Category: health care

“Must Prescribe Antibiotic, Must Prescribe Antibiotic … “

Seth Roberts7 Comments

Jim Purdy, who often comments here, told me the following story:

Recently, a health professional ordered two tests for infectious bacteria in a small foot wound (I think the tests were for gram negative or gram positive bacteria, or maybe aerobic and anaerobic). Even before the bacterial tests came back, she wanted me to start on antibiotics. Instead I waited. The first results showed a very low level of a harmless bacteria, so I was glad I hadn’t started antibiotics.

When I saw her again, a few weeks later, I asked about the second set of bacterial tests. She claimed that there had only been one test, but I insisted she check again. She left, and came back a few minutes later and said that she had found the second results, and there had been no bacteria.

Surely the health professional knew that antibiotics are overprescribed, that antibiotic resistant bacteria have become a serious problem, that antibiotics are dangerous, and yet she not only failed give the wound a chance to heal on its own, she failed to allow test results to guide what she did. No wonder she forgot about the second test.

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Seth Roberts7 Comments

Thanks to Paul Nash.

Hidden Side Effects of Statins and How Easily You Can Uncover Them

Seth Roberts6 Comments

In 2009, a British rheumatologist named Andrew Banji wrote about the hidden side effects of statins in the Daily Mail:

I discovered the link between statins and rheumatic side-effects quite by chance. My attack of tendon inflammation occurred at the front of my shin – a highly unusual place for tenosynovitis – so I decided to do some research into what could have triggered this. I was amazed to discover the only other related case was linked to a patient on statins.

Following a high cholesterol-reading of 9.2 a couple of months before, I’d been put on the drug. Intrigued by the connection, I decided to stop taking my statin to see what happened. Within a couple of weeks, the pain had gone.

I went back to my GP and, over successive months, tried various statins, including rosuvastatin which is one that is often prescribed.

Each form of the drug caused terrible problems, including night cramp, muscle pain, severe muscle disorders known as myopathy and general fatigue. In fact, I became so tired I couldn’t lift anything when I was gardening or even walk the half-mile from my home to the center of town.

Yet whenever I halted the medication, my symptoms disappeared within a few weeks. . . .

I began to realize many of my patients with musculoskeletal conditions such as polymyalgia – pain, stiffness, and tenderness in the muscles – were on statins. When I advised them to stop taking their medication, their problems went away.\

By 2009, statins were perhaps the most heavily prescribed drugs ever, making tens of billions of dollars for drug companies. Yet this story shows that at that point a doctor who was taking statins was not yet aware of major common side effects. How convenient for drug companies. The story also shows that patients with a variety of muscular problems had to be told by a doctor to stop taking their statins to find out if the statins were causing the problem. That should have been common sense. On a more positive note, this story shows how easily some health problems can be fixed (“when I advised them to stop taking their medicaiton, their problems went away”).

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Seth Roberts4 Comments

Thanks to Bryan Castañeda.

Extremely Disappointing Facts About Doctors

Seth Roberts11 Comments

The gist of Unaccountable: What Hospitals Won’t Tell You — and How Transparency Can Revolutionize Health Care (copy sent me by publisher) by Mart Makary, a med school professor at Johns Hopkins, is that doctors have failed to regulate themselves. Nobody else regulates them, so they are unaccountable. In many ways, Makary shows, bad behavior (e.g., unnecessary treatment, understating the risks of treatment) is common. Hospitals hide how bad things are. Makary mostly discusses surgeons — he’s a surgeon — but gives plenty of reasons to think other specialties are no better.

The book is one horror story after another. At one point, Makary quit medical school. He was disgusted and appalled by seeing doctors — his teachers — push an old woman to consent to an operation she didn’t want and didn’t need. She refused, again and again, but the doctors kept pushing. Makary objected. He was ignored. Finally she agreed. The operation killed her.

I know Peter Attia as a co-founder, with Gary Taubes, of the recently formed Nutritional Science Initiative. Makary met him when Attia did a surgery residency at John Hopkins Hospital. Attia had seen a doctor about back pain and had been told he needed surgery. They operated on the wrong side, causing damage that prevents Attia, an excellent athlete, from playing most sports. Eventually Attia left medicine. He felt “modern medicine was too frequently dishonest with patients, at times understating risks and overtreating patients as a matter of reflex” — “as a matter of reflex” meaning “as a matter of course”, i.e., usually. And Johns Hopkins Hospital is one of the better hospitals in America. “Almost everyone I talk to has a story about a friend or a family member who was hurt, disfigured, or killed by a medical mistake,” writes Makary. He has six such stories, including his grandfather and his brother. His grandfather died from unnecessary surgery.

The “when-you’re-a-hammer problem” says Makary, “plagues modern medicine at every level.” He witnessed a case conference where a young otherwise-healthy patient had a small liver tumor. “The transplant surgeons [more than one] in the audience recommended a liver transplant. I was flabbergasted. Why on earth would any doctor recommend a transplant?” Makary asked around. He discovered there was nothing unusual about the transplant surgeons in the audience. He called a friend who was one of the few surgeons trained in both cancer treatment and transplants. His friend said “there was a battle for turf taking place nationwide between transplant surgeons and cancer surgeons. Both claim to be liver experts.”

Makary tells about trying to obtain informed consent for a surgery when he was an intern. He didn’t know much about the surgery. The patient didn’t agree. “It was well-known among interns that if an attending senior surgeon found out that a patient refused surgery close to surgery date, duck for cover. Mine would surely be livid.” Makary spoke to an upper resident. He couldn’t get approval. They went to the chief resident. He got approval. Congratulations all around amongst the doctors, “glad that the wrath of the attending surgeon would be averted.”

Supposedly state medical boards oversee doctors. Makary devotes part of a chapter to describing how they don’t. He asked state medical boards why they don’t search a national database before issuing a medical license. “My favorite excuse was that they could not afford the four-dollar-per-doctor fee.”

In 1978, the Shah of Iran needed an operation. The United States government set him up with a Texan named Michael DeBakey, “considered by many to be the best surgeon in the world.” During the surgery, DeBakey failed to take “a simple standard safety measure.” Due to this failure, the Shah developed a serious complication, became very sick, and died. The Shah and the United States government had failed to realize — and, more important, none of the experts they consulted had told them (I assume) — is that DeBakey was a famous heart surgeon. The Shah’s operation involved his spleen. DeBakey knew little about such operations and had done almost none — but (I assume) didn’t point this out.

A survey done at many hospitals asks employees if they “feel comfortable speaking up when [they] sense a patient safety concern.” At the median hospital, the percentage is about 70%. In the Milgram experiment (where subjects are ordered to give painful shocks), when audiences were asked by Milgram to predict what they would do in that situation almost all said they wouldn’t give the shocks. In fact, most people did give the shocks — indicating that people vastly overestimated their likelihood of resistance and speaking up. So 70% is likely an overestimate. (A study of nurses found that about 95% of them broke safety rules when ordered to do so. Roughly all of them had said they would never do such a thing.) Since talk is cheap, why is the median percentage as low as 70%? No doubt many respondents had seen themselves fail to speak up.

These aren’t the worst stories, these are average, I just opened the book here and there. There are dozens more. No previous book has spelled out so clearly the depth and width of doctor misbehavior, especially how common it is, and the failure of those supposedly responsible, such as hospital administrators and state boards, to do anything about it.

Title from 12 extremely disappointing facts about popular music.

 

 

Drug Companies Hide Unfavorable Evidence

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Ben Goldacre, a British epidemiologist and newspaper columnist (“Bad Science”), who used to attack homeopathy (trivial), has now written about something important: drug companies hide vast amounts of unfavorable evidence. I already knew this but many details were new to me.

I liked some of the comments:

We live in France and used a traditional GP for five years. Every time one of us went [to see him] he or she would come back with prescriptions for three or four medicines. Over that time he prescribed our family of five an estimated 60-80 medicines. We only ever took one, and everyone always got better without using these medicines. . . .This same GP also would refer us to thoroughly incompetent specialists. A few years ago I had a frozen shoulder. I went to see a ‘specialist’ who yanked my arm and shoulder about, clearly having no idea how an arm actually moves, and he then suggested operating. . . . Instead I looked on the Internet for info and found some exercises I could do and also underwent some Bowen technique treatment. A year later I was fine.

As a business consultant, I was approached many many years ago by a company who wanted help to set up an independent research institute evaluating farm pesticides. They’d found the doses prescribed for actual application were many times the amount actually needed (for obvious profit reasons), sometimes efficacy was in doubt, and loads of hideous ecological side effects were buried.

Speaking of “many times the amount actually needed”, I attended a talk about lighting standards in office buildings in which the speaker said the standards were too high (e.g., desks were better lit than necessary). His explanation was that the more lighting there is, the more air conditioning you need. The more air conditioning, the more cost, and architects are paid a fixed percentage of the cost. One of his slides showed that someone in the industry wrote down this rationale.

My GP often says the pharmaceutical industry wants to see everybody on prescription. He does prescribe tests, a lot of them, but drugs very rarely, and most of his recommendations are targeted at patients’ lifestyle: diet, exercise, work, relationships. When he does prescribe drugs, if it is an antibiotic or an antifungal, you have to come back after 1 week so that he can see if the treatment has worked/is working. If you need longer term treatment, for example physiotherapy and painkillers for back pains, or if you have a long term condition such as diabetes, he insists on seeing every month, to check that you are treatment compliant. . . . I have to thank him for a lot. Until fairly recently, I was stuck in a really unhealthy work environment, and could not find another job. I had done a Psychology course which had nothing but praise about antidepressants, so I asked him if he would prescribe me one of the newest tricyclic ones. He was extremely angry, told me I needed a new job, not tablets, and that if I ever got that drug elsewhere and he found out, he did not want to see me again (he would probably have found a blood test to check up I was ‘clean’). So I did not go down the tablet route, and he was right: all I needed was to change job.

Two or three years ago, I was working in Germany and went to see a German doctor. He looked at the list of daily medications my British doctor had prescribed (5 different drugs), ostensibly to help me survive middle age. He looked shocked, and told me that the British medical profession is dominated by the pharmaceutical industry, and he advised I stop taking three of the drugs prescribed. Now, having come back to the UK, every time I visit my GP, I am bullied once again to take this or that. If I try to resist, I receive very patronizing lectures about this or that risk.

Thirty years of bi-polar disorder taking virtually every possible anti-depressant over time, and at times when hospitalized, forced to take them under the duress of threatened sectioning under the Mental Health Act. Throughout those years I told the psychiatrists that the drugs didn’t work beyond an initial “placebo effect” lasting about 2 weeks, and that the side effects were often awful. Now it seems I may have been right all along. . . . Big Pharma, [you] made a difficult life a lot worse.

Maybe Goldacre will someday grasp that “evidence-based medicine”, which he often praises, also hides a vast amount of unfavorable evidence.

Assorted Links

Seth Roberts5 Comments
  • American-Afghan detainee dispute. “The conflict over the Americans’ insistence that some detainees should continue to be held without charge had [become] public.” Via Ron Unz.
  • Hydrogen therapy
  • How to improve doctor performance. “Without telling his partners, Dr. Rex began reviewing videotapes of their [colonoscopy] procedures, measuring the time and assigning a quality score. After assessing 100 procedures, he announced to his partners that he would be timing and scoring the videos of their future procedures (even though he had already been doing this). Overnight, things changed radically. The average length of the procedures increased by 50%, and the quality scores by 30%. The doctors performed better when they knew someone was checking their work.”
  • Pistachio miso and other unusual fermented foods.

Thanks to Tyler Cowen, Alex Chernavsky, Patrick Vlaskovits, Chuck Currie and Bryan Castañeda.

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Seth Roberts3 Comments

Thanks to Bryan Castañeda and Alex Chernavsky.

Two Recent Health Care Experiences

Seth Roberts5 Comments

A friend and his pregnant wife, who live in Los Angeles and are not poor, recently had an ultrasound. (Probability of the ultrasound machine not operating properly and producing more than the stated amounts of energy: unknown, but a recent Stockholm survey found one-third of the machines malfunctioned.) Part of the office visit was a post-ultrasound visit with a genetic counselor. The genetic counselor walked them through illnesses in their family tree and assessed their coming baby with very low risk for Trisomy 21 (Down syndrome), Trisomy 13 and Trisomy 18.

At the end of their session, they were offered other services they might opt to buy to better know their chances of knowing about any fetal problems: Chorionic villus sampling and amniocentesis as well as a maternal blood test. None were really necessary.

My friend was irked that the CVS and the amniocentesis were called “low risk”. Maybe you know that a large fraction of doctors claim to practice “evidence-based medicine”. You might think this means they pay attention to all evidence. In fact, evidence-based medicine practitioners subscribe to a method of ranking evidence and ignore evidence that is not highly ranked. Most evidence of harm is not highly ranked, so evidence-based medicine practitioners ignore it. This makes every treatment appear less dangerous — misleadingly so. When a doctor says “low risk,” the truth, because the practice of ignoring evidence of harm is widespread (and drug companies routinely underestimate risk), is closer to “unknown risk”. The combination of (a) understating risk, (b) selling unnecessary stuff of which you have understated the risk, and (c) doing this with pregnant women, whose fetuses are especially vulnerable, is highly unattractive.

Also recently, the friend’s toddler had some sort of infection. The toddler had a bit of a fever, but was generally in good spirits, and played with his toys (i.e., was not bed-ridden or in severe distress). After a few days, his wife took the child to their pediatrician to make sure everything was fine.

“Don’t just accept the antibiotics,” my friend told his wife. “Push back a little. See what happens.”

The pediatrician did prescribe antibiotics. When my friend’s wife said she preferred not to give the child antibiotics if it were not really necessary, the doctor (female) said, “You’re right. I actually don’t know if the infection is bacterial or viral.”

Both stories — which obviously reflect common practice — illustrate how the healthcare system is biased toward treatment, including treatments that are unnecessary and dangerous. The good news is that this bias is clearer than ever before.