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Archive for November, 2007

Wednesday, November 28th 2007

Open Courseware

Go Learn About Biology

How cool is MIT for putting 1800 course syllabi, written notes, even a helluva lotta video and audio lectures all online for free.

A Very Introductory Lecture On Biochem

Go visit MIT’s OpenCourseWare page and learn something today.

Wednesday, November 28th 2007

Docs As Drug Reps

It may come as a surprise the relationships some physicians have with drug companies. Thousands of physicians, practicing physicians, maybe your physician, serve as Vaudevillians for a host of drugs. Psychiatrists are especially guilty of this, but they’re not alone. In a New York Times piece one psychiatrist goes into how he was dragged into the mess.

How many doctors speak for drug companies? We don’t know for sure, but one recent study indicates that at least 25 percent of all doctors in the United States receive drug money for lecturing to physicians or for helping to market drugs in other ways. This meant that I was about to join some 200,000 American physicians who are being paid by companies to promote their drugs. I felt quite flattered to have been recruited, and I assumed that the rep had picked me because of some special personal or professional quality.

The first talk I gave brought me back to earth rather quickly. I distinctly remember the awkwardness of walking into my first waiting room. The receptionist slid the glass partition open and asked if I had an appointment.

“Actually, I’m here to meet with the doctor.”

“Oh, O.K. And is that a scheduled appointment?”

“I’m here to give a talk.”

A light went on. “Oh, are you part of the drug lunch?”

Regardless of how I preferred to think of myself (an educator, a psychiatrist, a consultant), I was now classified as one facet of a lunch helping to pitch a drug, a convincing sidekick to help the sales rep. Eventually, with an internal wince, I began to introduce myself as “Dr. Carlat, here for the Wyeth lunch.”

During my first few talks, I worried a lot about my performance. Was I too boring? Did the doctors see me as sleazy? Did the Wyeth reps find me sufficiently persuasive? But the day after my talks, I would get a call or an e-mail message from the rep saying that I did a great job, that the doctor was impressed and that they wanted to use me more. Indeed, I started receiving more and more invitations from other reps, and I soon had talks scheduled every week.

The entire process is fishy, no doubt. But why I’m posting on it is the role organized medicine is playing in such. The level of detail the drug companies have on what your doctor is prescribing is pretty remarkable. Don’t fret, they don’t have info on patients or on who is getting what. But they can certainly tell that this doctor prescribes Zoloft 80% of the time for depression, then a drug rep from the maker of Effexor busts in and tries to convince the doctor that Effexor is better than Zoloft.

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Tuesday, November 20th 2007

So What's The Big Complaint On Reimbursement?

There are a lot of upset physicians out there, rallying to the issues of physician reimbursement. Even amongst some of my favorite bloggers. I hear often about the death of primary care, about the SGR and Medicare reimbursement. There’s something to these and, at the least, you can hardly blame physicians for looking out for their self interests. But it is worth looking at some comparisons before we condemn the current reimbursement system.

Let’s start off with the pragmatic. The average primary care physician continues to earn more than any of his OECD nation counterparts. Not only more in absolute dollars, but also as a percentage of the average household income. In 2006 the average general practitioner in the United States earned 4.1-times the per capita GDP.

Even with the debt burden of the current medical student, such as myself, my lifetime earning potential is considerable and more than most of western country counterparts.

If, instead of going to medical school, one were given a million dollars to invest at 6 percent interest and pursued a career as a college graduate instead, the financial returns would be roughly the same as going to medical school.

As said above, harping for your own economic self interest isn’t a terrible thing. But where is this anger about physician reimbursement coming from? Where is this hyperbole about the death of medicine, the death of primary care coming from? Now granted, without such passion physicians may be in a much worse place than they currently find themselves. There are certainly situations where physicians are losing money – consider Medicaid in some states.

The growth of physician income has been…marginal in the past two decades. Without those who passionately advocate perhaps we would not be in a stale position but instead on a downward slope.

Physician Income
Physician Income In Adjusted Dollars

What peeves me is the hyperbole and the seeming ungratefulness. I truly believe that what physicians have that is most important in the fight over health care reform is physician trust. Doesn’t the current tone from organized medicine and individual physicians concerning physician income endanger that?

We know American physicians earn more than the rest of the world. The second question is if health care is inherently overvalued. Clearly, virtually no health care system represents a free market system. Even the American system is seemingly controlled by a cabal of payers.

The gut reaction is an obvious ‘no.’ But physicians have done marvelously well for themselves in lobbying Medicare and promoting their own reimbursement. The question is, outside of the current payer structure, in a truly free market system, could physicians further maximize their income?

In a world where the consumer=the payer, I’m sure for a large part they could not. Sure there are a set of unique services which could potentially further maximize their income. Acute care providers from emergency room docs to some types of surgeons. True the hyper-specialization of medicine is in and of itself partly a product of the current reimbursement structure. But that and other complexities aside, the vast majority of physicians and certainly the primary care physicians certainly could not earn more in a true free market system. Could they?

It seems to me that considering the health literacy of the populace and the seeming dis concern for future consequences, only both immediate and life or QoL threatening conditions would see increased reimbursement in a system where payment is more directly tied to the consumer.

If these things are the case, then don’t the cries of anguish over the SGR, over physician reimbursement, against those who favor single payer sometimes seem…histrionic and ungrateful? Or am I just not seeing the real picture here?

Saturday, November 17th 2007

Obese Cannot Immigrate

Cannot Move To New Zealand Until She Loses Some Weight

New Zealand asks a woman to lose weight or not immigrate.

Rowan Trezise, 33, has been left behind in England while her husband Richie, 35, has already made the move down under leaving her desperately trying to lose weight.

When the couple first tried to gain entry to the country they were told that they were both overweight and were a potential burden on the health care system.

Mr Trezise managed to shed two inches from his sizeable waistline to fulfil criteria set out as part of his visa application to work as a technician in the country.

His wife however has had no such luck and faces a desperate battle to shed the pounds before Christmas, at which point the couple say they will abandon their overseas plans.

New Zealand officials assess people’s weight using Body Mass Index which measures fat by comparing the height and weight of an individual.

There is legitimate debate here, but don’t be reactionary:

“My doctor laughed at me. He said he’d never seen anything more ridiculous in his whole life,” he said.

“He said not every overweight person is unhealthy or unfit.”

Not every overweight person is unhealthy or unfit? What type of comment is that. This is supposedly a national policy, applied towards a population. Across the whole obesity is a bigger contributor to morbidity than being poor, than having a cigarette everyday, than having 2+ drinks a day.

This is the biggest public health crisis facing the west. If there was ever a burden to try to save your health care system from its obesity. So maybe New Zealand shouldn’t screen it’s potential incoming ex-pats for lifestyle risks, but if it is going to the one that should be at the top of their list is obesity. Don’t tell me, “not every overweight person is unhealthy or unfit.” *rolls eyes*

Thursday, November 15th 2007

Last Laugh For Merck

No need to rehash, but I will.

Merck recently anounced one of the biggest settlements in American civil history for those plantiffs suing it over the infamous COX-2 inhibitor Vioxx. When Merck first got sued their liability was estimated as high as $25 or 30 billion dollars, but Merck did surprisingly well with its promise to fight each suit individually.

Take that back – stunningly well.

But the legal fees and the uncertainty factor weighing on its stock and earnings made settling (finally) in Merck’s best interest. A few days ago I was sympathetic to their decision from a financial standpoint but bemoaned it based on the job they had done showing looney-bin plantiffs out to make a buck what life is all about.

But now, the Los Angeles Times has a story saying Merck may have gotten an even bigger last laugh than I initially suspected. On the surface, $5 billion dollars is a lot of money, but probably chump change when you consider the decades of legal fees they’re facing (and the occasional award charged to them). And of course its pocket change compared to what some suspected would be Merck’s original liability for Vioxx.

On top of the money though, could the plantiffs be getting an even shriller deal than originally reported?

The highly unusual agreement not only requires 85% of plaintiffs to agree before it can be finalized but also might unduly force some claimants to settle or risk losing their lawyer.

That’s because the deal includes highly unusual restrictions on plaintiffs’ lawyers. The settlement requires them to recommend the deal to all of their clients or none. In addition, lawyers must stop representing any clients who turn it down as long as they don’t violate ethics rules.

Settle or lose your lawyer.

“It’s always the clients’ decision to accept a settlement or not, and lawyers aren’t going to do anything that’s unethical,” he said. But “those considering this should know these are not easy cases to try in court.”

The emphasis is my own for the funniest line in the entire story. That’s not the point though. The point is, there is no major plantiff lawfirm who is going to let their clients walk away from this deal.

“Look The Settlement Is Just Like Cotton Candy. You Like Cotton Candy, Right?”

The biggest plantiff attorneys are going to be selling this settlement to their clients, like pie to a fat kid. You’re either going to take the deal or you’re going to end up some shaftball attorney representing you when you go to trial. Good luck getting a dime out of Merck represented by some guy working out the warehouse district.

Thursday, November 15th 2007

US Maternal Death Rate Higher Than Europe's

Blah blah blah blah blah.

The United States has a sharply higher rate of women dying during or just after pregnancy than European countries, even some relatively poor countries such as Macedonia and Bosnia, according to the first estimates in five years on maternal deaths worldwide.

The report, published in the Lancet medical journal, places the United States 41st among 171 countries.

“Americans tend to be complacent about pregnancy and childbirth. Most believe it is now more or less routine and no longer the deadly risk it was for their grandmothers. This is true for most U.S. women, but by no means for all,” the U.N.-led group said in a statement.

You know how much ‘research’ they did for this publication? How many times they visited each country? None.

You know the variation in the self collection/reporting methods used here? You know how applicable these figures are in judging the American health care system?

I’ve blogged extensively on international comparisons of health care quality measurements, such as this. They’re junk. This data is essentially meaningless. And to show my disrespect, here’s something that’s more important than this UN/World Bank report:

Family Guy Does Soulja Boy

Tuesday, November 13th 2007

Bird Flu Reaches The West

Not the first case in Europe, but considering the relative down time in the media hysteria this is semi-big news. H5N1 has shown up on a turkey farm in Britain.

The Department for Environment Food and Rural Affairs (Defra) said some 10% of birds in one shed at the farm had died during one night.

Redgrave Poultry Limited, which is operating the farm, has issued a statement in which it said it had continued to fully co-operate with Defra over the outbreak.

It is expected that all the birds will be gassed and then put in sealed containers.

They’re gasing approximately 6500 birds. No birds from the farm had reached the food chain yet (they were being prepared for the holiday season).

Sunday, November 11th 2007

Merck Settles

Oh the woe. The pharmaceutical industry couldn’t give two-cents about the status of physician’s medical liability, so let us not confuse the issue. Even so, I thought that the Vioxx trials were a clear example of the kind’ve litiganous society we’re living in.

So many cases, with so many risk factors for CAD and yet somehow these plantiffs who had taken Vioxx for all of a week in some cases felt that they knew Vioxx had caused their heart attack and they expected a jury of their peers to come to the same conclusion.

Merck’s initial refusal to settle these cases and to take them all on was not decided based on anything but the finances I’m sure, but still held some nobility in a world where so many are forced to duck and cover when pelted with medical lawsuits. But after three years of putting up such a fight, Merck has finally settled for nearly $5 billion dollars.

As proof of the soundness of their decision from a financial standpoint, their stock immediately went up. Still it is sad to see considering Merck’s ‘success’ in defending itself to this point.

The settlement, one of the largest ever in civil litigation, comes after nearly 20 Vioxx civil trials over the last two years from New Jersey to California. After losing a $253 million verdict in the first case, Merck has won most of the rest of the cases that reached juries, giving plaintiffs little choice but to settle.

Pressure on Merck to not continue to tie up the court system, is ridiculous if true.

Judges in Louisiana, New Jersey and California, who oversee nearly all the lawsuits, had pressed for a deal before a new wave of trials was scheduled to begin in January.

[Plantiff attorney Danny] Becnel credited Judge Eldon Fallon of Federal District Court, who is overseeing the federal lawsuits from his court in New Orleans, with pressing the two sides to the table.

“He had everything to do with it,” Becnel said. “He was critical.”

A much more reasonable pressure to apply would’ve been to the steering committee for the plantiff attorneys, for them to drop most of their markedly frivolous cases.

But, even with that pressure Merck still obviously made this decision as a financial one.

Merck, which has already spent more than $1.2 billion on Vioxx-related legal fees, the settlement will put to rest any fears that Vioxx lawsuits might bankrupt the company, or even have a significant financial impact. While eye-popping, the settlement payment represents less than one year’s profits for the company, the third-largest American drug maker.

[T]he agreement is far smaller than Wall Street analysts and lawyers predicted when Merck withdrew Vioxx, and especially after the verdict in the first case. In 2005, most analysts estimated that Merck’s ultimate liability in Vioxx would be between $10 billion and $25 billion.

Another chapter comes to a close in the Vioxx ordeal.

Monday, November 5th 2007

Remember, Remember The Fifth of November…

Almost forgot. Today is the fifth of November. Guy Fawkes Day. Well, not in the UK anymore, but over here.

V For Vendetta Had The Protagonist Wear A Fawkes Mask

I’ve posted on the whole mythology of this rather minor but interesting holiday in the past. This post today serves as only a remember…

Remember, remember the fifth of November,
The gunpowder, treason and plot,
We see of no reason,
Why the gunpowder treason,
Should ever be forgot

Friday, November 2nd 2007

Why Censoring Watson Was A Mistake

In mid-October Noble laureate James Watson put his foot in his mouth one too many times, by voicing this highly un-politically correct view,

He says that he is “inherently gloomy about the prospect of Africa” because “all our social policies are based on the fact that their intelligence is the same as ours – whereas all the testing says not really”, and I know that this “hot potato” is going to be difficult to address. His hope is that everyone is equal, but he counters that “people who have to deal with black employees find this not true”. He says that you should not discriminate on the basis of colour, because “there are many people of colour who are very talented, but don’t promote them when they haven’t succeeded at the lower level”. He writes that “there is no firm reason to anticipate that the intellectual capacities of peoples geographically separated in their evolution should prove to have evolved identically. Our wanting to reserve equal powers of reason as some universal heritage of humanity will not be enough to make it so”.

Despite the public outcry, there was nothing new to the idea. This is an idea that needs confronting and when the public and the scientific community were offered this high profile opportunity for such, they dropped the ball.

The Bell Curve Dedicated Two Chapters To Intelligence & Race

The main point of this post is that censoring Dr. Watson, rather than confronting him in debate on the science, was a mistake. Almost as soon as the words were printed Watson backed up, denying that there was true evidence for such a disparity in intelligence; but really there wasn’t a lot of discussion of the ‘science’ of what Watson and so many others (some from unexpected places) claimed. There was simply indignation and alarm and then Watson’s suspension and finally resignation.

Closer now to 80 than 79, the passing on of my remaining vestiges of leadership is more than overdue. The circumstances in which this transfer is occurring, however, are not those which I could ever have anticipated or desired.


This week’s events focus me ever more intensely on the moral values passed on to me by my father, whose Watson surname marks his long ago Scots-Irish Appalachian heritage; and by my mother, whose father, Lauchlin Mitchell, came from Glasgow and whose mother, Lizzie Gleason, had parents from Tipperary. To my great advantage, their lives were guided by a faith in reason; an honest application of its messages; and for social justice, especially the need for those on top to help care for the less fortunate.

But the way this entire ordeal went down doesn’t seem like an appropriate way to advance race relations; to advance science.

Let me tip toe around the subject for a minute, and try to be as impartial as possible in presenting the evidence against and for a “racial intelligence gap.”

The immediate reaction, from what I read, seems to have been to tout the politically correct line and deny the very existence of biological “race.” And true, in terms of the distinct self identified thing we have come to identify as “race” there’s some validity to that. As this NEJM article quotes,

Race is a social construct, not a scientific classification. In a 1999 position paper, the American Anthropological Association stated the following:

It has become clear that human populations are not unambiguous, clearly demarcated, biologically distinct groups. . . . Throughout history whenever different groups have come into contact, they have interbred. The continued sharing of genetic materials has maintained humankind as a single species. . . . Any attempt to establish lines of division among biological populations is both arbitrary and subjective.

But that politically correct position misses the point I imagine. It is true that the genetic variability between individuals is greater than between “races” or geographically grouped peoples. But, we wouldn’t expect anything else. And the fact is that there is considerable, predictable genetic differences between geographically defined human populations.

Even as geographic populations interbreed, researchers can pretty accurately place people’s origins based on a set number of alleles,

[W]e asked what is the probability of allocating an individual to the correct continent, on the basis of her or his genotype. Different statistical methods gave somewhat different results, but three conclusions appear justified: (1) most individuals are allocated correctly, but (2) the rate of misclassification is never < 27%, and (3) the rate of misclassification is roughly the same, whether allocation is based on autosomal or Y-chromosome polymorphisms, although for the latter the variance among continents is four times as large.

Geographic Distribution of Five Polymorphisms

True the confidence interval in defining where your lineage hailed from can be wide, and clearly I am nearly illiterate on the subject myself. My ignorance being admitted, there looks to be pretty considerable genetic variability amongst geographic populations. No surprise.

Indeed, to step into a minefield, the geographic variability seems to be greatest between Africans and non-Africans.

[F]or an allele with a frequency of 20 percent or greater in one racial group, the odds are in favor of seeing the same variant in another racial group. However, variants with a frequency below that level are more likely to be race-specific. This race-specificity of variants is particularly common among Africans, who display greater genetic variability than other racial groups and have a larger number of low-frequency alleles.

These low frequency alleles even if some day identified with the genetic component of intelligence, might not be able to explain a large portion of the “intelligence gap,” because they are low frequency in the population. That aside, let’s get back to the discussion at hand.

Even though Dr. Watson chose the word “race,” he could’ve just as easily substituted “geographically defined populations” and maintained his point. Isn’t this variability amongst geographic populations enough to make his claims worthy of discussion? Should we be censoring science topics that cross some ill defined line?

The reactionary denial of the existence of “race,” as a biological reality, is a matter of semantics in this case. That was the largest argument I heard in the media and amongst the public.

But there were more sensible, better versed arguments out there, which did not get the attention they deserved. The more sensible arguments that came out were:

1) there is no evidence linking the limited genetic variability between “races” to intelligence
2) the measurements of intelligence used are flawed and biased
3) the differences can be explained by nurture and so there is no reason to look to nature.

These were things that needed to be discussed out in the open as an educational resource. Instead you found them on obscure science weblogs or in journals. The headlines revolved around Watson’s comments and not the articulate and insightful responses, which were too few before the discussion was cut off prematurely by those who broke ties with Dr. Watson.

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