Guest Blog: I Want to Work in A Hospital

Cortney Davis is the author of four poetry collections, most recently "Leopold's Maneuvers," winner of the 2003 Prairie Schooner Poetry Prize. She is co-editor of two anthologies of poetry and prose by nurses, "Between the Heartbeats" and "Intensive Care," and is the author of two non-fiction books, "I Knew a Woman: the Experience of the Female Body" and "The Heart's Truth: Essays on the Art of Nursing." A nurse practitioner, she is the poetry editor of the literary journal Alimentum: the Literature of Food. Her website is http://www.cortneydavis.com/. The following piece was first published in the Bellevue Literary Review (edited by physician-author Danielle Ofri, who also wrote a guest blog last month).

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I WANT TO WORK IN A HOSPITAL

where it's okay
to climb into bed with patients
and hold them -
pre-op, before they lose
their legs or breasts, or after,
to tell them
they are still whole.

Or post-partum,
when they have just returned
from that strange garden,
or when they are dying,
as if somehow because I stay
they are free to go,
taking with them
the color of my eyes.

I want the daylight
I walk out into
to become the flashlight they carry,
waving it
so God might find them
as we go together
into their long night.

- Cortney Davis

Doctors' conflicts of interest can harm your health - Part 3 of 3

It's football season, so I begin this concluding post on the problem of doctors' conflicts of interest with an admittedly farfetched football-related scenario. Let's say that NFL commissioner Roger Goodell has hired you to make sure that the ceremonial coin used for the Super Bowl coin toss is a fair coin. Your testing procedure consists of flipping the coin some number of times and then tallying the heads and tails. If you flip a fair coin enough times, you're likely to come up with a roughly equal number of heads and tails. But what if you secretly work for a rival ceremonial coin-making company that has an interest in getting the NFL to switch business partners? To make it seem as if the coin isn't fair, you decide to selectively report all of the times it comes up heads, but only 20 percent of the times it comes up tails.

Medical journals are all too familiar with this phenomenon of selective reporting. In the case of research, it occurs when clinical studies funded by commercial interests are more likely to be submitted (and therefore, published) when they show a positive effect of the drug or device, and less likely to do so when the results show no effect. Later on, when a trusted international scientific review group such as the Cochrane Collaboration decides to summarize the results of all studies on this drug or device, publication bias may lead them to draw erroneous conclusions about its true effectiveness.

This is not a small problem in real life care situations. Take depression, for example. The introduction of the drug class of selective serotonin reuptake inhibitors in 1987, beginning with the drug Prozac, in many ways revolutioned the treatment of depression and brought its diagnosis and management into the realm of primary care. Recently, however, serious questions have been raised about the true effectiveness of these drugs, based on the results of a 2008 study published in the online journal PLoS Medicine that analyzed the results of all published and unpublished results submitted to the U.S. Food and Drug Administration and concluded surprisingly that for all but the most severely depressed patients, new antidepressants were no better than placebo pills. This finding doesn't necessarily mean that "the drugs don't work" - since effects were averaged over all patients who took the drugs, some people's depression may have improved, some may have stayed the same, and some may have gotten worse. But it does mean that the benefits of antidepressants have been systematically exaggerated in the medical literature, thanks to selective reporting.

How are medical editors and others fighting back against this now widely recognized problem? In 2004, the International Committee of Medical Journal Editors began requiring that investigators register clinical trials on publicly accessible registries such as Clinicaltrials.gov as a precondition for publication. Earlier this year, this group went a step further by establishing a uniform format for conflict-of-interest disclosures, in the hope of making it more difficult for industry-funded authors to "forget" to inform journals about whom they're working for. Finally, two of the health reform bills pending action in the House and Senate would require all drug and device-makers to file annual reports to the government, to be made freely available online, on payments to physicians and health organizations. Which gives me and all of those who are hoping that health reform passes soon in some form another reason to do so.

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Note: if you missed the first two posts in this mini-series, you can access them here:

Part 1 - Drug Reps and Ghostwriting

Part 2 - Conference Exhibitions and Dishonest Disclosures

Guest Blog: Advice to the Young Physician

Richard Colgan, MD, is a practicing family physician, Associate Professor and Director of Undergraduate Education in the Department of Family and Community Medicine at the University of Maryland School of Medicine. He is a Past President of the Maryland Academy of Family Physicians and serves as editor-in-chief of the Maryland Family Doctor. This guest post is excerpted from the conclusion to his recently published book, Advice to the Young Physician, which he describes as a book "for those who believe that there is an art to medicine, but are not sure where to turn to learn where to find it, beyond the role modeling which their exemplary teachers display. By looking through the history of medicine, the author identifies some of the recurring themes of the art of medicine, as taught or displayed by some of history's greatest physicians." You can preview the book's cover on my Shelfari bookshelf.

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THE HEALER'S PRAYER

God, let me begin each clinical encounter by always putting my patient's needs first. Grant me the strength to not be seduced by the allure of worldly pleasures, so as to be the best healer I can be, as I look to be thorough and careful in practicing my art. Guide me as I practice this sacred vocation. May I have the wisdom to learn from the lessons of my teachers, as I contemplate how to best serve each person who seeks my counsel. Help me to use all of my senses as I strive for excellence in caring for my patients, and to understand that if I cannot help someone, then at a minimum I will do no harm.

Strengthen me to have an inner and outer calmness when faced with the inevitable difficulties that lie before me. Show me how to best educate my patients on how to live longer and healthier lives, while being open to learning from those whom I serve. Show me how to be temperate and modest as I look to assist nature by incorporating proper diet, exercise and my patient's own resources in their overall care. Never let me forget that I am caring for someone who is suffering from a disease, and not taking care of a disease.

May I never forget my duty to practice medicine based upon a conviction of pursuing altruistic beneficence, marked by showing compassion for others as I commit myself to a life of service. May I not abandon, but look to serve the poor and advocate for those who suffer because of disparities in our health care system. Remind me to keep matters between physician and patient confidential and that I am accountable for my actions. May I always show respect and care for myself and my family, while being kind in my everyday interactions with others.

I ask you for humility in knowing the limitations of my art. May I always end each encounter with my patient knowing that I have done my best in assisting you by applying the bandages, while taking comfort in the fact that only power greater than I heals.

- Richard Colgan

Doctors' conflicts of interest can harm your health - Part 2 of 3

For the uninitiated (which aptly described me when I attended my first conference, the American Academy of Family Physicians Scientific Assembly in Orlando in October 2004), medical conferences can be truly awe-inspiring things. I'm not talking about the quality of the lectures, procedural workshops, or other officially sanctioned learning activities. I'm talking about the mammoth Exhibition Hall filled with wall-to-wall twelve-foot tall displays marketing the latest blockbuster drugs, medical devices, and electronic gizmos to physicians. Impeccably attired, physically attractive (and in some cases, stunning) salesmen and saleswomen beckoning conference attendees toward their wares - I remember that the Exhibition Hall that year included several high-end massage chairs, an operational 3-dimensional pregnancy ultrasound, and countless smaller "goodies" such as free pharmaceutical company-emblazoned bags, flash drives, cellular phone headsets, prescription pads, and penlights.

The supposed rationale for providing a separate "exhibit hall" is to cordon off commercial activities from genuine medical education. Conference speakers are generally required to disclose affiliations with industry that might represent conflicts of interest (COI); for example, a speaker who works for Pfizer (maker of the popular cholesterol-lowering drug Lipitor) could hardly be expected to give unbiased recommendations regarding threshold levels for cholesterol treatment. Cynics note that because conference organizers rarely make an effort to verify the accuracy of such disclosures, many speakers fail to disclose disqualifying affiliations. Judging from a recent study published in the New England Journal of Medicine, the cynics are right.

In this study, investigators compared the COI disclosure statements of speakers at the 2008 meeting of the American Academy of Orthopaedic Surgeons with publicly reported information from manufacturers of orthopedic devices. They found that more than 20% of speakers failed to disclose payments related directly to the topic of their presentation, and fewer than half of speakers disclosed payments that were judged to be less related to the presentation topic. More than 80 percent of these payments were greater than $10,000; more than 40 percent were for more than $100,000. (By comparison, before I become a federal employee, the largest honorarium I ever received for giving a talk was $800.) Speakers were statistically more likely to disclose payments greater than $10,000 - but it's not as if $9,999 is exactly chump change!

So what do I conclude from this study? That I should never again trust an orthopedic surgeon who tries to teach me something? That I clearly chose the wrong medical specialty, if financial success was my measuring stick? I prefer to look on the bright side: at least these conflicts of interest, and the myriad ways that unscrupulous physicians and commercial interests try to game the disclosure system, are finally seeing the light of day. As President Reagan said about his policy toward arms control during the waning days of the Cold War, "Trust, but verify." That maxim should be medical education's policy, too.

Public option or no public option: that is not the question

I'm interrupting a series of posts on conflicts of interest in medicine in order to say something about health care reform, which is approaching a critical point as Senate and House negotiators try to combine the various bills that have emerged from different committees. One widely reported point of contention is whether or not the final bill should include a so-called "public option," a government-sponsored insurance product that its supporters feel would provide needed competition with private insurers and make the cost of insurance more affordable. Opponents believe that the public option would end up driving private insurers out of business and end up being the only option. While I think that this idea is hardly revolutionary - Medicare, after all, is a "public option" for senior citizens that's been around for 45 years - I also believe that it's a distracting side issue to what our health care system really needs: comprehensive cost control.

Public option or no public option, health care premiums are on a course to consume the entire average income of an American household by 2025 - a mere 16 years from now, when my oldest child will be entering college. While you might think it's okay in an abstract sense to spend a million or more dollars to save one life (especially if it's your life or that of someone you love), even the wealthiest nation on the planet can't afford to pay for every possible intervention that promises a tiny bit of improved health or longer life for somebody. We need to make choices, as a society, about our collective health priorities.

Other measures that have the potential to address skyrocketing costs (but are being underemphasized or completely ignored in the focus on the "public option") include:

1) Flat-fee primary care combined with insurance for catastrophic medical events. Your car insurance doesn't pay for oil changes, your home or rental insurance doesn't pay for furniture, and your health insurance shouldn't pay for basic primary care visits.

2) No-fault compensation programs for all but the most egregious medical errors (e.g., if your surgeon cuts off the wrong leg, or your internist prescribes toxic drugs for conditions you don't have, you would still have the right to sue).

3) Reforming medical education and continuing medical education to provide safeguards against conflicting interests (e.g. pharmaceutical and medical device companies) that lead to inappropriate or potentially unsafe prescribing practices. More on this in future posts, but I think we have a long way to go.

4) Let the insurance "bureaucrats" make informed decisions based on cost-effectiveness of medical interventions. I know that this is an unpopular position. I'm not talking about setting up death panels, or even dialysis panels, which actually existed in the past. And I'm not saying that insurance shouldn't cover every medication or surgery with a high price tag. What I'm advocating is that we take a hard look at what we're getting for the billions we spend on health care, the way you make decisions about how to spend your own limited budget. After all, drug companies still do business with the United Kingdom, even though their National Institute for Health and Clinical Excellence (NICE) applies strict cost-effectiveness criteria to determine whether drugs are worth paying for. If a drug doesn't meet NICE's standard, the company will often lower the cost of the drug so that it does. Not so in the U.S. - which is why we generally pay the highest prices.

Guest Blog: Medicine in Translation

Since I started this blog a few months ago, I've supplied nearly all of the content myself, occasionally quoting others in posts but also adding reflections of my own. However, I always planned to eventually invite guest bloggers with other "common sense" perspectives on health and health care to add to the variety and breadth of content that you will find on this blog, and this is the first of (hopefully) many guest postings.

A practicing internist and Assistant Professor of Medicine at my alma mater (NYU School of Medicine), Danielle Ofri, MD, PhD is the author of three books about her medical experiences and also serves as editor-in-chief of the Bellevue Literary Review. The following piece is excerpted from a blog that was originally posted on the website of Psychology Today.

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MEDICINE IN TRANSLATION

If asked what a doctor does, most people would probably come up with the standard description of diagnosing and treating disease, usually while wearing an ill-fitting white coat. Before I entered practice, even during my medical training, that probably would have been my answer too. But my years in the trenches of real medicine have altered that definition greatly. I do spend time doing the things I learned in medical school like diagnosing disease and writing prescriptions, but that turns out to be only a part of the job, often a very small part. ...

But when I think about what might be the overriding job description, the one that not only incorporates the above but also extends to the more existential aspects of medicine, I see the doctor as a translator. For most people, medicine is a foreign country, with its own language, customs, and mores. My patients are immigrants to this country, and many feel very disoriented. My job, as their physician, is to translate this alien world for them, to help them acclimatize and hopefully thrive. ...

Being a translator can often be burdensome. It is not enough, as a doctor, to assemble the clinical details, deduce a diagnosis, compose a treatment plan. You also have to be sure the patient understands it all—and that can be an infinitely harder and longer process. But there are also many joys to being a translator. I once had a new patient who suffered from both osteoporosis and osteoarthritis. Her previous doctor had worked out a meticulous treatment plan, including hand-written charts of how and when to take each pill. Yet the patient was entirely confused about her medications.

After a complicated conversation with many false starts, I finally realized that the patient thought that osteoporosis and osteoarthritis were one and the same thing. The pills for each condition were dumped into a communal pill bottle and taken in a random manner. My “diagnosis” was that this patient did not have a full understanding of the language of medicine and that these terms had never been fully translated for her. We spent a long time going over the difference between osteoporosis and osteoarthritis. It wasn’t easy, but by the end of our visit she had a basic comprehension that these were two different diseases and the medicines were treating entirely different things. This patient had many more serious medical conditions to contend with, but she seemed delighted at this small victory, that she finally understood these diseases, that she finally “owned” this aspect of her health.

There was, of course, no place on the insurance form for this sort of effort. The insurance company would never pay my hospital for the painstaking “translation” work that is so critical to good health. But that’s the reality. Luckily there is the patient’s happiness and hopefully improved health that is the real payback.

-Danielle Ofri