Category: health care

Health Care: Why Problems Have Piled Up Unsolved

Seth RobertsLeave a comment

In an amusing comment on health care, Jonathan Rauch (via Marginal Revolution) imagines an airline system as archaic and inefficient as our health care system.

“Cynthia, I have filled out my travel history half a dozen times already this year. I’ve told six different airlines that I flew to Detroit twice and Houston once. Every time I fly, I answer the same battery of questions. At least a dozen airlines have my travel history. Why don’t you get it from them?”

“We have no way we could do that. We do not have access to other companies’ records, and our personnel have our own system for collecting travel history.”

The health care system, in other words, is full of problems that have built up unsolved. Solutions exist — the problems are not impossible — but haven’t been implemented. Jane Jacobs’s great point, in The Economy of Cities, is that this is what happens when those who benefit from the status quo have too much power relative to those who benefit from change. The stagnation in American health care is profound. It isn’t solved by universal health insurance. There would remain the horrible dependence on expensive dangerous drugs that don’t work very well (e.g., antidepressants, Accutane) and the complete lack of interest in prevention. The underlying problem, the source of many visible problems, is too little innovation.

Anti-Depressants Associated With Birth Defects

Seth Roberts6 Comments

In the latest BMJ, a group of epidemiologists reports that SSRI’s (selective serotonin reuptake inhibitors, a commonly-prescribed type of anti-depressant) are associated with a certain type of birth defect when the mom takes the drug early in pregnancy:

There is an increased prevalence of septal heart defects among children whose mothers were prescribed an SSRI in early pregnancy,

We have a health care system built on dangerous drugs — and those drugs are poorly tested for safety. It isn’t in the drug companies’ interest to do so, of course. In this particular case, I wonder if the drugs were safety-tested on pregnant rats and if so what happened.

The Ethical Stupidity of Med School Professors: Plagiarism Very Very Bad, Ghostwriting Okay

Seth Roberts2 Comments

Do medical school professors live in a different ethical world than the rest of us? Apparently. A friend of mine just entered grad school at Tsinghua. She was required to attend four different lectures about how academic dishonesty is wrong. (The last one, she said, was good; the speaker told a lot of stories.) China has a huge plagiarism problem, sure, but at least they say that plagiarism is wrong.

Whereas medical school professors haven’t managed to grasp that ghostwriting is plagiarism (taking someone’s words and ideas as yours without acknowledgment). And it happens all the time. NYU med school Professor Lila Nachtigall, as I’ve noted, considered the deed so minor she forgot that she’d done it. Apparently using a different word confuses them. A recent article in Nature reveals the befuddlement of the entire medical establishment about this. We’re not sure what to do about it, journal editors say. As Tony Soprano’s mom would say: Poor you.

What’s so nauseating about this is that ghostwriting is certainly worse than the garden-variety plagiarism that American undergraduates and the odd Harvard professor engage in. (And at least they are embarrassed, unlike Nachtigall, when caught.) Garden-variety plagiarism is merely self-serving; you save time, get a higher grade. Whereas drug-company ghostwriting makes drugs appear better than they are. Which harms millions of sick people.

Although American universities publicly condemn plagiarism and other types of cheating, in practice they allow them. (Believe me, I know. When I tried to stop cheating in my Intro Psych class at Berkeley, the chairman of my department told me, “We’re not in that business.”) And the student cheaters — having been told by university blind-eye-turning that cheating is okay — grow up to be med school professors who do horrible things routinely. That’s my theory.

Thanks to Dave Lull.

Perverse Incentives in Medicine

Seth Roberts4 Comments

In the comments, Timothy Beneke wrote:

My experience with a friend who had unexplained stomach pain was instructive. She saw 6 “experts,” 3 who worked for fixed salaries at institutions (Kaiser, Stanford, etc.) and 3 who were in the marketplace getting paid based on what they brought in each year. The three who were on fixed salaries were professionally cordial, and openly admitted that they could not say with confidence what was causing her pain. The three who were not on fixed salaries were very touchy-feely and charming and spoke with complete confidence about the cause.

Wow. This reminds me of my surgeon, Eileen Consorti, telling me that the operation she recommended would help me, that there was evidence for this, and then — when I couldn’t find any evidence — telling me she would find it and never doing so. She would have gotten thousands of dollars for that operation. It also reminds me of my dermatologist prescribing a medicine that didn’t work and, until I did an experiment that showed it didn’t work, having no idea it didn’t work. He got paid in any case.

Does H. Pylori Cause Stomach Ulcers?

Seth Roberts17 Comments

In a previous post I said that the Nobel Prize to Barry Marshall and Robin Warren — for supposedly showing that H. pylori causes stomach ulcers — was a mistake. Because half the world has the bug in their stomach, and only a tiny fraction of them get ulcers, the true cause of those ulcers lies elsewhere, probably with an impaired immune system. Marshall famously drank a flask full of H. pylori and didn’t get an ulcer, yet took this to support his theory. A classic example of self-deception.

Recently Lam Shiu-kum, a former dean of medicine at the University of Hong Kong, was convicted of a giant fraud. He siphoning millions of dollars of medical fees into his own pocket:

Dr Lam, 66, brought a 39 year association with the university, his alma mater, to an abrupt end in March 2007 when the investigation into billing irregularities began. He is a distinguished gastroenterologist who conducted pioneering research into chemoprevention of stomach cancer through the eradication of Helicobacter pylori. His team also conducted the first double blind, controlled study into curing peptic ulcers by H pylori eradication.

I suppose this supports my case. As far as I know, almost all doctors and med school professors believe H. pylori causes stomach ulcers; I have never heard dissent about this.

More. What goes unsaid, and maybe unnoticed, in the debate about health care, is that it is hard to have decent health care (that is, decent health) when those in charge don’t know what they’re doing. The stomach-ulcer-etiology problem is a small example of a big thing. In case I’m not being blunt enough, let me be even more blunt: This example illustrates that the average doctor, the average med school professor, and at least two Nobel-Prize-winning med school professors (not to mention those who award Nobel Prizes) have a lot of room for improvement in their interpretation of simple facts. My previous example of the infectious-disease expert (a med school professor) who overlooked the immune system is another example of vast room for improvement. It’s hard to get good health care from people whose understanding of health is terribly incomplete yet don’t realize this.

Med School Profs As Drug Company Lackeys

Seth Roberts2 Comments

What a cesspool. I mean the dirty work medical school professors do for drug companies. The profs make the drugs appear better than they are. Let me count the ways:

1. I blogged earlier about Duke professor Charles “Disgraced” Nemeroff taking huge amounts of money — which he then failed to disclose — to encourage doctors to give dangerous poorly-tested drugs to children. Nemeroff is (or at least was) considered a top psychiatry professor!

2. When the practice of drug companies ghostwriting articles for professors was revealed, New York University professor of obstetrics and gynecology Lila Nachtigall, the nominal author of a ghostwritten article, told a reporter (contrary to evidence supplied by Wyeth) that she had written all of her 1000 articles and 3 books. And she said this:

If they [Wyeth] came up with the idea or gave me an outline or something, I don’t remember that at all. It kind of makes me laugh that with what goes on in the Senate, the senator’s worried that something’s ghostwritten. I mean, give me a break.

It made her laugh. Yes, why should anyone care about the dishonesty of med school professors? What cave has Nachtigall been living in?

3. About half of published clinical trials were not properly registered, a new study showed (abstract here). A large fraction of these studies were drug-company-funded, I’m sure. (More than half were “industry” funded.) And the authors were often med school professors. Failure to register your study means you can distort the results to make them closer to the outcome you prefer by changing the “endpoint” (the dimension you use to measure whether the drug worked). Even among the registered studies, one-third used a different endpoint than the registration said. It is hard to avoid the conclusion that a lot of misleading results — making drugs look better than they really are — are being published. The level of cheating appears to be incredibly high — perhaps more than half of published papers.