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The Horrors of Hepatitis Research | Carl Elliott | The New York Review of Books
The names of physicians once celebrated for ethically questionable research are finally being removed from medical school buildings, awards, and lectureships. In 2008 the University of Pittsburgh discontinued a lecture series named for John Cutler, one of the principal researchers in the Tuskegee syphilis study from 1932 to 1972 and the Guatemala syphilis study of the mid-1940s. Ten years later it removed the name of Thomas Parran, another Tuskegee researcher, from a building in its School of Public Health. In 2021 the University of Pennsylvania took similar measures with Albert Kligman, the dermatologist responsible for decades of barbarous experiments at Holmesburg Prison in Philadelphia, renaming the Kligman Professorship and phasing out a lectureship named after him. A movement is now underway at the University of Cincinnati to honor those who died in the Pentagon-funded radiation experiments conducted there in the 1960s and early 1970s by Eugene Saenger, a radiologist honored by the university with the Daniel Drake Medal, the College of Medicine’s highest honor.
Of all the infamous research scandals that emerged in the 1960s and 1970s, however, none is more contested than the one over the Willowbrook hepatitis study. Between 1956 and 1972 a team of researchers from New York University led (beginning in 1958) by Saul Krugman deliberately infected institutionalized, mentally disabled children at the Willowbrook State School on Staten Island with the hepatitis virus. Along with the Tuskegee syphilis study and the 1963 cancer study at the Jewish Chronic Disease Hospital in Brooklyn, Willowbrook is part of what the historian Susan Reverby calls the bioethics “holy trinity” of research horror stories. Yet Krugman was widely celebrated among his peers. The year the study ended, he was elected president of the American Pediatric Society. Later he was honored with some of medicine’s most prestigious prizes, including the Robert Koch Gold Medal (1978), the John Howland Award (1981), and the Mary Woodard Lasker Public Service Award (1983). Even today Krugman has defenders. The Oxford Textbook of Clinical Research Ethics argues that misguided criticism of the Willowbrook study has “cast a restrictive ethical pall” over pediatric research.
A moratorium on strong recommendations is needed | The BMJ
Medicine is addicted to so-called hopium, an unwarranted confidence in the value of its tests and treatments. Clinicians overestimate their value,1 while experts on guideline panels make strong recommendations about care backed by untrustworthy evidence.2 Rigorous guideline methods can highlight this problem, but they are far from a perfect antidote—it is time for a moratorium on strong recommendations.
In a linked paper (doi:10.1136/BMJ-2021-066045),3 Yao and colleagues report that almost half (1246 of 2528) of the recommendations issued by the leading American cardiology and oncology professional societies were strong, “just do it” recommendations.4 About a quarter (354 of these were based on low certainty evidence. Compared to a consensus process, an evidence based guideline process reduced the risk of issuing such inappropriately strong recommendations, but not completely: the evidence based approach produced about a third (105 of 354) of the inappropriately strong recommendations in this study. Most of them simply conveyed the panels’ overconfidence in the benefit of following their recommendation.
Cognitive errors in medicine: The common errors - First10EM
This list represents the cognitive biases that are most often described in the context of medical errors, but there are many other cognitive biases that affect our daily lives. For example, I particularly like the IKEA effect: our tendency to disproportionately value objects we had a hand in putting together, regardless of end result.
The medium is the medicine: a novel history
Before 1900, “many people thought of medicine as an inferior profession, or at least a career with inferior prospects,” according to Starr. The average American doctor earned less than “an ordinary mechanic,” riding miles each day on horseback to see just a handful of patients.
The status of doctors changed dramatically in the first decade of the 20th century, when cars, telephones and urbanization made practicing medicine more efficient and therefore more lucrative.
Yale study: Doctors give electronic health records an ‘F’ | YaleNews
But the rapid rollout of EHRs following the Health Information Technology for Economic and Clinical Health Act of 2009, which pumped $27 billion of federal incentives into the adoption of EHRs in the U.S., forced doctors to adapt quickly to often complex systems, leading to increasing frustration.
The study notes that physicians spend one to two hours on EHRs and other deskwork for every hour spent with patients, and an additional one to two hours daily of personal time on EHR-related activities.
“As recently as 10 years ago, physicians were still scribbling notes,” Melnick said. “Now, there’s a ton of structured data entry, which means that physicians have to check a lot of boxes. Often this structured data does very little to improve care; instead, it’s used for billing. And looking for communication from another doctor or a specific test result in a patient’s chart can be like trying to find a needle in a haystack. The boxes may have been checked, but the patient’s story and information have been lost in the process.”
Melnick’s study zeroed in on the effect of EHRs in physician burnout.
Data standards may be wonky, but they will transform health care - STAT
The proposed rule creates a highly promising road map toward the easy exchange of electronic health information that exemplifies a minimalist regulatory approach for creating the standardization and uniformity needed to spark an apps marketplace. It would also create economic and commercial guardrails to promote a level playing field between electronic health record vendors and app developers. These regulations are an essential ingredient for a burgeoning apps market.
All six individuals who previously served as the national coordinator of health information technology have endorsed the rule. It has sparked robust conversation: During the public comment period on the proposed rule, nearly 2,000 comments were submitted about interoperability and information blocking. As might be expected, there is pushback from the electronic health record industry on timelines and price controls.
The proposed timeline — two years of development— has proven highly realistic, given the successful implementation of SMART on FHIR among the major brands of electronic health records by the Argonaut working group in just one year, and the work of the CARIN alliance to help connect patient apps to the SMART API.
Persistence of Contradicted Claims in the Literature | Dementia and Cognitive Impairment | JAMA | JAMA Network
For the 2 vitamin E epidemiological studies, even in 2005, 50% of citing articles remained favorable. A favorable stance was independently less likely in more recent articles, specifically in articles that also cited the HOPE trial (odds ratio for 2001, 0.05 [95% confidence interval, 0.01-0.19; P < .001] and the odds ratio for 2005, 0.06 [95% confidence interval, 0.02-0.24; P < .001], as compared with 1997), and in general/internal medicine vs specialty journals. Among articles citing the HOPE trial in 2005, 41.4% were unfavorable. In 2006, 62.5% of articles referencing the highly cited article that had proposed beta-carotene and 61.7% of those referencing the highly cited article on estrogen effectiveness were still favorable; 100% and 96%, respectively, of the citations appeared in specialty journals; and citations were significantly less favorable (P = .001 and P = .009, respectively) when the major contradicting trials were also mentioned. Counterarguments defending vitamin E or estrogen included diverse selection and information biases and genuine differences across studies in participants, interventions, cointerventions, and outcomes. Favorable citations to beta-carotene, long after evidence contradicted its effectiveness, did not consider the contradicting evidence.
My health: Consumers empowered by sharing medical 'selfies' -- ScienceDaily
"The first study asked a range of people what they think about the role of this kind of consumer-generated data, and the second study was to see how people engage with it, as there can be a difference between what people say they will do and what they will do," she said.
"But these two studies largely confirmed each other. Consumers feel this data is valuable, it helps them have a sense of autonomy in their care, improves their view of the service they are being provided, and it enhances the relationship between doctor and patient because there is a sense of mutual respect and communication.
New doctors' DNA ages six times faster than normal in first year: Long work hours of intern year associated with accelerated shortening of telomere regions of chromosomes -- ScienceDaily
Published online in the journal Biological Psychiatry, the new study is the first to measure telomere length before and after individuals faced a common prolonged intense experience. It involved 250 interns from around the country who volunteered for the Intern Health Study, based at the University of Michigan, and a comparison group of college students from U-M.
"Research has implicated telomeres as an indicator of aging and disease risk, but these longitudinal findings advance the possibility that telomere length can serve as a biomarker that tracks effects of stress, and helps us understand how stress gets 'under the skin' and increases our risk for disease," says Srijan Sen, M.D., Ph.D., the U-M neuroscientist and psychiatrist who is the study's senior author and heads the Intern Health Study.
He adds, "It will be important to study how telomere changes play out in larger groups of medical trainees, and in other groups of people subjected to specific prolonged stresses such as military training, graduate studies in the sciences and law, working for startup companies, or pregnancy and the first months of parenting."
The Lab Coat Is on the Hook in the Fight Against Germs - The New York Times
This change took place in part because doctors wanted to spruce up their dubious reputation. Until the advent of such medical reformers as Abraham Flexner and Sir William Osler about 100 years ago, medical training in the United States was notoriously lax. Lectures, not clinical experience, were the norm. It was the age of horse sense and the quack.
So to more closely associate themselves in the public mind with sound science, physicians began donning the lab coats that were being worn by chemists and other laboratory types. These coats were generally beige. But white soon became the standard.
“Our notion since the 1880s, when the germ theory of disease began to take hold, is that microbes hide in dark, dirty places, and that white stands for purity, both material and moral,” said Guenter Risse, a physician and author of “Mending Bodies, Saving Souls: A History of Hospitals” (Oxford, 1999). “Wearing white coats was a symbol that you were clean.”
Inactive ingredients in pills and capsules may cause allergic, adverse reactions: Majority of oral medications available to consumers contain ingredients that can affect sensitive individuals -- ScienceDaily
A new study led by a team of investigators from Brigham and Women's Hospital and Massachusetts Institute of Technology has found that the vast majority of the most frequently prescribed medications in the U.S. contain at least one ingredient capable of causing an adverse reaction. Known as inactive ingredients, these components are added to improve the taste, shelf-life, absorption and other characteristics of a pill, but the authors found that more than 90 percent of all oral medications tested contained at least one ingredient that can cause allergic or gastrointestinal symptoms in sensitive individuals. Such ingredients include lactose, peanut oil, gluten and chemical dyes.
Machine learning could eliminate unnecessary treatments for children with arthritis: An algorithm predicted disease outcome in children suffering from arthritis, helping doctors better tailor treatment -- ScienceDaily
"We had to use machine learning just to detect these seven patterns of disease in the first place," says Morris, whose team modified the technique known as multilayer non-negative matrix factorization. "And then we realized there are some children who do not fall into any of the patterns and they have a very bad version of the disease. Now we understand the disease much better we can group children into these different categories to predict response to treatment, how fast do they go into remission and whether or not we can tell they are in remission and remove therapy."
What if the Placebo Effect Isn’t a Trick? - The New York Times
The findings of the I.B.S. study were in keeping with a hypothesis Kaptchuk had formed over the years: that the placebo effect is a biological response to an act of caring; that somehow the encounter itself calls forth healing and that the more intense and focused it is, the more healing it evokes. He elaborated on this idea in a comparative study of conventional medicine, acupuncture and Navajo “chantway rituals,” in which healers lead storytelling ceremonies for the sick. He argued that all three approaches unfold in a space set aside for the purpose and proceed as if according to a script, with prescribed roles for every participant. Each modality, in other words, is its own kind of ritual, and Kaptchuk suggested that the ritual itself is part of what makes the procedure effective, as if the combined experiences of the healer and the patient, reinforced by the special-but-familiar surroundings, evoke a healing response that operates independently of the treatment’s specifics. “Rituals trigger specific neurobiological pathways that specifically modulate bodily sensations, symptoms and emotions,” he wrote. “It seems that if the mind can be persuaded, the body can sometimes act accordingly.”
Everything You Know About Obesity Is Wrong - The Huffington Post
the decisive factor in obesity care was not the diet patients went on, but how much attention and support they received while they were on it. Participants who got more than 12 sessions with a dietician saw significant reductions in their rates of prediabetes and cardiovascular risk. Those who got less personalized care showed almost no improvement at all.
Wait, just a second, is your doctor listening? -- ScienceDaily
On average, patients get about 11 seconds to explain the reasons for their visit before they are interrupted by their doctors. Also, only one in three doctors provides their patients with adequate opportunity to describe their situation. The pressure to rush consultations affects specialists more than primary care doctors says Naykky Singh Ospina of the University of Florida, Gainesville and the Mayo Clinic in the US. She led research that investigated the clinical encounters between doctors and their patients, how the conversation between them starts, and whether patients are able to set the agenda.
Everything big data claims to know about you could be wrong: To understand human health and behavior, researchers would do better to study individuals, not groups -- ScienceDaily
"If you want to know what individuals feel or how they become sick, you have to conduct research on individuals, not on groups," said study lead author Aaron Fisher, an assistant professor of psychology at UC Berkeley. "Diseases, mental disorders, emotions, and behaviors are expressed within individual people, over time. A snapshot of many people at one moment in time can't capture these phenomena."
Moreover, the consequences of continuing to rely on group data in the medical, social and behavioral sciences include misdiagnoses, prescribing the wrong treatments and generally perpetuating scientific theory and experimentation that is not properly calibrated to the differences between individuals, Fisher said.
Black moms die in childbirth 3 times as often as white moms. Except in North Carolina. - Vox
When a woman on Medicaid in North Carolina becomes pregnant, her doctor is incentivized (through Medicaid financial reimbursements) to screen for issues that might make her pregnancy high-risk, looking out for potential obstetric or psychosocial risks as early as possible, such as high blood pressure, diabetes, or depression. If the patient is deemed to be high risk, she’s connected with a “pregnancy care manager,” who helps the mom understand and adhere to steps needed to reduce her health risks.
Psychiatric drugs killing more users than heroin, cocaine: experts | Vancouver Sun
“The interesting thing about this is that it’s a prescription drug and people think they’re safe,” Ahamad said. “But as it turns out, we’re probably prescribing these drugs in a way that’s leading to harm.”
Kerr noted that the rise in BZD-related deaths — “It’s been an epidemic brewing for many, many years” — very closely mirrors a rise in opioid-related deaths that has been widely documented. He cited a fourfold increase in BZD-related deaths in the United States between 1999 and 2014, and also noted that there are 50 per cent more deaths each year in the U.S. due to psychiatric medicine than heroin.
“These studies really reveal how very dangerous these drugs are, and they should be used with great caution,” Kerr said. “We can’t just focus on opioids, we need to look at other medications that are used in combination.”
Generic drug collusion
Embattled drugmaker Perrigo said that federal agents executed search warrants at company headquarters, as part of a wide-ranging investigation into price collusion in the generics industry. Shares fell more than 6% Wednesday morning.
Several other companies have received subpoenas as part of this investigation. The Government Accountability Office issued a report last year that found that prices of 300 out of 1,441 generic drugs doubled at least one time between 2010 and 2015.
Cognitive Enhancement Drug Use Among Future Physicians: Findings from a Multi-Institutional Census of Medical Students
Of these, 11 % (117/1,115) of students reported use during medical school (range 7–16 % among schools). Psychostimulant use was significantly correlated with use of barbiturates, ecstasy, and tranquilizers (Pearson’s correlation r > 0.5, Student’s t-test p < 0.01); male gender (21 % male versus 15 % female, Chi squared p = 0.007); and training at a medical school which by student self-report determined class rank (68 % versus 51 %, Chi-squared p = 0.018). Non-users were more likely to be first year students (Chi-squared p = 0.048) or to have grown up outside of the United States (Chi-squared p = 0.013).
Drug Abuse Among Doctors: Easy, Tempting, and Not Uncommon
Another reason that physicians don't report their colleagues, researcher Lisa Merlo says, is because medical schools fail to educate them about the disease of addiction. Most medical schools include only a lecture or two on addiction, she says. By contrast, the University of Florida requires all third-year students to complete a 2-week rotation in addiction medicine. "Every physician in the United States has to deliver a baby to graduate, but how many of them are ever going to deliver babies in practice?" she asks. "But every doctor is going to see addicted patients."
Drug Abuse Among Doctors: Easy, Tempting, and Not Uncommon
Access rapidly becomes an addict's top priority, he notes, and self-medicating physicians will do everything in their power to ensure it continues.
"They're often described as the best workers in the hospital," he says. "They'll overwork to compensate for other ways in which they may be falling short, and to protect their supply. They'll sign up for extra call and show up for rounds they don't have to do." Physicians are intelligent and skilled at hiding their addictions, he says. Few, no matter how desperate, seek help of their own accord.
My Stimulant Use in Med School: The Good, The Bad, The Victory » in-Training, the online magazine for medical students
ADD medications are generally marketed to “unleash the potential of the student,” which is accurate. In my case, I could finally barrel through those lecture notes without stopping five times to look at some shiny thing in order to earn a slightly below average grade on an exam (I’d stop only 2 times, instead).
Indeed, there is evidence to suggest that high-functioning students do not benefit from stimulant use the way lower-functioning students do. Of course, “high” and “low” functioning takes on a whole new meaning when we’re now splicing up classes of some of the highest achieving students from their colleges, but this is part of the issue in saying “ADD versus ‘normal.’” It’s really “ADD versus your potential.” The ability to synthesize complex ideas in my head had never been the issue, even through college (i.e. my intellect on its own was plenty strong). My ability to utilize this abstract synthetic ability was the issue, thus the obvious utility of Focalin.
Study bias
Selective publication of clinical trials on antidepressants also could cause a bias about their perceived effectiveness, according to a study led by researchers at the Portland Veterans Affairs Medical Center (New England Journal of Medicine, 2008). The study examined 74 FDA-registered studies for a dozen antidepressants and found that most studies with negative results were not published in scientific literature or were published in a way that conveyed a positive outcome. The FDA studies showed that half of the drug trials had positive results, but 94 percent of the trials cited in published literature were positive.
Heart docs paid to operate
the starting income for cardiologists who perform invasive procedures is twice that of cardiologists who mainly provide preventive, longitudinal care.
The Heroism of Incremental Care - The New Yorker
Rose told me, “I think the hardest transition from residency, where we are essentially trained in inpatient medicine, to my practice as a primary-care physician was feeling comfortable with waiting. As an outpatient doctor, you don’t have constant data or the security of in-house surveillance. But most of the time people will get better on their own, without intervention or extensive workup. And, if they don’t get better, then usually more clues to the diagnosis will emerge, and the steps will be clearer. For me, as a relatively new primary-care physician, the biggest struggle is trusting that patients will call if they are getting worse.” And they do, she said, because they know her and they know the clinic. “Being able to tolerate the anxiety that accompanies taking care of people who are sick but not dangerously ill is not a skill I was expecting to need when I decided to become a doctor, but it is one of the ones I have worked hardest to develop.”
