Certainly there are professions and lives with similar dedication. But lawyers and journalist I can’t reasonably place amongst them. This from someone who favors liberty and transparency in society above most else; certainly things that lawyers and journalists can help foster.

And yet, for all the respect thrown towards physicians by society, even amongst the access crisis and the accusations of greed, you can’t help but get the sense that some people are delusional. I take this from a speech by Gerry Spence,

“[Lawyers] are the most important people in America,” Spence said. “There is no other profession in America that fights for freedom, that fights for what America is about, that fights for justice for ordinary people.”

[...]

“I want to ask you which would be more important: If all of the doctors in the country somehow disappeared or all the trial lawyers in America somehow disappeared?” he asked. “We can live without medical care, but we cannot live without justice.”

Spence was a prominent trial lawyer, a near celebrity trial lawyer, who may be prone to such hyperbole. But the reality is no American will ever need a lawyer quite like they need an operation for a perforated bowel. Not even if facing criminal charges to potentially include execution as punishment, if for no other reason than the difference in acuity amongst the two examples.

To claim the legal profession as more important than the practice of medicine borders on delusional.

So does the next quote,

“Journalism is not brain surgery; it’s more difficult than that,” said Andrew Cline, an assistant professor of journalism at Missouri State University, who has written on the perception of bias in news coverage.

The blogosphere jumped on this quote, as it appeared in an Ombudsman’s article in the New York Times. See Kevin, MD or The Happy Hospitalist or Pursuing Holiness.

There are people who do great things with their lives, on par with any healing effort. But a trial lawyer and a mainstream journalist cannot claim their importance to society as such. And the fact people exist who think such shows that, for all the respect it is granted, there may still not be quite enough for exactly what physicians do.

er·ror
   /ˈɛrər/ Show Spelled[er-er] Show IPA
–noun
1. a deviation from accuracy or correctness; a mistake, as in action or speech: His speech contained several factual errors.
2. belief in something untrue; the holding of mistaken opinions.
3. the condition of believing what is not true: in error about the date.
4. a moral offense; wrongdoing; sin.

A mistake. That’s how I think of an error.

Here’s how we’re to think of contextual errors apparently,

A contextual error occurs when a physician overlooks elements of a patient’s environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.

The above appears in a work by Weiner, et al in the Annals of Internal Medicine last month. I’m terribly poorly read on healthcare QA and medical errors but it appears to be a relatively novel concept. A search by title or keyword for “contextual error” in Medline reveals a total of three articles. The two other than Weiner’s have nothing to do with the idea as his group defines it.

I like the idea; I think it raises important considerations.

I don’t like the way Weiner’s group designed a study to document the prevalence of contextual errors.

Here is how a Huffington Post blog summarized the study from the Annals,

He sent undercover patients into doctor’s offices with regular complaints: a diabetic with blood sugar out of control. Raging asthma. Need for a hip replacement. They functioned as the “secret shoppers” of health care.)

In each case the actors could present a standard version of the problem, or versions where they offered a clue to an extra fact, something all physicians would agree should change the plan of care, if it were known. For the patient with raging asthma, one clue was “it’s been worse since I lost my job.”

A smart doctor would ask if new financial problems meant the patient could not pay for medicines. With that information in hand, the doctor could readily change to cheaper medications or identify a source of support. If a doctor fails to pick up on that clue, however, then they are likely to add new prescriptions. That would be the wrong decision.

Physicians only asked follow-up questions about those clues to good care about half the time. When there was a problem in the patient’s life situation, like inability to afford medicines, doctors only came up with an appropriate plan of care one time in five. Four times out of five, the patient left the office without receiving good care.

I’m not sure the example given represents a mistake on the part of the physician. Not in full. Not enough to claim,

That error rate is unacceptable.

Patient non-compliance with therapy is a failure of the medical system, but it is largely a patient side error. I’m not denying the responsibility of providers to promote social health and situations that facilitate patient compliance. But a patient who presents to a physician with worsening of his symptoms and doesn’t offer the fact that he’s been non-compliant with the recommended therapy because he can’t afford it, well, that is fully on the patient.

Telling physicians they’ve made a mistake for not ferreting out the complex situations in which patients aren’t compliant during a fifteen minute office visit is bollocks.

I’ve commented on this ‘trend’ before, of criminalizing risky behavior. Despite my earlier post on the issue, I’m pretty adamant that this shouldn’t be a criminal matter. It’s not that I’m concerned with the shadowing consequences such a trial and potential verdict will have on those who are HIV+, it is merely that there is shared responsibility here enough. Unless the trial brings to light some form of actual deceit, for instance if she lied about her HIV status, then I’m not sure unprotected sex with a person of unknown HIV status in the modern risk environment doesn’t exculpate the accuse somewhat.

But there should be penalties and if not in a criminal court then in civil opportunities for those she’s put at risk. I guess we’ll see just how aggressive this German court wants to be over the coming weeks.

Having to draw the line of what qualifies as pathology is an issue for psychiatrists as it is for no other physicians. Diabetes is not “normal,” a brain tumor is not “normal,” coronary artery disease is not “normal.” Beyond that they all have comparatively well vetted treatments for things like improved long term survival and decreased major morbidity.

But beyond the psychotic disorders psychiatry has no such certainty. What qualifies as “normal” amongst our thoughts and emotions and behaviors is something not so cut and dry. Nor are the treatments particularly well proven when compared to much of what the rest of medicine might called evidence based.

True, other specialties have their share of poorly defined diseases whose pathologicization has been tied at times to the cost to treat. Anecdotally I can think of restless leg syndrome. But the rest of medicine doesn’t have to hold a vote on what to call “normal” and what to call pathology. Consider a new change to the next edition of the Diagnostic and Statistical Manual of Mental Disorders,

Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder.

This would be a wholesale medicalization of normal emotion, and it would result in the overdiagnosis and overtreatment of people who would do just fine if left alone to grieve with family and friends, as people always have.

It makes pscyhiatry, fairly I would argue, prone to questions of the validity of some of the places it dares to tread. Can psychiatry ever aspire to be a science as say, nephrology or oncology?

Depression is a good example of the problem this makes. A fever is not a disease; it’s a symptom of disease, and the disease, not the symptom, is what medicine seeks to cure. Is depression—insomnia, irritability, lack of energy, loss of libido, and so on—like a fever or like a disease? Do patients complain of these symptoms because they have contracted the neurological equivalent of an infection? Or do the accompanying mental states (thoughts that my existence is pointless, nobody loves me, etc.) have real meaning? If people feel depressed because they have a disease in their brains, then there is no reason to pay much attention to their tales of woe, and medication is the most sensible way to cure them. Peter Kramer, in “Against Depression” (2005), describes a patient who, after she recovered from depression, accused him of taking what she had said in therapy too seriously. It was the depression talking, she told him, not her.

The diagnosis and treatment of non-psychotic psychiatric disorders has sky rocketed since the 1980s. Whether that reflects legitimate outreach or the unnecessary medicalization of the “normal” or some combination of both needs to be seriously looked at by psychiatry. To be fair my experience with psychiatry is limited to my time as a medical student and I’m hardly the first or the most prominent or the last to question the validity of some mental health diagnoses. But the unique position of psychiatry as a medical specialty necessitates that organized psychiatry address questions and concerns about the medicalization of the “normal” with a more social campaign and with more self awareness about just what the future of psychiatry is.

Here he is talking about a patient’s responsibility in his or her health care. His advice is a well touted motto: be involved. Ask questions, offer your observations, have family members around to speak up on your behalf.

But as he may admit the problem is huge. It is more than just a social one, a cultural one. True, for most of its life medicine has promoted paternalism and such is ingrained in many physician-patient relationships. But beyond that there is such a monopoly of information in health care.

Often, in complex critical situations, there is so much that cannot be conveyed to the patient in the time afforded them. There are so many times when the understanding of the situation is so far below just the basics, when, no matter the social and communication skills of the providers, it is impossible to even put more than a basic understanding of what is going on to empower the patient and family to even ask appropriate questions.

I’m not arguing for paternalism, just that sometimes the situation is more difficult than the ideal.

Pretty cool how far trauma care reaches nowadays. Improvements in prehospital care have had such an impact on morbidity and mortality in trauma care in the civilian sector; looks like it’s true for the military experience as well.

The benefits of freestanding children’s hospitals and the problems pediatric care in my hometown faces should seem cognizant to even the layperson. While children’s hospitals certainly have higher charges they provide value for such, providing better care from everything in trauma to acute asthma exacerbation. The lack of a freestanding children’s hospital means tertiary pediatric care is fragmented. Pediatric services at hospitals around the city see fewer of each case of pediatric illness. Volume, as has long been shown, means quality. Concentrating tertiary care also promises to promote recruitment of everything from pediatric subspecialists to pediatric nurses.

I’ve always had a place in my heart for pediatrics. It represents unique challenges and at times can be tragic and gut wrenching caring for the young and critically ill. It is also incredibly rewarding. Your patients share no responsibility for their conditions and the promise they hold when you help heal them is virtually limitless. But of course, as easy as it is for pols to talk about children’s issues, they lack a constituency and children’s healthcare doesn’t exactly have the political will as, say, care for those over 65 does.

So I’m happy to see the movement for a new children’s hospital in San Antonio. A public-private venture the hurdles it faces are more than political but the backing of prominent politicians like Nelson Wolff is a very positive turn for pediatrics in this town. Amongst others in town, the former Mayor and long term head of Bexar County seems to have thrown his full weight behind a freestanding children’s hospital. That can only be a good thing.

Supportive media coverage as well is a positive. The local newspaper has it here and here, saying,

Far from standing still, San Antonio is losing ground in pediatric care as other cities expand theirs, Austin moves closer to getting a medical school, and local military realignments reduce pediatric care resources.

In July, Texas Children’s Hospital bought full-page ads in the San Antonio Express-News promoting its services, evidence that this city is seen as a lucrative market for other cities’ children’s hospitals.

As has local television media. Hopefully that forecasts well for the future. San Antonio needs a children’s hospital.

Jamie Oliver talking at TED2010 on childhood obesity.

In just over half of the published and unpublished studies, he and colleagues reported in 2002, the drug alleviated depression no better than a placebo. “And the extra benefit of antidepressants was even less than we saw when we analyzed only published studies,” Kirsch recalls. About 82 percent of the response to antidepressants—not the 75 percent he had calculated from examining only published studies—had also been achieved by a dummy pill.

Here’s the 2002 paper Sharon Begley is referencing in her piece in Newsweek.

“Many have long been unimpressed by the magnitude of the differences observed between treatments and controls,” psychology researcher Steven Hollon of Vanderbilt University and colleagues wrote—”what some of our colleagues refer to as ‘the dirty little secret.’ “

Essentially except for those with severe depression, the vast vast majority of benefit seen with antidepressants can be attributed to a placebo effect.

The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.

That’s the reality that is hardly well penetrated into primary care and the non-psychiatric medical community.

That raises serious questions about the potential overuse of anti-depressants. Drugs with serious side effects and potential consequences all for a placebo effect.

Don’t get me wrong I am all for the placebo effect. If it works, it works. And depression is a serious illness that needs something to work for it. But with the efficacy of therapy and perhaps other clinical options to draw out the placebo effect you have to question the rate at which anti-depressants are given out. The major problem may be how little the medical field realizes the lack of effectiveness of these drugs beyond the placebo effect.

And I think the treatment of depression is a paradigm for where we’re going with psychiatric diseases in general. Don’t get me wrong. On the margins of the bell curve, where irrefutable and severe psychiatric disease live, psychoactive drugs can do wonders. But with an ever growing list of psychiatric diseases to medicate and questionable effectiveness it’s not beyond questioning psychiatric pharma.

Pathologizing behavior and feelings and thoughts has always been dangerous. Even more dangerous is over medicating for such.

We’ve gotten smarter, more sophisticated, more skilled at manipulating radiation to do the most benefit in medicine and minimize harm. Ionizing radiation has spurned two whole medical specialties. Doctors now describe themselves as radiologists or radiation oncologists. Whole technology has arisen to more precisely diagnose diseases with radiation and to treat them. Radiosurgery, the use of linacs like the Gamme Knife or Cyberknife to more precisely target pathological areas and spare the normal, has been a huge development.

Of course the more technically complicated medicine gets, the more places things can go wrong. Nowhere is medicine as technically savvy or complicated than in in some of the ways we deliver radiation to patients. And, while admittingly slightly alarmist, the New York Times had a recent expose reminding us of that.

At a VA treatment facility in Virginia,

56 patients were treated incorrectly for cancer of the prostate, head and neck, lung, breast and two other malignancies. Thirty-six had been overradiated and 20 more subjected to “errors in technique,” the hospital said.

The Radiological Physics Center sponsored by the National Cancer Institute,

reported in 2008 that among hospitals seeking admission into clinical trials, nearly 30 percent failed to accurately irradiate an object, called a phantom, that mimicked the human head and neck. The hospitals were all using I.M.R.T., which shapes and varies the intensity of radiation beams to more accurately attack the tumor, while sparing healthy tissue.

“This is a sobering statistic, especially considering that this is a sample of those institutions that felt confident enough in their I.M.R.T. planning and delivery process to apply for credentialing and presumably expected to pass,” said a task group investigating I.M.R.T. guidelines for the American Association of Physicists in Medicine.

Not to quote a comic book or a Sam Rami film but with great power comes great responsibility. To err is human, but we shouldn’t accept it. Every error in medicine is something precious lost to someone, something that should be unacceptable. And when we push the boundaries of technology the odds of mistakes only tick up. Like so much in medicine and life, but to the margins, radiation is a boon and a bust; technology promises to potentially deliver it in more effective and safer ways but only if healthcare knows how to use such technology, only if healthcare respects the power of what it’s dosing out and works to prevent errors.