What????

Sent from my iPhone

When is the critic-at-large the ultimate example of the "conflicted" interest?

An interesting, and well-written article in the NY Times today discusses the most recent career ambition of Dr. Steven Nissen, the cardiologist at the Cleveland Clinic whose outspoken views on the risks of COX-2 inhibitors and Avandia have drawn dramatic headlines and FDA attention.  The NEJM jumped on this latest post-Vioxx bandwagon early, fitting, as it did, so well in Dr. Jeff Drazen’s lightly veiled and vociferous anti-industry campaign.  Of course, Dr. Drazen’s long-time lucrative association with Merck, and the Singulair program, as well as a large number of pharmaceutical companies for which he was a key opinion-leader for many years and from which he profited handsomely, is now just a distant memory, rarely spoken of since he’s taken his post at the NEJM.  Dr. Nissan seems cut from the same hypocritical cloth.  Though Dr. Nissen likes to think of himself as “both an insider and an outsider”, one is left wondering if in fact he’s neither.  Instead his position seems driven more by self-promotion, and using the “bully pulpit” of academia to over-promote marginally statistically significant results as a intentional slaughter of the innocents by big pharma.  The results of his Avandia meta-analysis are not significant in the strictest sense and would not be accepted by the NEJM if they came from anyone other than an academic with a reputation for indicting Big Pharma.  And yet, the NY Times article nicely outlines how things are never quite as clear or idealistic as they seem when individuals’ careers are carefully analyzed.   

 

http://www.nytimes.com/2007/07/22/business/22nissen.html?_r=1&th&emc=th&oref=slogin

 

 

The Academic Emperor

The economics of academic medicine are THE "third rail" topic. It leads to a lot of hidden costs to and hiding of costs by academic physicians and their families. To publicly ask about it during, for example, contract negotiations, leads quickly to the pregnant pause that implicitly asks the question "are you sure you're really in this for the right reason?" Obviously a nice "out" for the department chair. And yet, fundamentally, bills need to be paid. Hidden "moonlighting" is common among junior (and senior) faculty members, who do it under a sort of "don't ask, don't tell" policy. The moonlighting morphs as faculty move up to become extensive medico-legal, pharmaceutical, or investment "consulting" - all done in addition to the ever-spiraling and time-consuming "pro-bono" work (study sections, manuscript reviews, society work, etc) that further erases an academician's time for free-thinking, creative scientific inquiry. This is a MAJOR issue which, though not to be spoken of "in polite company," leads to an erosive hypocrisy which flies in the face of nominal academic honesty and integrity. This issue should be taken seriously by academic leaders, but will only be so when honesty prevails over wishful thinking and averted eyes.

See www.jci.org/cgi/content/full/117/6/1727 for a very interesting discussion on some of these issues. It is the 2007 American Society for Clinical Investigation Presidential address, by Barbara Weber, a prominent oncology clinical trialist who recently moved from U Penn to GSK where she is VP of Oncology Discovery and Translational Medicine. One is left wondering if the "sultan," like the emperor, may be a bit less well-dressed than he (or she) would like to think.

And on a related note...

A nice resource…. Check it out if you take any sort of medication. The pill ID’s are nice. Even though the names are similar, I'm not associated with this website in any official (or unofficial) way...

http://www.pharmer.org/about

The be-all and end-all?

I'm learning a lot about transplantation lately. Mostly I mean organ transplantation as the hospital where I work resuscitates a program and I find myself having to send more and more of my patients to them. It a bit of a crazy business - particularly in the area I deal with most. Lung transplantation that is. I find myself sending people all over the country in search of a program that will "have them." I, and more importantly, my patients, are caught in this insane vortex of transplant programs trying to optimize their statistics (i.e., have no "bad outcomes") for fear of being run out of business and insurance companies trying hard not to pay for them. Nobody, it seems, but me and my patient want the transplant to actually occur.

To add even more complexity, the guidelines for lung transplantation aren't very standardized. In other words, patients who are rejected at one center may be acceptable at another. But which program? What are the parameters for disqualification? Is it the day of the week? Who's on call that week? Is the decision made by an individual? A committee? A coordinator? Who knows??

We, as the patients advocate, are rolling the dice and our patient is the one left holding the bag. The evaluation process is arduous, time-consuming, and exhausting for everybody - referring docs included. It is also VERY EXPENSIVE and is also just the beginnning. The disease I'm dealing with most is pulmonary fibrosis - a lethal disease that has no treatment proven to prolong life, except transplant. A lot of people who get this disease, which isn't that common, are older - over 65. Unfortunately that also happens to be the upper age limit for lung transplantation at most centers. Most... but not all. And, it seems, even the age limit can be a bit of a moving target depending on how well the patient "sells" themselves. Interview "like your life depends on it" I tell people. Interesting concept, isn't it?

What are we doing here?

I need to be clear up front. I don't claim to have answers to the problem, but I have a lot of experience with the scope of the problem. I see critically ill people with diabetes who are in the intensive care unit because they can't afford to get their insulin. On the other hand, I see 90 year old patients with multi-organ system failure who are getting advanced and expensive interventions because their families feel that "everything must be done." I see incredible inequities in physician reimbursement leading to an abundance of procedures and testing. I see the cost of the nursing manpower crisis on the morale of staff. I see hospitals trying to cut costs by decreasing the number of nurses caring for patients, and the cost of the resulting complications as patients who can't swallow come to the intensive care unit after inhaling dinner. And I see patients so bewildered and scared that medical mistakes can happen to them and their loved ones that they're afraid to even come into hospitals. I see patients with advanced disease whose faith so shaken in traditional medicine, its practitioners and their entrenched financial conflicts that they would prefer to take customized concoctions of herbs than intensively studied and validated compounds.

There is a problem and it needs to be fixed! We can't delay, and we can't let political special interest groups dictate the terms.

I know that people are tired of the endless debates - I am too. But people are suffering and dying unnecessarily and a lot of money is being spent in the wrong places. I'll be talking about what I see on the ground floor, and try to point readers to info that I find that captures all sides of this debate.

I'm new to this and spend most of my time taking care of patients and doing medical research so I don't get a chance to add all of the techno-savvy bells and whistles so I'm sorry if this isn't the most sophisticated blog. I'll do my best to add things as I learn them. I do see your comments and would appreciate any readers pointing out things of interest. I will do my best to get the links posted so that we can all become better informed. Thanks for reading!

Let the games begin

There needs to be a serious dialogue about what to do to fix our national blindness about the impending health care crisis. The American people are clueless about what is about to happen as our system slides into bankruptcy... We are losing our research funding faster than we're losing troops in Iraq and talented people aren't choosing medicine as a career (probably wisely). What can we do to stop it? Why are people happy to spend a fortune on entertainment and nothing on their health? Is nationalized health care the only option? There seems to be an endless fascination with health, medicine, and technology but an unrealistic expectation of the cost of unending access and the latest and greatest for everybody.

I'll be talking about clinical work (confidentially, of course). I'll talk about issues facing academic physicians and researchers, and issues of industry and it's role in American medicine. I hope that this will help us all understand these important issues and start a conversation about an important and proud profession.