, Washington Post editorialist Dana Milbank cited cancer activist Nancy Brinker, who mentioned her sister "whose breast cancer was found with a mammogram at age 37," (and apparently who tragically is no longer alive).(4)
Going Well Beyond the Evidence
As noted above, no trial has shown that screening mammography for women under 50 increases overall longevity. We all hope it does, but so far, there is no clear evidence that it does.
Yet multiple media reports included assertions that screening mammography saves lives. For example, the breast cancer activist mentioned above said, "mammography saves lives," apparently including mammography under age 50.(4) An op-ed column by Dr Alan Kaye, chairman of radiology at Bridgeport Hospital, asserted "large, multinational research studies have shown that mammography saves lives in all age groups covered by the current guidelines."(5) I would challenge him to show me a single such study that found a statistically significant increase in overall survival for patients under 50. A Texas radiologist stated, "I diagnosed a 40-year old woman with breast cancer last week. If she had waited 10 years, with pre-menopause breast cancer she would have been dead."(6) Unfortunately, since she was just diagnosed, how can he be certain that she will survive any given amount of time? How could he know that the cancer might not have become manifest, absent that single mammogram, later while still treatable?
I do not want to be too hard on patients who do not appreciate that the outcomes of testing and treatment for breast cancer are not certain. However, one would hope that physicians would be able to deal with this uncertainty.
Conflicted Opinions
Some of the more strident discourse came from those who may have had financial vested interests in promoting screening mammography. Fugh-Berman and Bell pointed out numerous "fact-free emotionally charged statements" made by people who appeared to "reading from the same script-book."(7) They identified that many of the loudest critics of the USPSTF guidelines were affiliated with not-for-profit organizations with impressive names, but also with substantial financial support from corporations that make products used in mammography. Also, some had personal financial relationships with such corporations.
An op-ed article by former US Food and Drug Agency (FDA) commissioner Dr Andrew von Eschenbach and Ms Nancy Desmond distorted the USPSTF guidelines to mean "most women should delay screening until they are 50," and claimed that was based on cost concerns, not clinical evidence.(8). Desmond is the CEO of and von Eschenbach is now a senior advisor to the Center for Health Transformation. The Center's members include numerous pharmaceutical and device manufacturing corporations, including several that make mammography equipment (e.g., GE Healthcare and Siemens).
Summary
Cancer, especially breast cancer, has major emotional connotations, and can be a difficult issue to deal with from many people. The conflicting emotions cancer brings out in many patients may understandably affect their physicians, as well as friends and family. Nonetheless, physicians, other health policy professionals, and health policy experts can serve patients better if they do not allow the patients' understandable affective responses cloud their understanding of the clinical and scientific issues.
Yet the late 2009 debate in the US about screening mammography included many responses in which emotion seemed to overwhelm reason. It may also be that some such responses came from people who had vested interests, or whose employers had vested interests that supported the emotional, rather than the reasoned approach. Meanwhile, no one seemed to acknowledge that a big reason we are still debating this topic is that we have not made the effort or expended the resources to do good trials of sufficient size to answer the questions that need answering. Of course, such trials might provide answers that would upset some people, or threaten others' incomes. (As one news article pointed out, mammography is now a $5 billion a year industry in the US.)(6)
So my end of annus horribilis 2009 message on Health Care Renewal is to better serve our patients, from 2010 onward we health care professionals need to try harder to put evidence and logic ahead of our own emotions, and certainly ahead of our financial self-interest.
Note that numerous bloggers have taken on this topic, so see posts on Respectful Insolence, GoozNews, Health Care Organizational Ethics, and the Evidence in Medicine blog.
References
1. US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151: 716-726. [link here]
2. Nelson HD, Tyne K, Naik A et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151: 727-737. [link here]
3. Partridge AH, Winer EP. On mammography - more agreement than disagreement. N Engl J Med 2009; 361: 2499-2501. [link here]
4. Milbank D. Feeling farther from the finish. Washington Post, Nov 24, 2009. [link here]
5. Kaye A. An alarming retreat on early detection. Hartford Courant, Nov 25, 2009 [link here]
6. Jacobson SJ. Dallas-area clinics ignore proposed rules, still push for mammograms. Dallas News, Nov 27, 2009. [link here]
7. Fugh-Berman A, Bell A. Mammography and the corporate breast. Bioethics Forum, Nov 24, 2009. [link here]
8. von Eschenbach A, Desmond N. Government panels can't put price on human life. Associated Press, Nov 24, 2009. [link here]
Wednesday, December 30, 2009
Prostate Cancer
PROSTATE CANCER:-
Prostate cancer is the cancerous growth of the cells inside the prostate . It usually grows slowly over many years . However , in later stages, the growth usually speeds up. In the prostate, the hormone testosterone is converted into DHT, which stimulates the growth of the cancer cells. As the cancer grows , it can spread outside the prostate – usually into the surrounding lymph nodes and bones.
Perhaps one of the greatest areas of health concerns for men over the age of 45 is their prostate , Prostate cancer is the most common cancer in men, other than skin cancer. The American Cancer Society estimates that last year more than1,80,000 new cases were diagnosed in the U.S and that more than 32,000 men died from the disease , making it the second -leading cause of cancer death among men in the country.
The urologists at the Vattikuti Urology Institute specialize in the world's most state-of-the -art treatments of prostate cancer.
The Vattikuti Urology Institute has performed more robotic procedures than any other hospital in the world .Surgeons at the Institute developed the Vattikuti Institute Prostatectomy, (VIP) and were the first in the world to perform the procedure on an outpatient basis. Some of the following questions that the physicians are frequently asked and their answers may help you to better understand various topics about the prostate cancer.
RISKS AND WARNING SIGNS:---
Who is at risk for prostate cancer?
Although prostate cancer generally occurs in older men, younger men can get it too. African -American males and those men who have a family history of prostate cancer have a higher risk of getting it.Therefore , screening and early diagnosis are especially important for individuals at risk.
Are there any warning signs?
Unfortunately , there are no early warning signs of prostate cancer . It usually grows very slowly, and due to its location , many men do not have any physical symptoms .
Frequent urination
Blockage of urinary flow
Dribbling at the end of urination
The need to get up out of bed and urinates at night.
Urinary leakage
Straining to empty the bladder.
These symptoms are usually due to benign prostate enlargement , and do not necessarily represent symptoms of prostate cancer.
SCREENING AND DETECTION:---
How is prostate cancer detected?
Early detection of prostate cancer is critical to successful treatment. Most prostatic cancers are initially detected through an elevated prostate specific antigen (PSA) test and digital rectal exam (DRE) .A DRE is a gloved finger examination of the prostate through the rectum. The PSA test is a blood test that is used to help screed for prostate cancer .The only conclusive form of detection is biopsy. This is usually done with the aid of ultrasound.
by: DrMani Menon
Prostate cancer is the cancerous growth of the cells inside the prostate . It usually grows slowly over many years . However , in later stages, the growth usually speeds up. In the prostate, the hormone testosterone is converted into DHT, which stimulates the growth of the cancer cells. As the cancer grows , it can spread outside the prostate – usually into the surrounding lymph nodes and bones.
Perhaps one of the greatest areas of health concerns for men over the age of 45 is their prostate , Prostate cancer is the most common cancer in men, other than skin cancer. The American Cancer Society estimates that last year more than1,80,000 new cases were diagnosed in the U.S and that more than 32,000 men died from the disease , making it the second -leading cause of cancer death among men in the country.
The urologists at the Vattikuti Urology Institute specialize in the world's most state-of-the -art treatments of prostate cancer.
The Vattikuti Urology Institute has performed more robotic procedures than any other hospital in the world .Surgeons at the Institute developed the Vattikuti Institute Prostatectomy, (VIP) and were the first in the world to perform the procedure on an outpatient basis. Some of the following questions that the physicians are frequently asked and their answers may help you to better understand various topics about the prostate cancer.
RISKS AND WARNING SIGNS:---
Who is at risk for prostate cancer?
Although prostate cancer generally occurs in older men, younger men can get it too. African -American males and those men who have a family history of prostate cancer have a higher risk of getting it.Therefore , screening and early diagnosis are especially important for individuals at risk.
Are there any warning signs?
Unfortunately , there are no early warning signs of prostate cancer . It usually grows very slowly, and due to its location , many men do not have any physical symptoms .
Frequent urination
Blockage of urinary flow
Dribbling at the end of urination
The need to get up out of bed and urinates at night.
Urinary leakage
Straining to empty the bladder.
These symptoms are usually due to benign prostate enlargement , and do not necessarily represent symptoms of prostate cancer.
SCREENING AND DETECTION:---
How is prostate cancer detected?
Early detection of prostate cancer is critical to successful treatment. Most prostatic cancers are initially detected through an elevated prostate specific antigen (PSA) test and digital rectal exam (DRE) .A DRE is a gloved finger examination of the prostate through the rectum. The PSA test is a blood test that is used to help screed for prostate cancer .The only conclusive form of detection is biopsy. This is usually done with the aid of ultrasound.
by: DrMani Menon
Pain Free, Anti-Aging, Over 50, Living Healthy by: Dr. Clifton Mays
This day is about starting the path to healthy living, and before we get too crazy about getting healthy, we need to talk with our doctors. You see, many of us are seeing 3 or 4 physicians and are doing a variety of things to keep us moving, but seldom do we get everyone on the same page and talking about getting healthy.
If you have a primary care physician, they're the one to start with. They should be the most up to date about your medicines and health history and the basics you should be concerned with. The second one to talk to is your physical specialist - ie the chiropractor, physical medicine doctor,Orthopedist or the like. If you are dealing with any of the degenerative processes of aging, then motion
is going to bring life, and you can't have motion if there's a "hitch in your git-a-long". So the best person to update next is the physical specialist. I'm of course partial to the chiropractor, since he/she is the most versed on whole body mechanics and has the background that is as diverse at the primary care physician. Also the chiropractor is willing to look more at the natural side of health and healing, than increasing your need for more medicines and drugs which can often hinder the process of healing.
The only down side with the chiropractor is that they should not be taking you off any of the medications. That is the job of the medical physician. Of course the chiropractor may recommend that certain medications be discussed with your primary care physician, but ultimately the decision is yours.
In this day and age of instant information, you can do some of the research yourself on the medications you are taking and the current status of your health via basic blood work and the other physical check-ups that are routinely performed in an annual physical.
So time for a check up and it's time to get organized! Get all the health information together and bring it to your doctor. Make sure you're all on the same page and that you and your doctors are ready to keep you on the path to living healthier and pain free for many years to come!
If you have more questions, feel free to e-mail me and we'll answer the questions to the best of our ability.
Until Tomorrow - live healthy
by: Dr. Clifton Mays
If you have a primary care physician, they're the one to start with. They should be the most up to date about your medicines and health history and the basics you should be concerned with. The second one to talk to is your physical specialist - ie the chiropractor, physical medicine doctor,Orthopedist or the like. If you are dealing with any of the degenerative processes of aging, then motion
is going to bring life, and you can't have motion if there's a "hitch in your git-a-long". So the best person to update next is the physical specialist. I'm of course partial to the chiropractor, since he/she is the most versed on whole body mechanics and has the background that is as diverse at the primary care physician. Also the chiropractor is willing to look more at the natural side of health and healing, than increasing your need for more medicines and drugs which can often hinder the process of healing.
The only down side with the chiropractor is that they should not be taking you off any of the medications. That is the job of the medical physician. Of course the chiropractor may recommend that certain medications be discussed with your primary care physician, but ultimately the decision is yours.
In this day and age of instant information, you can do some of the research yourself on the medications you are taking and the current status of your health via basic blood work and the other physical check-ups that are routinely performed in an annual physical.
So time for a check up and it's time to get organized! Get all the health information together and bring it to your doctor. Make sure you're all on the same page and that you and your doctors are ready to keep you on the path to living healthier and pain free for many years to come!
If you have more questions, feel free to e-mail me and we'll answer the questions to the best of our ability.
Until Tomorrow - live healthy
by: Dr. Clifton Mays
Tuesday, December 29, 2009
Regional Variation in Total Knee Replacement
It has been proven than there is tremendous variation in the practice of medicine across the United States. The Dartmouth data (Wennberg et al) has documented the differences in how medical resources are used and how different physicians practice medicine, depending upon where they live. The Dartmouth studies are mainly focused on cost and outcomes and make the case that improved quality is
Monday, December 28, 2009
On Automobile, and Health Care Companies Run by Finance People
The New Republic published "Upper Mismanagement" about what happens when businesses are run by people who do not understand their companies' businesses. Although the article was focused on the decline of manufacturing in the US, its applicability to health care is obvious:
Furthermore,
If business schools did little to teach about manufacturing, they did almost nothing to teach about health care. But at the same time the finance people were taking over manufacturing, health care organizations were pushed to turn over their leadership to business people to improve efficiency and break the physician's "guild." Would there be any reason to expect that a finance background would be better preparation to run a health care corporation than to run an automobile company?
For the latest thought- and wince-provoking example of how leaders of health care corporations seem to know almost nothing about the actual health care their companies provide, see a DailyFinance interview with Mr Kent Thiry, CEO of DaVita, a for-profit corporate provider of dialysis services. According to the company web-site, "prior to working for Vivra, Mr. Thiry was a partner at Bain & Company, an International management consulting company. He earned his BA degree, with distinction and Phi Beta Kappa, in Political Science from Stanford University in 1978, and his MBA, with honors from Harvard Business School in 1983" So he got his MBA from an elite US business school at the time in which finance was becoming dominant as described above.
Asked to explain his business model, Mr Thiry responded:
To be charitable, I do not think that would merit a "C" on a high school biology test. [Medical science cannot "replicate" hearts or lungs. Kidney function is not the same thing as "urinating." The functions of the kidney are far more complex than "cleaning out toxins."]
Does it make any sense to put someone who obviously understands so little about kidneys in charge of a kidney dialysis company? (On the other hand, see this post on accusations that DaVita's ruthless business practices treat patients like "dialysis dollars.")
So, if putting finance people in charge of automobile companies turned out to be a recipe for bankruptcy, why should we expect from putting finance people in charge of dialysis companies, or hospitals, or drug, biotechnology or medical device companies, or health care insurance companies, or health care information technology companies?
The CEOs of big health care organizations, most of whom have business, not health care backgrounds, have mainly been good at paying themselves and their cronies well. (For example, according to the 2009 DaVita proxy statement, in 2008, Mr Thiry owned over 2 million shares of stock, 1.9% of all shares outstanding, and received more than $11 million in total compensation. Clearly, he was not paid according to his knowledge of kidney biology.) Meanwhile, health care costs rise, access falls, and quality degrades.
If we really want to reform health care, maybe we should take a lesson from Toyota. Put the car guys and gals in charge of car companies. And put the health care guys and gals in charge of health care.
Harvard business professor Rakesh Khurana, with whom I discussed these questions at length, observes that most of GM’s top executives in recent decades hailed from a finance rather than an operations background. (Outgoing GM CEO Fritz Henderson and his failed predecessor, Rick Wagoner, both worked their way up from the company’s vaunted Treasurer’s office.) But these executives were frequently numb to the sorts of innovations that enable high-quality production at low cost. As Khurana quips, “That’s how you end up with GM rather than Toyota.”
How did we get to this point? In some sense, it’s the result of broad historical and economic forces. Up until World War I, the archetypal manufacturing CEO was production oriented—usually an engineer or inventor of some kind. Even as late as the 1930s, business school curriculums focused mostly on production. Khurana notes that many schools during this era had mini-factories on campus to train future managers.
After World War II, large corporations went on acquisition binges and turned themselves into massive conglomerates. In their landmark Harvard Business Review article from 1980, 'Managing Our Way to Economic Decline,' Robert Hayes and William Abernathy pointed out that the conglomerate structure forced managers to think of their firms as a collection of financial assets, where the goal was to allocate capital efficiently, rather than as makers of specific products, where the goal was to maximize quality and long-term* market share.
By the 1980s, the conglomerate boom was reversing itself. Investors began seizing control of overgrown public companies and breaking them up. But this task was, if anything, even more dependent on fluency in financial abstractions. The leveraged-buyout boom produced a whole generation of finance tycoons—the Michael Milkens of the world—whose ability to value corporate assets was far more important than their ability to run them.
The new managerial class tended to neglect process innovation because it was hard to justify in a quarterly earnings report, where metrics like “return on investment” reigned supreme. 'In an era of management by the numbers, many American managers … are reluctant to invest heavily in the development of new manufacturing processes,' Hayes and Abernathy wrote. 'Many of them have effectively forsworn long-term technological superiority as a competitive weapon.' By contrast, European and Japanese manufacturers, who lived and died on the strength of their exports, innovated relentlessly
Furthermore,
The business schools had their own incentives to channel students into high-paying fields like finance, thanks to the rising importance of school rankings, which heavily weighted starting salaries. The career offices at places like Harvard, Stanford, and Chicago institutionalized the process—for example, by making it easier for Wall Street outfits and consulting firms to recruit on campus. A recent Harvard Business School case study about General Electric shows that the company had so much trouble competing for MBAs that it decided to woo top graduates from non-elite schools rather than settle for elite-school graduates in the bottom half or bottom quarter of their classes.
No surprise then that, over time, the faculty and curriculum at the Harvards and Stanfords of the world began to evolve. 'If you look at the distribution of faculty at leading business schools,' says Khurana, '“they’re mostly in finance. … Business schools are responsive to changes in the external environment.' Which meant that, even if a student aspired to become a top operations man (or woman) at a big industrial company, the infrastructure to teach him didn’t really exist.
If business schools did little to teach about manufacturing, they did almost nothing to teach about health care. But at the same time the finance people were taking over manufacturing, health care organizations were pushed to turn over their leadership to business people to improve efficiency and break the physician's "guild." Would there be any reason to expect that a finance background would be better preparation to run a health care corporation than to run an automobile company?
For the latest thought- and wince-provoking example of how leaders of health care corporations seem to know almost nothing about the actual health care their companies provide, see a DailyFinance interview with Mr Kent Thiry, CEO of DaVita, a for-profit corporate provider of dialysis services. According to the company web-site, "prior to working for Vivra, Mr. Thiry was a partner at Bain & Company, an International management consulting company. He earned his BA degree, with distinction and Phi Beta Kappa, in Political Science from Stanford University in 1978, and his MBA, with honors from Harvard Business School in 1983" So he got his MBA from an elite US business school at the time in which finance was becoming dominant as described above.
Asked to explain his business model, Mr Thiry responded:
Most of us have a couple of kidneys. These kidneys are amazing organs -- some of the most complex, sophisticated organs in the human body, which is why they've been so difficult to replicate compared to other organs like the heart and lung and others. And when the kidney fails, you need to go on dialysis, unless you're one of the fortunate few to get a transplant. And we operate the centers that people come to if their kidney fails and they can't get a transplant.
And what we do in our centers is take care of these people typically three times a week -- four hours each time -- where we take their blood out of their body, clean out all the toxins that they would normally clean out themselves through the act of urinating. But you don't do that anymore once you've lost your kidney function. And we take that part out, take the toxins out and then put the blood back in with some other nutrients.
To be charitable, I do not think that would merit a "C" on a high school biology test. [Medical science cannot "replicate" hearts or lungs. Kidney function is not the same thing as "urinating." The functions of the kidney are far more complex than "cleaning out toxins."]
Does it make any sense to put someone who obviously understands so little about kidneys in charge of a kidney dialysis company? (On the other hand, see this post on accusations that DaVita's ruthless business practices treat patients like "dialysis dollars.")
So, if putting finance people in charge of automobile companies turned out to be a recipe for bankruptcy, why should we expect from putting finance people in charge of dialysis companies, or hospitals, or drug, biotechnology or medical device companies, or health care insurance companies, or health care information technology companies?
The CEOs of big health care organizations, most of whom have business, not health care backgrounds, have mainly been good at paying themselves and their cronies well. (For example, according to the 2009 DaVita proxy statement, in 2008, Mr Thiry owned over 2 million shares of stock, 1.9% of all shares outstanding, and received more than $11 million in total compensation. Clearly, he was not paid according to his knowledge of kidney biology.) Meanwhile, health care costs rise, access falls, and quality degrades.
If we really want to reform health care, maybe we should take a lesson from Toyota. Put the car guys and gals in charge of car companies. And put the health care guys and gals in charge of health care.
On Automobile, and Health Care Companies Run by Finance People
The New Republic published "Upper Mismanagement" about what happens when businesses are run by people who do not understand their companies' businesses. Although the article was focused on the decline of manufacturing in the US, its applicability to health care is obvious:
Furthermore,
If business schools did little to teach about manufacturing, they did almost nothing to teach about health care. But at the same time the finance people were taking over manufacturing, health care organizations were pushed to turn over their leadership to business people to improve efficiency and break the physician's "guild." Would there be any reason to expect that a finance background would be better preparation to run a health care corporation than to run an automobile company?
For the latest thought- and wince-provoking example of how leaders of health care corporations seem to know almost nothing about the actual health care their companies provide, see a DailyFinance interview with Mr Kent Thiry, CEO of DaVita, a for-profit corporate provider of dialysis services. According to the company web-site, "prior to working for Vivra, Mr. Thiry was a partner at Bain & Company, an International management consulting company. He earned his BA degree, with distinction and Phi Beta Kappa, in Political Science from Stanford University in 1978, and his MBA, with honors from Harvard Business School in 1983" So he got his MBA from an elite US business school at the time in which finance was becoming dominant as described above.
Asked to explain his business model, Mr Thiry responded:
To be charitable, I do not think that would merit a "C" on a high school biology test. [Medical science cannot "replicate" hearts or lungs. Kidney function is not the same thing as "urinating." The functions of the kidney are far more complex than "cleaning out toxins."]
Does it make any sense to put someone who obviously understands so little about kidneys in charge of a kidney dialysis company? (On the other hand, see this post on accusations that DaVita's ruthless business practices treat patients like "dialysis dollars.")
So, if putting finance people in charge of automobile companies turned out to be a recipe for bankruptcy, why should we expect from putting finance people in charge of dialysis companies, or hospitals, or drug, biotechnology or medical device companies, or health care insurance companies, or health care information technology companies?
The CEOs of big health care organizations, most of whom have business, not health care backgrounds, have mainly been good at paying themselves and their cronies well. (For example, according to the 2009 DaVita proxy statement, in 2008, Mr Thiry owned over 2 million shares of stock, 1.9% of all shares outstanding, and received more than $11 million in total compensation. Clearly, he was not paid according to his knowledge of kidney biology.) Meanwhile, health care costs rise, access falls, and quality degrades.
If we really want to reform health care, maybe we should take a lesson from Toyota. Put the car guys and gals in charge of car companies. And put the health care guys and gals in charge of health care.
Harvard business professor Rakesh Khurana, with whom I discussed these questions at length, observes that most of GM’s top executives in recent decades hailed from a finance rather than an operations background. (Outgoing GM CEO Fritz Henderson and his failed predecessor, Rick Wagoner, both worked their way up from the company’s vaunted Treasurer’s office.) But these executives were frequently numb to the sorts of innovations that enable high-quality production at low cost. As Khurana quips, “That’s how you end up with GM rather than Toyota.”
How did we get to this point? In some sense, it’s the result of broad historical and economic forces. Up until World War I, the archetypal manufacturing CEO was production oriented—usually an engineer or inventor of some kind. Even as late as the 1930s, business school curriculums focused mostly on production. Khurana notes that many schools during this era had mini-factories on campus to train future managers.
After World War II, large corporations went on acquisition binges and turned themselves into massive conglomerates. In their landmark Harvard Business Review article from 1980, 'Managing Our Way to Economic Decline,' Robert Hayes and William Abernathy pointed out that the conglomerate structure forced managers to think of their firms as a collection of financial assets, where the goal was to allocate capital efficiently, rather than as makers of specific products, where the goal was to maximize quality and long-term* market share.
By the 1980s, the conglomerate boom was reversing itself. Investors began seizing control of overgrown public companies and breaking them up. But this task was, if anything, even more dependent on fluency in financial abstractions. The leveraged-buyout boom produced a whole generation of finance tycoons—the Michael Milkens of the world—whose ability to value corporate assets was far more important than their ability to run them.
The new managerial class tended to neglect process innovation because it was hard to justify in a quarterly earnings report, where metrics like “return on investment” reigned supreme. 'In an era of management by the numbers, many American managers … are reluctant to invest heavily in the development of new manufacturing processes,' Hayes and Abernathy wrote. 'Many of them have effectively forsworn long-term technological superiority as a competitive weapon.' By contrast, European and Japanese manufacturers, who lived and died on the strength of their exports, innovated relentlessly
Furthermore,
The business schools had their own incentives to channel students into high-paying fields like finance, thanks to the rising importance of school rankings, which heavily weighted starting salaries. The career offices at places like Harvard, Stanford, and Chicago institutionalized the process—for example, by making it easier for Wall Street outfits and consulting firms to recruit on campus. A recent Harvard Business School case study about General Electric shows that the company had so much trouble competing for MBAs that it decided to woo top graduates from non-elite schools rather than settle for elite-school graduates in the bottom half or bottom quarter of their classes.
No surprise then that, over time, the faculty and curriculum at the Harvards and Stanfords of the world began to evolve. 'If you look at the distribution of faculty at leading business schools,' says Khurana, '“they’re mostly in finance. … Business schools are responsive to changes in the external environment.' Which meant that, even if a student aspired to become a top operations man (or woman) at a big industrial company, the infrastructure to teach him didn’t really exist.
If business schools did little to teach about manufacturing, they did almost nothing to teach about health care. But at the same time the finance people were taking over manufacturing, health care organizations were pushed to turn over their leadership to business people to improve efficiency and break the physician's "guild." Would there be any reason to expect that a finance background would be better preparation to run a health care corporation than to run an automobile company?
For the latest thought- and wince-provoking example of how leaders of health care corporations seem to know almost nothing about the actual health care their companies provide, see a DailyFinance interview with Mr Kent Thiry, CEO of DaVita, a for-profit corporate provider of dialysis services. According to the company web-site, "prior to working for Vivra, Mr. Thiry was a partner at Bain & Company, an International management consulting company. He earned his BA degree, with distinction and Phi Beta Kappa, in Political Science from Stanford University in 1978, and his MBA, with honors from Harvard Business School in 1983" So he got his MBA from an elite US business school at the time in which finance was becoming dominant as described above.
Asked to explain his business model, Mr Thiry responded:
Most of us have a couple of kidneys. These kidneys are amazing organs -- some of the most complex, sophisticated organs in the human body, which is why they've been so difficult to replicate compared to other organs like the heart and lung and others. And when the kidney fails, you need to go on dialysis, unless you're one of the fortunate few to get a transplant. And we operate the centers that people come to if their kidney fails and they can't get a transplant.
And what we do in our centers is take care of these people typically three times a week -- four hours each time -- where we take their blood out of their body, clean out all the toxins that they would normally clean out themselves through the act of urinating. But you don't do that anymore once you've lost your kidney function. And we take that part out, take the toxins out and then put the blood back in with some other nutrients.
To be charitable, I do not think that would merit a "C" on a high school biology test. [Medical science cannot "replicate" hearts or lungs. Kidney function is not the same thing as "urinating." The functions of the kidney are far more complex than "cleaning out toxins."]
Does it make any sense to put someone who obviously understands so little about kidneys in charge of a kidney dialysis company? (On the other hand, see this post on accusations that DaVita's ruthless business practices treat patients like "dialysis dollars.")
So, if putting finance people in charge of automobile companies turned out to be a recipe for bankruptcy, why should we expect from putting finance people in charge of dialysis companies, or hospitals, or drug, biotechnology or medical device companies, or health care insurance companies, or health care information technology companies?
The CEOs of big health care organizations, most of whom have business, not health care backgrounds, have mainly been good at paying themselves and their cronies well. (For example, according to the 2009 DaVita proxy statement, in 2008, Mr Thiry owned over 2 million shares of stock, 1.9% of all shares outstanding, and received more than $11 million in total compensation. Clearly, he was not paid according to his knowledge of kidney biology.) Meanwhile, health care costs rise, access falls, and quality degrades.
If we really want to reform health care, maybe we should take a lesson from Toyota. Put the car guys and gals in charge of car companies. And put the health care guys and gals in charge of health care.
The $20 Million Dollar Journal Editor
Last week, the Milwaukee Journal-Sentinel reported on a royally paid journal editor:
Here are some specifics:
Dr Zdelblick declined to comment for the Journal-Sentinel, but:
Of course, as the Journal-Sentinel pointed out, editors can make publication decisions independent of the recommendations of peer-reviewers. They also are free to select peer-reviewers who might have a particular viewpoint about a manuscript, its topic or authors, and to make and enforce editorial suggestions for changes in manuscripts. It is beyond me what good that disclosure of conflicts of interest to a for-profit publishing corporation does in the absence of further disclosure. Keep in mind also that the division of Wolters Kluwer that publishes the journals, Wolters Kluwer Health & Pharma Solutions, not only publishes journals and textbooks, but "provides marketing and publications services, business intelligence products, and advanced analytical tools and services" to pharmaceutical corporations.
Furthermore,
Just to add icing to the cake, Prof Margaret Soltan pointed out on her University Diaries blog that Dr Zdeblick is not only a journal editor, but a Professor and Chairman of Orthopedics and Rehabilitation at the University of Wisconsin. In addition, his web-page at the University notes that he is on the editorial board of another orthopedics journal, Spine, also published by Wolters Kluwer Health.
So here we go again. How should we assess the objectivity of an ostensibly scholarly medical journal whose editor was made rich by royalties from a company whose devices were often evaluated in the articles published in the journal? How should we assess the honesty of a journal editor who received millions in royalties from Medtronic, but who only deigned to disclose as an author in his own journal, "One or more of the author(s) has/have received or will receive benefits, (e.g., royalties, stocks, stock options, decision making position) for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript." (as in Zdelblick TA, Phillips FM. Interbody cage devices. Spine 2003; 28: S2-S7.) (Note that this sort of disclosure seems to be standard operating procedure for orthopedic surgeons who make millions from royalties and consulting fees, e.g. see this post.)
Prof Zdelblick had numerous opportunities to influence his colleagues, trainees, and students in his roles as journal editor, journal editorial board member, author of scholarly articles, and professor and chair of orthopedics. At the very least, the people who read his journal or his articles, listened to his lectures, or participated in his clinical teaching should have at least had the opportunity to judge for themselves whether being paid over $20 million might have just biased what he wrote and said a tiny bit. But can anyone doubt that $20 million dollars would profoundly influence one's thinking? Can anyone doubt that an inventor who got rich from royalties might not be more enthused about the use of the devicesthat generated the royalties than would an academic whose salary is unrelated to the use of any device? It seems to be an abuse of entrusted power for a journal editor, professor, and department chairman not to clearly disclose such huge conflicts of interests to readers, learners and colleagues.
This is just the latest vivid example of the conflicts of interest that permeate health care. When multi-million dollar men pretend to be unbiased editors and professors, is it any wonder that we regularly overuse and overvalue the devices and drugs that they are selling?
ADDENDUM (6 January, 2010) - See also comments on the Spine Blogger, and by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.
In 2002, Thomas Zdeblick, a University of Wisconsin orthopedic surgeon who has pocketed millions of dollars in royalties from the spinal device maker Medtronic, took over as editor-in-chief of a medical journal about spinal disorders.
It would be the beginning of a beautiful friendship.
In the years to come, Zdeblick would receive more than $20 million in patent royalties from Medtronic for spinal implants sold by the company. And the medical journal he edited would become a conduit for positive research articles involving Medtronic spinal products, a Journal Sentinel analysis found.
Zdeblick took over editorship of the Journal of Spinal Disorders & Techniques seven years ago. Since then, studies involving Medtronic spinal products or that were funded by Medtronic appeared in the journal at least once per issue, on average.
Dozens of studies that mentioned Medtronic products have been published while Zdeblick has been editor. But in issue after issue, readers of the journal were not told that he was receiving millions of dollars in royalty payments from Medtronic at the same time.
Most of the time the articles, including some co-authored by Zdeblick himself about devices for which he gets royalties, had good things to say about the Medtronic products. Only on a small number of occasions did the articles find major problems with Medtronic devices.
And often the articles did not disclose financial ties the authors had to Medtronic.
Here are some specifics:
From 2003 through 2007, Zdeblick got more than $19 million in royalty payments for spinal devices from Medtronic, according to a January 2009 letter by U.S. Sen. Charles Grassley (R-Iowa), who has been investigating payments to orthopedic surgeons by Medtronic. In 2008, Zdeblick got another $2 million from Medtronic from royalties and working as a consultant, according to UW records.
To assess the relationship, the Journal Sentinel reviewed every article published in the journal since Zdeblick became editor.
The journal is published seven or eight times a year and typically has a dozen or so articles. The articles were searched to see if Medtronic products were used as a part of the study or if the study was funded by Medtronic.
At least 70 such articles were found in 56 issues of the journal from 2002 through October 2009.
• A 2005 study by researchers in France found favorable preliminary results with Medtronic's Maverick artificial disc.
In 2007, Medtronic paid Zdeblick $144,000 in royalties for the Maverick disc, according to Grassley's letter.
• In August 2009, Zdeblick co-authored a study that involved Medtronic's Premier Anterior Cervical Plate as well as the plate of another company, Synthes. The study involved using two different kinds of bone grafts with the plates. Zdeblick got $654,000 in Premier royalties from Medtronic in 2007.
• Zdeblick also co-authored three articles, in 2002, 2003 and 2005, involving Medtronic's BMP-2 and the LT-Cage, a device that paid him $1.4 million in royalties in 2007. None of those studies disclosed that he received millions of dollars in royalties from Medtronic.
Often articles in the journal had good things to say about Medtronic products:
• In the 2002 study, Zdeblick and the co-authors concluded that BMP-2 and the LT-Cage led to a solid union and high fusion rates. In the 2003 study they found that BMP-2 may become 'the new gold standard.'
• In a 2006 study, a different group of authors concluded that BMP-2 when used with a hip bone graft significantly improved the success of the fusion surgery with minimal risk to the patient. The 2005 French study of Medtronic's Maverick artificial disc that did not involve Zdeblick concluded it was a 'promising therapeutic technique.'
Dr Zdelblick declined to comment for the Journal-Sentinel, but:
In a statement, a spokesman for the spinal journal said Zdeblick has disclosed his financial relationship with Medtronic to the company that publishes the journal, Wolters Kluwer Health/Lippincott Williams & Wilkins.
All manuscripts submitted to the journal go through a rigorous review process using reviewers who have an objective viewpoint, Robert Dekker, director of communications with Philadelphia-based Wolters Kluwer Health & Pharma Solutions, said in a statement. 'Thanks to our strict peer review policies and processes, we have no concerns about the existence of this relationship,' Dekker said in an e-mail.
Dekker declined to provide a list of the reviewers used by the journal or information about their financial relationships with device companies. He also declined to comment on how Zdeblick made decisions about manuscripts and reviewers.
Of course, as the Journal-Sentinel pointed out, editors can make publication decisions independent of the recommendations of peer-reviewers. They also are free to select peer-reviewers who might have a particular viewpoint about a manuscript, its topic or authors, and to make and enforce editorial suggestions for changes in manuscripts. It is beyond me what good that disclosure of conflicts of interest to a for-profit publishing corporation does in the absence of further disclosure. Keep in mind also that the division of Wolters Kluwer that publishes the journals, Wolters Kluwer Health & Pharma Solutions, not only publishes journals and textbooks, but "provides marketing and publications services, business intelligence products, and advanced analytical tools and services" to pharmaceutical corporations.
Furthermore,
'It's absolutely a conflict,' said Richard Smith, the former editor of the British Medical Journal.
At a minimum, Zdeblick's conflict should be fully disclosed by his journal whenever a study involving a Medtronic product is published, said Smith, the author of 'The Trouble with Medical Journals.'
However, because he makes so much money from Medtronic royalties, he really should not be editing the journal at all, Smith said.
Just to add icing to the cake, Prof Margaret Soltan pointed out on her University Diaries blog that Dr Zdeblick is not only a journal editor, but a Professor and Chairman of Orthopedics and Rehabilitation at the University of Wisconsin. In addition, his web-page at the University notes that he is on the editorial board of another orthopedics journal, Spine, also published by Wolters Kluwer Health.
So here we go again. How should we assess the objectivity of an ostensibly scholarly medical journal whose editor was made rich by royalties from a company whose devices were often evaluated in the articles published in the journal? How should we assess the honesty of a journal editor who received millions in royalties from Medtronic, but who only deigned to disclose as an author in his own journal, "One or more of the author(s) has/have received or will receive benefits, (e.g., royalties, stocks, stock options, decision making position) for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript." (as in Zdelblick TA, Phillips FM. Interbody cage devices. Spine 2003; 28: S2-S7.) (Note that this sort of disclosure seems to be standard operating procedure for orthopedic surgeons who make millions from royalties and consulting fees, e.g. see this post.)
Prof Zdelblick had numerous opportunities to influence his colleagues, trainees, and students in his roles as journal editor, journal editorial board member, author of scholarly articles, and professor and chair of orthopedics. At the very least, the people who read his journal or his articles, listened to his lectures, or participated in his clinical teaching should have at least had the opportunity to judge for themselves whether being paid over $20 million might have just biased what he wrote and said a tiny bit. But can anyone doubt that $20 million dollars would profoundly influence one's thinking? Can anyone doubt that an inventor who got rich from royalties might not be more enthused about the use of the devicesthat generated the royalties than would an academic whose salary is unrelated to the use of any device? It seems to be an abuse of entrusted power for a journal editor, professor, and department chairman not to clearly disclose such huge conflicts of interests to readers, learners and colleagues.
This is just the latest vivid example of the conflicts of interest that permeate health care. When multi-million dollar men pretend to be unbiased editors and professors, is it any wonder that we regularly overuse and overvalue the devices and drugs that they are selling?
ADDENDUM (6 January, 2010) - See also comments on the Spine Blogger, and by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.
The $20 Million Dollar Journal Editor
Last week, the Milwaukee Journal-Sentinel reported on a royally paid journal editor:
Here are some specifics:
Dr Zdelblick declined to comment for the Journal-Sentinel, but:
Of course, as the Journal-Sentinel pointed out, editors can make publication decisions independent of the recommendations of peer-reviewers. They also are free to select peer-reviewers who might have a particular viewpoint about a manuscript, its topic or authors, and to make and enforce editorial suggestions for changes in manuscripts. It is beyond me what good that disclosure of conflicts of interest to a for-profit publishing corporation does in the absence of further disclosure. Keep in mind also that the division of Wolters Kluwer that publishes the journals, Wolters Kluwer Health & Pharma Solutions, not only publishes journals and textbooks, but "provides marketing and publications services, business intelligence products, and advanced analytical tools and services" to pharmaceutical corporations.
Furthermore,
Just to add icing to the cake, Prof Margaret Soltan pointed out on her University Diaries blog that Dr Zdeblick is not only a journal editor, but a Professor and Chairman of Orthopedics and Rehabilitation at the University of Wisconsin. In addition, his web-page at the University notes that he is on the editorial board of another orthopedics journal, Spine, also published by Wolters Kluwer Health.
So here we go again. How should we assess the objectivity of an ostensibly scholarly medical journal whose editor was made rich by royalties from a company whose devices were often evaluated in the articles published in the journal? How should we assess the honesty of a journal editor who received millions in royalties from Medtronic, but who only deigned to disclose as an author in his own journal, "One or more of the author(s) has/have received or will receive benefits, (e.g., royalties, stocks, stock options, decision making position) for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript." (as in Zdelblick TA, Phillips FM. Interbody cage devices. Spine 2003; 28: S2-S7.) (Note that this sort of disclosure seems to be standard operating procedure for orthopedic surgeons who make millions from royalties and consulting fees, e.g. see this post.)
Prof Zdelblick had numerous opportunities to influence his colleagues, trainees, and students in his roles as journal editor, journal editorial board member, author of scholarly articles, and professor and chair of orthopedics. At the very least, the people who read his journal or his articles, listened to his lectures, or participated in his clinical teaching should have at least had the opportunity to judge for themselves whether being paid over $20 million might have just biased what he wrote and said a tiny bit. But can anyone doubt that $20 million dollars would profoundly influence one's thinking? Can anyone doubt that an inventor who got rich from royalties might not be more enthused about the use of the devicesthat generated the royalties than would an academic whose salary is unrelated to the use of any device? It seems to be an abuse of entrusted power for a journal editor, professor, and department chairman not to clearly disclose such huge conflicts of interests to readers, learners and colleagues.
This is just the latest vivid example of the conflicts of interest that permeate health care. When multi-million dollar men pretend to be unbiased editors and professors, is it any wonder that we regularly overuse and overvalue the devices and drugs that they are selling?
ADDENDUM (6 January, 2010) - See also comments on the Spine Blogger, and by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.
In 2002, Thomas Zdeblick, a University of Wisconsin orthopedic surgeon who has pocketed millions of dollars in royalties from the spinal device maker Medtronic, took over as editor-in-chief of a medical journal about spinal disorders.
It would be the beginning of a beautiful friendship.
In the years to come, Zdeblick would receive more than $20 million in patent royalties from Medtronic for spinal implants sold by the company. And the medical journal he edited would become a conduit for positive research articles involving Medtronic spinal products, a Journal Sentinel analysis found.
Zdeblick took over editorship of the Journal of Spinal Disorders & Techniques seven years ago. Since then, studies involving Medtronic spinal products or that were funded by Medtronic appeared in the journal at least once per issue, on average.
Dozens of studies that mentioned Medtronic products have been published while Zdeblick has been editor. But in issue after issue, readers of the journal were not told that he was receiving millions of dollars in royalty payments from Medtronic at the same time.
Most of the time the articles, including some co-authored by Zdeblick himself about devices for which he gets royalties, had good things to say about the Medtronic products. Only on a small number of occasions did the articles find major problems with Medtronic devices.
And often the articles did not disclose financial ties the authors had to Medtronic.
Here are some specifics:
From 2003 through 2007, Zdeblick got more than $19 million in royalty payments for spinal devices from Medtronic, according to a January 2009 letter by U.S. Sen. Charles Grassley (R-Iowa), who has been investigating payments to orthopedic surgeons by Medtronic. In 2008, Zdeblick got another $2 million from Medtronic from royalties and working as a consultant, according to UW records.
To assess the relationship, the Journal Sentinel reviewed every article published in the journal since Zdeblick became editor.
The journal is published seven or eight times a year and typically has a dozen or so articles. The articles were searched to see if Medtronic products were used as a part of the study or if the study was funded by Medtronic.
At least 70 such articles were found in 56 issues of the journal from 2002 through October 2009.
• A 2005 study by researchers in France found favorable preliminary results with Medtronic's Maverick artificial disc.
In 2007, Medtronic paid Zdeblick $144,000 in royalties for the Maverick disc, according to Grassley's letter.
• In August 2009, Zdeblick co-authored a study that involved Medtronic's Premier Anterior Cervical Plate as well as the plate of another company, Synthes. The study involved using two different kinds of bone grafts with the plates. Zdeblick got $654,000 in Premier royalties from Medtronic in 2007.
• Zdeblick also co-authored three articles, in 2002, 2003 and 2005, involving Medtronic's BMP-2 and the LT-Cage, a device that paid him $1.4 million in royalties in 2007. None of those studies disclosed that he received millions of dollars in royalties from Medtronic.
Often articles in the journal had good things to say about Medtronic products:
• In the 2002 study, Zdeblick and the co-authors concluded that BMP-2 and the LT-Cage led to a solid union and high fusion rates. In the 2003 study they found that BMP-2 may become 'the new gold standard.'
• In a 2006 study, a different group of authors concluded that BMP-2 when used with a hip bone graft significantly improved the success of the fusion surgery with minimal risk to the patient. The 2005 French study of Medtronic's Maverick artificial disc that did not involve Zdeblick concluded it was a 'promising therapeutic technique.'
Dr Zdelblick declined to comment for the Journal-Sentinel, but:
In a statement, a spokesman for the spinal journal said Zdeblick has disclosed his financial relationship with Medtronic to the company that publishes the journal, Wolters Kluwer Health/Lippincott Williams & Wilkins.
All manuscripts submitted to the journal go through a rigorous review process using reviewers who have an objective viewpoint, Robert Dekker, director of communications with Philadelphia-based Wolters Kluwer Health & Pharma Solutions, said in a statement. 'Thanks to our strict peer review policies and processes, we have no concerns about the existence of this relationship,' Dekker said in an e-mail.
Dekker declined to provide a list of the reviewers used by the journal or information about their financial relationships with device companies. He also declined to comment on how Zdeblick made decisions about manuscripts and reviewers.
Of course, as the Journal-Sentinel pointed out, editors can make publication decisions independent of the recommendations of peer-reviewers. They also are free to select peer-reviewers who might have a particular viewpoint about a manuscript, its topic or authors, and to make and enforce editorial suggestions for changes in manuscripts. It is beyond me what good that disclosure of conflicts of interest to a for-profit publishing corporation does in the absence of further disclosure. Keep in mind also that the division of Wolters Kluwer that publishes the journals, Wolters Kluwer Health & Pharma Solutions, not only publishes journals and textbooks, but "provides marketing and publications services, business intelligence products, and advanced analytical tools and services" to pharmaceutical corporations.
Furthermore,
'It's absolutely a conflict,' said Richard Smith, the former editor of the British Medical Journal.
At a minimum, Zdeblick's conflict should be fully disclosed by his journal whenever a study involving a Medtronic product is published, said Smith, the author of 'The Trouble with Medical Journals.'
However, because he makes so much money from Medtronic royalties, he really should not be editing the journal at all, Smith said.
Just to add icing to the cake, Prof Margaret Soltan pointed out on her University Diaries blog that Dr Zdeblick is not only a journal editor, but a Professor and Chairman of Orthopedics and Rehabilitation at the University of Wisconsin. In addition, his web-page at the University notes that he is on the editorial board of another orthopedics journal, Spine, also published by Wolters Kluwer Health.
So here we go again. How should we assess the objectivity of an ostensibly scholarly medical journal whose editor was made rich by royalties from a company whose devices were often evaluated in the articles published in the journal? How should we assess the honesty of a journal editor who received millions in royalties from Medtronic, but who only deigned to disclose as an author in his own journal, "One or more of the author(s) has/have received or will receive benefits, (e.g., royalties, stocks, stock options, decision making position) for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript." (as in Zdelblick TA, Phillips FM. Interbody cage devices. Spine 2003; 28: S2-S7.) (Note that this sort of disclosure seems to be standard operating procedure for orthopedic surgeons who make millions from royalties and consulting fees, e.g. see this post.)
Prof Zdelblick had numerous opportunities to influence his colleagues, trainees, and students in his roles as journal editor, journal editorial board member, author of scholarly articles, and professor and chair of orthopedics. At the very least, the people who read his journal or his articles, listened to his lectures, or participated in his clinical teaching should have at least had the opportunity to judge for themselves whether being paid over $20 million might have just biased what he wrote and said a tiny bit. But can anyone doubt that $20 million dollars would profoundly influence one's thinking? Can anyone doubt that an inventor who got rich from royalties might not be more enthused about the use of the devicesthat generated the royalties than would an academic whose salary is unrelated to the use of any device? It seems to be an abuse of entrusted power for a journal editor, professor, and department chairman not to clearly disclose such huge conflicts of interests to readers, learners and colleagues.
This is just the latest vivid example of the conflicts of interest that permeate health care. When multi-million dollar men pretend to be unbiased editors and professors, is it any wonder that we regularly overuse and overvalue the devices and drugs that they are selling?
ADDENDUM (6 January, 2010) - See also comments on the Spine Blogger, and by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.
Finnish EHR's Clumsy, Mission Hostile, Consume Doctors' Precious Time
It seems common wisdom in the U.S. that the "Europeans are way ahead of us" in computerized medicine.
Perhaps the common wisdom is not so wise. This from Finland:
Can health IT be any more mission hostile than this? (Unfortunately, the answer to what started as a rhetorical question is probably "yes." See this post on the US military's EHR AHLTA, and see my eight part series "Are Health IT Designers, Testers and Purchasers Trying to Harm Patients?" on mission hostile commercial HIT starting here.)
Reports of difficulty in EHR Utopia have leaked out of other European countries such as the Netherlands and Germany, not to mention the UK.
The most startling observation is that “software companies have started to become interested in listening to users only in recent years."
What manner of cavalier simpletons and opportunists populate such health IT companies?
-- SS
Addendum:
It appears AHLTA may be a bad as it is due in part to "politics as usual" a.k.a. corruption. See "Company won earmarked funds for work on military health records." If such conduct has been commonplace during AHLTA'a tortured history, it could explain just how AHLTA became as terrible as the senior military officials describe it in the linked article above.
Perhaps the common wisdom is not so wise. This from Finland:
HELSINGIN SANOMAT
INTERNATIONAL EDITION - HOME
Clumsy computer systems consume doctors’ time
When Arto Virtanen, a doctor at a public health clinic, wants to access the information of a young patient, 12 windows of different sizes open up on different parts of his computer screen. Virtanen has to deal with each of them every time a patient visits him for routine postnatal care.
“It used to be that a municipal doctor would see six or seven patients in an hour, when documentation was not at its present level”, Virtanen says. “Then there came more paperwork, and four patients were seen in an hour. Now if a doctor wants to read all the information about a patient in the information system, there would only be time for consultations with, say, two patients in an hour.”
Clumsy computer systems are already seen as a danger to patient security, says Tiina Lääveri, a member of the board of the Finnish Medical Association, who has acquainted herself with the various systems.
Clumsy retrieval of data is one source of danger. Important information can disappear into the nooks and crannies of the software.
“There can be 100 pages of text without any summary, out of which a doctor should find information in a couple of minutes."
In hospitals, the systems do not separately tell nurses about changed dosages of medicines.
“The information is there, mixed in the mass of all of the rest of it, where it gets lost.”
In addition to causing outright dangers, computer systems waste precious working hours. In addition to actual medical data, the computer requires the recording of various items of statistical information.
Patients can see the problem as well. Up to 43 per cent of time reserved for a patient with an appointment to see a public health doctor can be spent dealing with a computer, according to a study published earlier this year in Lääkärilehti, the publication of the Finnish Medical Assotiation.
A national health archive now under development would not help things, as data would still be handled with existing software.
“Software companies have started to become interested in listening to users only in recent years”, Lääveri says.
Virtanen in Rajamäki would like to see more compatibility between systems. “There could be a common database, which should be easily accessible by a network browser”, Virtanen says.
“It might also be constructed according to what this working process really is.” [You don't say? - ed.]
Can health IT be any more mission hostile than this? (Unfortunately, the answer to what started as a rhetorical question is probably "yes." See this post on the US military's EHR AHLTA, and see my eight part series "Are Health IT Designers, Testers and Purchasers Trying to Harm Patients?" on mission hostile commercial HIT starting here.)
Reports of difficulty in EHR Utopia have leaked out of other European countries such as the Netherlands and Germany, not to mention the UK.
The most startling observation is that “software companies have started to become interested in listening to users only in recent years."
What manner of cavalier simpletons and opportunists populate such health IT companies?
-- SS
Addendum:
It appears AHLTA may be a bad as it is due in part to "politics as usual" a.k.a. corruption. See "Company won earmarked funds for work on military health records." If such conduct has been commonplace during AHLTA'a tortured history, it could explain just how AHLTA became as terrible as the senior military officials describe it in the linked article above.
Finnish EHR's Clumsy, Mission Hostile, Consume Doctors' Precious Time
It seems common wisdom in the U.S. that the "Europeans are way ahead of us" in computerized medicine.
Perhaps the common wisdom is not so wise. This from Finland:
Can health IT be any more mission hostile than this? (Unfortunately, the answer to what started as a rhetorical question is probably "yes." See this post on the US military's EHR AHLTA, and see my eight part series "Are Health IT Designers, Testers and Purchasers Trying to Harm Patients?" on mission hostile commercial HIT starting here.)
Reports of difficulty in EHR Utopia have leaked out of other European countries such as the Netherlands and Germany, not to mention the UK.
The most startling observation is that “software companies have started to become interested in listening to users only in recent years."
What manner of cavalier simpletons and opportunists populate such health IT companies?
-- SS
Addendum:
It appears AHLTA may be a bad as it is due in part to "politics as usual" a.k.a. corruption. See "Company won earmarked funds for work on military health records." If such conduct has been commonplace during AHLTA'a tortured history, it could explain just how AHLTA became as terrible as the senior military officials describe it in the linked article above.
Perhaps the common wisdom is not so wise. This from Finland:
HELSINGIN SANOMAT
INTERNATIONAL EDITION - HOME
Clumsy computer systems consume doctors’ time
When Arto Virtanen, a doctor at a public health clinic, wants to access the information of a young patient, 12 windows of different sizes open up on different parts of his computer screen. Virtanen has to deal with each of them every time a patient visits him for routine postnatal care.
“It used to be that a municipal doctor would see six or seven patients in an hour, when documentation was not at its present level”, Virtanen says. “Then there came more paperwork, and four patients were seen in an hour. Now if a doctor wants to read all the information about a patient in the information system, there would only be time for consultations with, say, two patients in an hour.”
Clumsy computer systems are already seen as a danger to patient security, says Tiina Lääveri, a member of the board of the Finnish Medical Association, who has acquainted herself with the various systems.
Clumsy retrieval of data is one source of danger. Important information can disappear into the nooks and crannies of the software.
“There can be 100 pages of text without any summary, out of which a doctor should find information in a couple of minutes."
In hospitals, the systems do not separately tell nurses about changed dosages of medicines.
“The information is there, mixed in the mass of all of the rest of it, where it gets lost.”
In addition to causing outright dangers, computer systems waste precious working hours. In addition to actual medical data, the computer requires the recording of various items of statistical information.
Patients can see the problem as well. Up to 43 per cent of time reserved for a patient with an appointment to see a public health doctor can be spent dealing with a computer, according to a study published earlier this year in Lääkärilehti, the publication of the Finnish Medical Assotiation.
A national health archive now under development would not help things, as data would still be handled with existing software.
“Software companies have started to become interested in listening to users only in recent years”, Lääveri says.
Virtanen in Rajamäki would like to see more compatibility between systems. “There could be a common database, which should be easily accessible by a network browser”, Virtanen says.
“It might also be constructed according to what this working process really is.” [You don't say? - ed.]
Can health IT be any more mission hostile than this? (Unfortunately, the answer to what started as a rhetorical question is probably "yes." See this post on the US military's EHR AHLTA, and see my eight part series "Are Health IT Designers, Testers and Purchasers Trying to Harm Patients?" on mission hostile commercial HIT starting here.)
Reports of difficulty in EHR Utopia have leaked out of other European countries such as the Netherlands and Germany, not to mention the UK.
The most startling observation is that “software companies have started to become interested in listening to users only in recent years."
What manner of cavalier simpletons and opportunists populate such health IT companies?
-- SS
Addendum:
It appears AHLTA may be a bad as it is due in part to "politics as usual" a.k.a. corruption. See "Company won earmarked funds for work on military health records." If such conduct has been commonplace during AHLTA'a tortured history, it could explain just how AHLTA became as terrible as the senior military officials describe it in the linked article above.
Are Dissmissive Industry and Government Reactions to Physician Concerns about EHR's and other Clinical IT Simply Perverse?
Yes, they are.
At the Nov. 10, 2009 essay "Academic Freedom and ED EHR's Down Under: Another Update and a Welcome Development" and preceding essays linked to it, I wrote about an Australian informatics professor's travails in writing about ED EHR's.
He wrote a mixed-method essay about the mission hostile user experiences ED physicians in NSW reported about the EHR's they were being compelled to use, in addition to similar negative commentary from ED physician experts in other lands. The latest version of the paper "A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck" is here (PDF) or accessible from his department's webpage here.
The government attempted to censor the paper and likely censure the author, and I speculate the HIT industry was not far behind.
Below is an example from my own city on why I found the reactions to the evolving ED EHR paper - reactions that "blamed the doctors" or dismissed what appear to be frequently encountered ED physician concerns - perverse.
I use the term "perverse" in the most formal sense of the word:
The very, very last thing patients need is to have ED clinicians slowed down.
Concerns expressed by even a minority of ED physicians that EHR's slow them down or reduce their effectiveness ought to set off alarm bells and rigorous government investigations of the kind that would arise if airline pilots started to complain about lax security allowing passengers on board with bombs:
A patient recently died of a heart attack, sitting in the waiting room of a hospital where I once rotated during my internship, Frankford Hospital. He was not found until others in the waiting room stole the dead patient-in-waiting's wristwatch. The man sat unresponsive for nearly an hour in the waiting area of Aria Health Frankford Hospital before a visitor notified security and a doctor arrived.
I reiterate, the very last thing in the world ER clinicians need are ill-conceived and ill-implemented electronic health records systems that slow them down.
Instead of attempted censorship and spin control, such concerns should be addressed throughly, impartially and promptly if not immediately.
What could one call the arrogance or devil-may-care mindset in the government and health IT industry that dismisses such concerns so cavalierly, other than "perverse?"
-- SS
At the Nov. 10, 2009 essay "Academic Freedom and ED EHR's Down Under: Another Update and a Welcome Development" and preceding essays linked to it, I wrote about an Australian informatics professor's travails in writing about ED EHR's.
He wrote a mixed-method essay about the mission hostile user experiences ED physicians in NSW reported about the EHR's they were being compelled to use, in addition to similar negative commentary from ED physician experts in other lands. The latest version of the paper "A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck" is here (PDF) or accessible from his department's webpage here.
The government attempted to censor the paper and likely censure the author, and I speculate the HIT industry was not far behind.
Below is an example from my own city on why I found the reactions to the evolving ED EHR paper - reactions that "blamed the doctors" or dismissed what appear to be frequently encountered ED physician concerns - perverse.
I use the term "perverse" in the most formal sense of the word:
Merriam-Webster dictionary:
Perverse (adj).
Etymology: Middle English, from Anglo-French purvers, pervers, from Latin perversus, from past participle of pervertere
Date: 14th century
1 a : turned away from what is right or good : corrupt b : improper, incorrect c : contrary to the evidence or the direction of the judge on a point of law
2 a : obstinate in opposing what is right, reasonable, or accepted : wrongheaded b : arising from or indicative of stubbornness or obstinacy
3 : marked by peevishness or petulance : cranky
4 : marked by perversion : perverted
The very, very last thing patients need is to have ED clinicians slowed down.
Concerns expressed by even a minority of ED physicians that EHR's slow them down or reduce their effectiveness ought to set off alarm bells and rigorous government investigations of the kind that would arise if airline pilots started to complain about lax security allowing passengers on board with bombs:
Dec 24, 2009The situation is actually even worse.
Philadelphia Inquirer
Philadelphia ERs seek solutions to crowding
By Marie McCullough
Inquirer Staff Writer
Two of the region's leading medical centers have racked up the city's highest number of "diversions" - periods when ambulances are advised to steer clear because the emergency room is so full.
The Hospital of the University of Pennsylvania and Thomas Jefferson University Hospital are working to reduce such diversions as the number of emergency rooms in the city has continued to fall. This year, Penn has reduced the disruptions by 22 percent and Jefferson by 28 percent.
As they seek solutions, the hospitals are examining their own practices, reflecting a national shift in efforts to address the perennial crisis of ER overcrowding.
Consider Jefferson. This year it reduced diversion hours even though the number of ER patients, the severity of their medical needs, and staffing stayed about the same. Jefferson relieved overcrowding by finding ways to move patients in and out of the ER - and the whole hospital - faster.
"That's where I'm focused, on improving efficiencies," said Rex Mathew, hired by Jefferson two years ago for the new job of vice president of emergency medicine clinical operations.
This is not to suggest that the nation's emergency medical-care system has been slacking. From 1992 to 2002, the number of annual emergency-room visits increased 23 percent, while the number of ERs decreased 15 percent, studies show.
In the Philadelphia region, the contraction has been more dramatic - from 62 ERs in 1993 to 38 now, a 39 percent decrease. The most recent loss was this year's closing of Northeastern Hospital, which had 45,000 emergency visits annually. The impact has been felt at Aria Health-Frankford Campus, where Joaquin Rivera died in the ER while waiting for care on Nov. 28.
While there is no evidence that overcrowding played a role in his death, Frankford had nearly as many diversions in November - 121 hours - as all of last year.
Emergency departments are beset by growing numbers of the uninsured, the chronically ill, and the aged.
Nonetheless, experts say it's time for hospitals to stop blaming ER overcrowding on economic, social, and demographic factors that are beyond their control, and start looking inward. A recent Government Accountability Office report found that even in life-and-death cases, large percentages of ER patients do not see doctors within recommended times.
"Many hospitals have done little to address the patient-flow obstacles that lead to overcrowded" emergency rooms, says a report by Urgent Matters, an ER improvement initiative funded by the Robert Wood Johnson Foundation.
Jefferson and Hahnemann University Hospital are among six U.S. hospitals using grants from Urgent Matters to develop practical strategies for reducing ER crowding. These will be shared nationally through newsletters, the Web, and conferences.
... Most fixes, however, are neither easy nor obvious. Sick patients may lie on gurneys for hours in ERs, uncomfortable and taking up precious space, while they wait for a hospital bed to become available.
... "The problem is not just physical space but effective space," said Robert McNamara, chair of emergency medicine at Temple University Hospital. "With hospital margins tight, there may be beds, but no staff to cover them. And hospitals try to keep staffing tight to keep costs down."
Temple has the city's busiest ER, with 74,000 adult and 20,000 pediatric patients this year - 24 percent of whom were admitted to the hospital, McNamara said. Anticipating a surge in demand following Northeastern's closure, Temple added ER staff and made a concerted effort to speed up testing and discharge procedures, he said.
This year, through November, Temple had 118 hours when ambulances were diverted.
The Hospital of the University of Pennsylvania, with about 60,000 ER patients and a 26 percent admission rate, was by far the city's leading diverter - more than 1,000 hours through November.
... the crowding conundrum continues to evolve. One question is whether health-care reform - which now seems imminent - may increase ER volume rather than reducing it, as millions more Americans become insured.
A patient recently died of a heart attack, sitting in the waiting room of a hospital where I once rotated during my internship, Frankford Hospital. He was not found until others in the waiting room stole the dead patient-in-waiting's wristwatch. The man sat unresponsive for nearly an hour in the waiting area of Aria Health Frankford Hospital before a visitor notified security and a doctor arrived.
Dec. 1, 2009
Philadelphia Inquirer
Waiting to be seen at hospital, dying Joaquin Rivera was robbed, police say
... According to Philadelphia police, Rivera walked into Aria Health's Frankford Campus, on Frankford Avenue near Harrison Street, about 10:45 p.m. Saturday.
He was alone, and apparently had walked from his nearby home on Duffield Street near Foulkrod, his son said.
Rivera complained of feeling pain in his left arm and abdomen, and was told to sit in the waiting area, said police spokesman Lt. Frank Vanore. [A middle aged man with left arm and abdominal pain told to 'sit in the waiting room?' One wonders who would qualify for sitting under medical observation - ed.]
At some point during the next hour, Rivera, a longtime bilingual counselor at Olney High School, lost consciousness. He inadvertently became a target, Vanore said, to three other people in the waiting room...
[One of the other people] signed up to be seen by a doctor, while his two cohorts sat near Rivera. "At some point, [one of the people] is observed taking the victim's watch and passing it to the other man," Vanore said.
When a witness ran to notify a security guard of the crime and Rivera's condition, the limping man and his female partner fled, Vanore said. Hospital personnel rushed to Rivera's aid, but it was too late.
He was pronounced dead shortly after midnight Sunday. Vanore said police have not yet learned of Rivera's cause of death.
The family said he was believed to have died of a heart attack.
I reiterate, the very last thing in the world ER clinicians need are ill-conceived and ill-implemented electronic health records systems that slow them down.
Instead of attempted censorship and spin control, such concerns should be addressed throughly, impartially and promptly if not immediately.
What could one call the arrogance or devil-may-care mindset in the government and health IT industry that dismisses such concerns so cavalierly, other than "perverse?"
-- SS
Are Dissmissive Industry and Government Reactions to Physician Concerns about EHR's and other Clinical IT Simply Perverse?
Yes, they are.
At the Nov. 10, 2009 essay "Academic Freedom and ED EHR's Down Under: Another Update and a Welcome Development" and preceding essays linked to it, I wrote about an Australian informatics professor's travails in writing about ED EHR's.
He wrote a mixed-method essay about the mission hostile user experiences ED physicians in NSW reported about the EHR's they were being compelled to use, in addition to similar negative commentary from ED physician experts in other lands. The latest version of the paper "A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck" is here (PDF) or accessible from his department's webpage here.
The government attempted to censor the paper and likely censure the author, and I speculate the HIT industry was not far behind.
Below is an example from my own city on why I found the reactions to the evolving ED EHR paper - reactions that "blamed the doctors" or dismissed what appear to be frequently encountered ED physician concerns - perverse.
I use the term "perverse" in the most formal sense of the word:
The very, very last thing patients need is to have ED clinicians slowed down.
Concerns expressed by even a minority of ED physicians that EHR's slow them down or reduce their effectiveness ought to set off alarm bells and rigorous government investigations of the kind that would arise if airline pilots started to complain about lax security allowing passengers on board with bombs:
A patient recently died of a heart attack, sitting in the waiting room of a hospital where I once rotated during my internship, Frankford Hospital. He was not found until others in the waiting room stole the dead patient-in-waiting's wristwatch. The man sat unresponsive for nearly an hour in the waiting area of Aria Health Frankford Hospital before a visitor notified security and a doctor arrived.
I reiterate, the very last thing in the world ER clinicians need are ill-conceived and ill-implemented electronic health records systems that slow them down.
Instead of attempted censorship and spin control, such concerns should be addressed throughly, impartially and promptly if not immediately.
What could one call the arrogance or devil-may-care mindset in the government and health IT industry that dismisses such concerns so cavalierly, other than "perverse?"
-- SS
At the Nov. 10, 2009 essay "Academic Freedom and ED EHR's Down Under: Another Update and a Welcome Development" and preceding essays linked to it, I wrote about an Australian informatics professor's travails in writing about ED EHR's.
He wrote a mixed-method essay about the mission hostile user experiences ED physicians in NSW reported about the EHR's they were being compelled to use, in addition to similar negative commentary from ED physician experts in other lands. The latest version of the paper "A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck" is here (PDF) or accessible from his department's webpage here.
The government attempted to censor the paper and likely censure the author, and I speculate the HIT industry was not far behind.
Below is an example from my own city on why I found the reactions to the evolving ED EHR paper - reactions that "blamed the doctors" or dismissed what appear to be frequently encountered ED physician concerns - perverse.
I use the term "perverse" in the most formal sense of the word:
Merriam-Webster dictionary:
Perverse (adj).
Etymology: Middle English, from Anglo-French purvers, pervers, from Latin perversus, from past participle of pervertere
Date: 14th century
1 a : turned away from what is right or good : corrupt b : improper, incorrect c : contrary to the evidence or the direction of the judge on a point of law
2 a : obstinate in opposing what is right, reasonable, or accepted : wrongheaded b : arising from or indicative of stubbornness or obstinacy
3 : marked by peevishness or petulance : cranky
4 : marked by perversion : perverted
The very, very last thing patients need is to have ED clinicians slowed down.
Concerns expressed by even a minority of ED physicians that EHR's slow them down or reduce their effectiveness ought to set off alarm bells and rigorous government investigations of the kind that would arise if airline pilots started to complain about lax security allowing passengers on board with bombs:
Dec 24, 2009The situation is actually even worse.
Philadelphia Inquirer
Philadelphia ERs seek solutions to crowding
By Marie McCullough
Inquirer Staff Writer
Two of the region's leading medical centers have racked up the city's highest number of "diversions" - periods when ambulances are advised to steer clear because the emergency room is so full.
The Hospital of the University of Pennsylvania and Thomas Jefferson University Hospital are working to reduce such diversions as the number of emergency rooms in the city has continued to fall. This year, Penn has reduced the disruptions by 22 percent and Jefferson by 28 percent.
As they seek solutions, the hospitals are examining their own practices, reflecting a national shift in efforts to address the perennial crisis of ER overcrowding.
Consider Jefferson. This year it reduced diversion hours even though the number of ER patients, the severity of their medical needs, and staffing stayed about the same. Jefferson relieved overcrowding by finding ways to move patients in and out of the ER - and the whole hospital - faster.
"That's where I'm focused, on improving efficiencies," said Rex Mathew, hired by Jefferson two years ago for the new job of vice president of emergency medicine clinical operations.
This is not to suggest that the nation's emergency medical-care system has been slacking. From 1992 to 2002, the number of annual emergency-room visits increased 23 percent, while the number of ERs decreased 15 percent, studies show.
In the Philadelphia region, the contraction has been more dramatic - from 62 ERs in 1993 to 38 now, a 39 percent decrease. The most recent loss was this year's closing of Northeastern Hospital, which had 45,000 emergency visits annually. The impact has been felt at Aria Health-Frankford Campus, where Joaquin Rivera died in the ER while waiting for care on Nov. 28.
While there is no evidence that overcrowding played a role in his death, Frankford had nearly as many diversions in November - 121 hours - as all of last year.
Emergency departments are beset by growing numbers of the uninsured, the chronically ill, and the aged.
Nonetheless, experts say it's time for hospitals to stop blaming ER overcrowding on economic, social, and demographic factors that are beyond their control, and start looking inward. A recent Government Accountability Office report found that even in life-and-death cases, large percentages of ER patients do not see doctors within recommended times.
"Many hospitals have done little to address the patient-flow obstacles that lead to overcrowded" emergency rooms, says a report by Urgent Matters, an ER improvement initiative funded by the Robert Wood Johnson Foundation.
Jefferson and Hahnemann University Hospital are among six U.S. hospitals using grants from Urgent Matters to develop practical strategies for reducing ER crowding. These will be shared nationally through newsletters, the Web, and conferences.
... Most fixes, however, are neither easy nor obvious. Sick patients may lie on gurneys for hours in ERs, uncomfortable and taking up precious space, while they wait for a hospital bed to become available.
... "The problem is not just physical space but effective space," said Robert McNamara, chair of emergency medicine at Temple University Hospital. "With hospital margins tight, there may be beds, but no staff to cover them. And hospitals try to keep staffing tight to keep costs down."
Temple has the city's busiest ER, with 74,000 adult and 20,000 pediatric patients this year - 24 percent of whom were admitted to the hospital, McNamara said. Anticipating a surge in demand following Northeastern's closure, Temple added ER staff and made a concerted effort to speed up testing and discharge procedures, he said.
This year, through November, Temple had 118 hours when ambulances were diverted.
The Hospital of the University of Pennsylvania, with about 60,000 ER patients and a 26 percent admission rate, was by far the city's leading diverter - more than 1,000 hours through November.
... the crowding conundrum continues to evolve. One question is whether health-care reform - which now seems imminent - may increase ER volume rather than reducing it, as millions more Americans become insured.
A patient recently died of a heart attack, sitting in the waiting room of a hospital where I once rotated during my internship, Frankford Hospital. He was not found until others in the waiting room stole the dead patient-in-waiting's wristwatch. The man sat unresponsive for nearly an hour in the waiting area of Aria Health Frankford Hospital before a visitor notified security and a doctor arrived.
Dec. 1, 2009
Philadelphia Inquirer
Waiting to be seen at hospital, dying Joaquin Rivera was robbed, police say
... According to Philadelphia police, Rivera walked into Aria Health's Frankford Campus, on Frankford Avenue near Harrison Street, about 10:45 p.m. Saturday.
He was alone, and apparently had walked from his nearby home on Duffield Street near Foulkrod, his son said.
Rivera complained of feeling pain in his left arm and abdomen, and was told to sit in the waiting area, said police spokesman Lt. Frank Vanore. [A middle aged man with left arm and abdominal pain told to 'sit in the waiting room?' One wonders who would qualify for sitting under medical observation - ed.]
At some point during the next hour, Rivera, a longtime bilingual counselor at Olney High School, lost consciousness. He inadvertently became a target, Vanore said, to three other people in the waiting room...
[One of the other people] signed up to be seen by a doctor, while his two cohorts sat near Rivera. "At some point, [one of the people] is observed taking the victim's watch and passing it to the other man," Vanore said.
When a witness ran to notify a security guard of the crime and Rivera's condition, the limping man and his female partner fled, Vanore said. Hospital personnel rushed to Rivera's aid, but it was too late.
He was pronounced dead shortly after midnight Sunday. Vanore said police have not yet learned of Rivera's cause of death.
The family said he was believed to have died of a heart attack.
I reiterate, the very last thing in the world ER clinicians need are ill-conceived and ill-implemented electronic health records systems that slow them down.
Instead of attempted censorship and spin control, such concerns should be addressed throughly, impartially and promptly if not immediately.
What could one call the arrogance or devil-may-care mindset in the government and health IT industry that dismisses such concerns so cavalierly, other than "perverse?"
-- SS
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