The Vaccine Song

Image by Getty Images via @daylife Today I saw this web site that has a country song about vaccines.  The Vaccine Song

The song writer did a great job of hitting on all the issues in the vaccine debate. There are also good links to other resources on the web for more information on the issues.  A few were new to me

What's the harm in vaccine denial?

The Truth About The Evils Of Vaccination

SMP

Science, sometimes - stroke and chiropractic

Image via Wikipedia

The Connecticut Board of Chiropractic Examiners ruled on the issue of informed consent.  There was a hearing on a declaratory ruling regarding informed consent and stroke.  The board heard four days of testimony (which are available as videos at CT-N).  Although the board's ruling hasn't yet hit the internet where I can find the exact text, it appears from newspaper reports that they ruled affirming that informed consent is the law in Connecticut but refused to require specific consent about a risk of stroke.  Both the New Haven Register and the Hartford Courant have weighed in on this issue and it appears that science isn't the strong suit for either newspaper.

Both papers believe that there is a risk of stroke from cervical manipulation.  Of course the two groups that advocated before the board for the ruling to require telling prospective chiropractic patients of the risk also believed there is a risk. To me what I have learned being part of this process is that science matters to many people only when it serves their interests. 

Nature of science

Science is an epistemological theory.  Epistemology is the study of how we acquire knowledge.  Science, as we know it, is just one method to acquire knowledge through what's called the scientific method.  Wikipedia's explanation of the scientific method is well done (at least today).  Simply, the method is to observe some phenomenon, create a hypothesis (i.e. a prediction) about that phenomenon, then test that hypothesis by controlled observation, an experiment. 

There are other epistemologies besides science.  For example divine revelation where knowledge comes from a deity. Some have called my profession, chiropractic a cult because there are some in the profession whose epistemology is based upon the work of a guru, typically BJ Palmer.  At one time most of medicine was based upon some guru's dogma.  For example anatomy was controlled by the works of Galen (1st - 2nd century of the common era) who really didn't have a clue what was in the human body - he'd looked at monkeys as human dissection wasn't allowed in his time. It wasn't until a skeptic Andreas Vesalius (16th century) applied the empirical method - noting that the bodies he dissected didn't look the way Galen said that anatomy progressed beyond the dogma of Galen.

One common epistemology is the use of anecdotes.  You know, "I once knew a guy who smoked a carton of cigarettes a day for 70 years and never got lung cancer.  So cigarettes are safe."  OK that's extreme but anecdotes have a tremendous hold upon our thinking and often it is very difficult to let science triumph when anecdote sits in contradiction of the science. Anecdotes which in health care publications are called case reports are very good at hypothesis generation, remember the scientific method is based upon an observation generating a hypothesis.  Case reports can help generate a hypothesis but never can validate the hypothesis.  I've heard it said often amongst skeptics of chiropractic that the pleural of anecdote is anecdotes not evidence.  I'll come back to this quote again!

Autism and Vaccinations

I know it looks like I'm completely switching gears but there is a logic to my digression.  As I have thought a lot about stroke and manipulation and autism and vaccinations I've come to see that they are analogous situations.  Think about this, a family has what appears to be a healthy normal baby.  They are in this blissful state of early parenthood enthralled with the baby who is developing a similar love for them.  Then suddenly the developing relationship on the babies side changes and the child becomes distant.  The parents seek advice and find that their now more withdrawn child appears to have autistic spectrum disorder.  To the parent this can be a devastating event. They want desperately to find a cure and if there isn't a cure (which there doesn't seem to be) they want to blame someone, something. This is only natural.  The parents feel as if someone, something has taken their child away from them.  Then they hear about a supposed link between autism and vaccinations.  Now they have people to blame.  They can blame the vaccine manufactures.  They can blame the government for trying to tell us that vaccines are safe. They can blame their doctors for giving their baby this poison which caused the problem.  To hear the anti-vaccination folks go on about autism and vaccines is to hear the voice of anger and vindictiveness.  They are not malicious people just untrained in the ways of science and prone to letting their emotions have greater sway over how they look at the evidence.

What about the evidence?  Those parents when confronted with the scientific evidence that does not support their belief that autism is caused by the vaccine, reject the evidence.  What is the basis for the rejection, valid critique of the science?  No, usually it is what comedian Stephen Colbert called truthiness.  Truthiness, which was the Merriam-Webster word of the year in 2006, is defined as: "Truth that comes from the gut, not books," and "The quality of preferring concepts or facts one wishes to be true, rather than concepts or facts known to be true."

Then a whole support industry develops around this belief.  There are organizations whose purpose is to advocate on behalf of the parents and spread the word that autism is definitively caused by vaccines.  This theory is advanced in such a way that reading the web one might believe it was the only one.

I was a participant in a webcast on vaccines for the California Department of Public Health titled "Wading through the Confusion".  As one of my colleagues on the webcast, David G. Amaral, PhD, an autism researcher from the UC Davis M.I.N.D. Institute lamented is that there is inadequate research money available to find the cause of autism because the theory advocated by these groups has so dominated the discussion.

[Any one wishing to know more about this battle should read Paul Offit's book Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure. The NYTimes article on Offit is enlightening about the lack of civility of public discourse on this issue.] 

Back to Stroke

Now think about ischemic strokes.  Isn't this what happens after a stroke in a younger person.  I mean we sort of think of stroke as a disorder that affects the elderly and it is.  The CDC lists death from stroke as the third most common cause of death behind heart attacks and cancer.  The rate of stroke increases dramatically as one ages. Stroke is a life changing event that affects not only the person who may be disabled, but the entire family and other caregivers as well. Utility analyses show that a major stroke is viewed by more than half of those at risk as being worse than death. (1)

So a younger person, say in their 40s - 50s has a ischemic stroke.  That person and their family are going have the same desire as the family who finds their child has developed autism, find someone to blame.  Well instead of a radicalized group of parents spreading the word that vaccines are the cause for autism there is a radicalized group of patients spreading the words that it must be a visit to a chiropractor. This theory that chiropractic cervical manipulation is the cause of strokes in the young has become so common that many MDs speak as if this is an established fact.  They don't really know what the research says about stroke but couple their distrust of chiropractic (2) which I think is a result of the AMA's illegal boycott(3) and it's easy to see how they would assume the connection between chiropractic care and stroke is valid.  Plus why search the literature to find this out, most people they know will tell them it is true.  It seems scientific evidence doesn't always matter.(4)

What is the epidemiology of these strokes?  They are rare representing 2% of all ischemic strokes but 10 to 25 percent of strokes in the young and middle aged.(5)  These facts are not well known so when someone in who is young or middle aged presents to a hospital with a stroke everyone wants to know why.   Given the bias and bad information then the question comes, "did you see a chiropractor within the past month?"  This only serves to expand the perceived value of this belief.  It is not uncommon to hear someone say that the risk is proven.  Proof is a word I tell my students that they can never use when referring to biomedical research.  There is either evidence that supports or refutes a particular hypothesis.  IF they want PROOF then their career choice should become mathematics not health care. 

Or that there is 80 years of science backing this up.  Well time to go back to that earlier quote: "the pleural of anecdote is anecdotes not evidence."    There isn't an 80 year history of science with respect to the association between cervical manipulation and stroke, there is an 80 year history of anecdotes that appears in the scientific literature.  The real science behind this issue has a much shorter history.  We get a survey of neurologists in 1995 (6) with a very poor response rate and which suffers from referral bias. (7)  Plus a survey doesn't establish cause and effect.  There are many studies of cases that have tried to discover the incidence.  For example this paper by Haldeman et al which estimated that one chiropractor in 48 would during the course of their practice career would be made aware of an arterial dissection following cervical manipulation.  But none of these papers actually evaluated the risk. 

There are only three studies that have evaluated the risk of stroke after manipulation.  And all three agree there is an association.  (9- 11)  The first two found a risk (9, 10) and the third (11) finding the same association provided evidence that explains the first two.  Cassidy et al (11) used the same data sources as Rothwell et al (9) but Cassidy et al study investigated one thing neither Smith (9) nor Rothwell (10) did and that is they determined the background rate of these strokes.  The issue is if the rate of strokes after chiropractic care was greater than the background rate (those that were occurring spontaneously not caused by the manipulation) then we would know what the added risk was due to manipulation. The finding, the rate of strokes in patients under 45 seeking care from their primary care physician was identical to the rate for those who had seen a chiropractor.  Thus seeking chiropractic care produced no extra risk for stroke over and above the background rate.  It appears that patients about to have a stroke from a dissection of a vertebral artery (the kind blamed on chiropractic for 80 years) seem to go to a doctor (a medical doctor or a chiropractic doctor) and the only reason the association between chiropractic and stroke appeared to be strong and not for PCPs is that no one asks the question in the emergency room, "did you see your MD within the past month?"

Some have complained that Cassidy et al was a "statistical study" (see this opinion piece or listen to Dr. Murray Katz's testimony before the Connecticut Board of Chiropractic Examiners)  That's almost comical as a critique if not that it might ring true to people who don't understand biomedical research.  Those same critics never said that Rothwell (9) and Lee (10) were "statistical studies" which they are. 

In the publication BottomLine Health there is an article about stroke risk.  The author Dr. Steven Messe essentially dismisses cervical manipulation as a risk factor based upon Cassidy et al's work.(12) 

The nature of science is that what was known one day may change the next.  This isn't often comfortable to the average person but it is the way it is.As the late Prof. Natalia Romalis-Reytblatt (she was a math professor at UB and UB’s 2006-07 Professor of the Year) wrote:

Mathematical results are either false or true (that is, proven or false) and nothing in between. Mathematics is one of the oldest fields of study and, probably, the only field whose findings are not reversed over time, only accumulated.

Math doesn't reverse it's findings but biomedical science does.  A few years ago I wrote about the risk of stroke from cervical manipulation.  But then the evidence changed.  So in the end this is an argument about looking at the science or ignoring the science and using emotion or choosing to use old science only.  To hear the science you can listen to Dr. David Cassidy testify before the board.  You can decide. 

SMP

1. Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline. Stroke. 2006 Jun;37(6):1583-633.  (this paper is available for free here)
2. Busse JW, Jacobs C, Ngo T, Rodine R, Torrance D, Jim J, et al. Attitudes toward chiropractic: a survey of North American orthopedic surgeons. Spine (Phila Pa 1976). 2009 Dec 1;34(25):2818-25. (Pubmed link)
3. Getzendanner S. Permanent injunction order against AMA. Jama. 1988;259(1):81-2. (Pubmed link)
4. Gabbay J, le May A. Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care. Bmj. 2004 Oct 30;329(7473):1013.(this paper is available for free here)
5. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. (Pubmed link)
6. Lee KP, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology. 1995;45(6):1213-5. (Pubmed link)
7. Haldeman S, Carey P, Townsend M, Papadopoulos C. Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias. Spine J. 2002 Sep-Oct;2(5):334-42. (Pubmed link)
8. Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ. 2001 Oct 2;165(7):905-6. (this paper is available for free here)
9. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001;32(5):1054-60. (this paper is available for free here)
10. Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003 May 13;60(9):1424-8. (Pubmed link)
11. Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83. (Pubmed link)
12. Messe SR. Stroke Risk. BottomLine Health. 2010;24(3):1-2. 

Decompression - Yeah right

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Marketplace, a Canadian Broadcasting Corp (CBC) investigative TV show did a piece on decompression for low back pain.  This news item might get a lot of people angry.  I figure those who get mad will mostly be those who own and market the "decompression" machines.  Some of my chiropractic colleagues might get mad because they might believe that the chiropractic profession is put in a bad light but really I don't think so.  There was no inference that the problem with decompression machines is a chiropractic problem, the news piece just looked at one chiropractor's offices.  In fact they note that the College of Chiropractors of Ontario (the regulatory board for chiropractors in ONT) after being notified by Marketplace, will be investigating the chiropractor in the news piece regarding his advertisements.

So what are these non-surgical decompression machines?  Well they are just low back traction devices that cost a lot of money, thus require lots of patients to make the expenditure worth the money for the doctor.  Big bills means big advertising.  It is not uncommon for one to see very large advertisements in local newspapers.  These ads often have lots of claims of great success rates.  There are also claims that these are NASA technology.  Well those claims don't hold water as Marketplace found.  In fact the Oregon Attorney General's office has ruled that neither of these claims are valid and can't be used in Oregon.  I guess it's too bad if you live elsewhere.  I live in Connecticut and regularly see these ads in my local paper.

The real problem here is that people suffering with back pain are vulnerable to believing the advertisements because they are desperate to get relief.  The ads make it sound so good.  Go to the office, get an exam (may be just a wallet exam) and then get relief from this device with NASA technology and an 86% success rate.  Seems too good to be true, and of course it is.

Are there people with low back pain for whom traction is helpful?  The answer is yes but it shouldn't take thousands of dollars and months of care.  Research (1, 2) is starting to identify those people for whom traction is the best option but a definitive answer hasn't bee found yet.

So what is a poor suffering person to do?  Well one needs to find the doctor who isn't quick ordering any treatment or isn't really a one trick pony.  That means one that doesn't do traction on everyone.  Or doesn't do spinal manipulation on every patient.  Or doesn't schedule surgery - first thing. Or doesn't say exercise is a must for everyone.  Really treatment needs to be individualized to the patient.  One method for doing that is to use what my colleague Dr. Donald Murphy of the Rhode Island Spine Center has published as the diagnosis-based clinical decision rule.(3, 4)  There is more research that needs to be conducted on this method but I think it's the best model for how to manage the patient with spinal pain and determine the appropriate treatment.

SMP

1.    Fritz JM, Lindsay W, Matheson JW, Brennan GP, Hunter SJ, Moffit SD, et al. Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? Results of a randomized clinical trial and subgrouping analysis. Spine. 2007 Dec 15;32(26):E793-800.
2.    Raney NH, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Deyle GD, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009 Mar;18(3):382-91.
3.    Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord. 2007;8:75.
4.    Murphy DR, Hurwitz EL, Nelson CF. A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature. Chiropr Osteopat. 2008;16:7.

Zero Tolerance - Sex With Patients

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The College of Chiropractors of Ontario (the equivocate of a state board of chiropractic examiners) suspended the license of a chiropractor for 5 years for professional misconduct.  The doctor in question, treated his girl friend and then marked her bills paid.  She submitted them to insurance and would give him the funds.  After they broke up he tried to collect the balance of her account and then referred her account to a collection agency.  She didn't complain about his having had a sexual relationship with her, she complained about his billing practices.  Nevertheless there is a zero tolerance policy for having sex with patients and the College
The college's decision was based upon one salient fact, the doctor was having sex with a patient.  The nature of their relationship was immaterial. 
The issue which I've stressed in my classes on ethics and risk management as well as my ethics column that any relationship founded upon an imbalance of power is not consensual.  In the doctor-patient relationship the doctor has the professional knowledge and knowledge is power.  Thus there is a professional boundary between the patient and the doctor that can never go beyond that relationship.
SMP
For more details see the article in the Globe and Mail:  Giving care to his girlfriend puts chiropractor in hot water or on CTV Waterloo chiropractor loses his license

Foot Detox Pads

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Laura Johannes writes in the WSJ online about the silliness called foot detox pads.  Congratulations for getting to the bottom of this pile of crap.  The sale of these pads and the use of ion detox foot baths are proof positive that science hasn't really affected the thinking of enough Americans to prevent snake oil salesman from making a living in our modern age. 

The great irony of today's internet, driven by content sensitive advertising is that the "sponsored links" just below her article are for three companies that sell the items she has just attempted to debunk.  Gotta love adsense or is it nonsense.

SMP

Autism's False Profit - Disciplined

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Andrew Wakefield is the medical doctor whose discredited research started the whole scare over MMR causing autism has been disciplined by the General Medical Council (GMC) in the UK.  The GMC (the regulatory agency that oversees the medical profession in the UK) ruled that Wakefield had showed a “callous disregard” for the suffering of children.  They also ruled that his research was deceptive. 

Wakefield and colleagues published a paper in the prestigious and venerable British medical journal, The Lancet which detailed 8 children who supposedly became autistic after getting the MMR vaccine.  The children had gastrointestinal symptoms which lead to the theory that the vaccine changed the permiablity of the GI track and allowed substances into the blood and eventually to the brain resulting in autism.  The paper said that the children were consecutively seen when this was not true.  Most of the authors retracted the paper 6 years after it was published and today the journal completely retracted the 1998 paper that created all the controversy.  What allowed the journal to retract the paper was the GMC's decision that the paper was deceptive. 

I guess one could say too little too late.  On the other hand I view this as the self correcting nature of science.  Clearly there has been significant harm because of this paper and the hysteria it has provoked.  Those who believe that vaccines are the cause of autism, of course, will not let any amount of scientific evidence change their minds.  As it is said “You cannot reason people out of a position they have not reasoned themselves into.”

SMP

NY Times article about this

Destroying the best health care system

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The great myth that some opposed to health care reform propagate is that we have the best health care system in the world and any reform effort will destroy it.  Nicholas Kristof destroys this myth in an Op-Ed piece in the NYTimes. 

The argument goes our health care is the best so reform will only destroy it.  Except that we are 31st in life expectancy, 37th in infant mortality, 34th in maternal mortality.  I could go on but check out Kristof's column yourself. 

The biggest problem I see is the reliance of the masses upon cable news or radio to learn what the truth is.  I do not suggest that anyone take Kristof's take as the reality find out the facts for yourself. 

For example I had a friend send me an email about how the health care reform bill was going to make seniors get end of life counciling.  You know Ms. Palin's idiot rant.  I didn't listen to Palin or any of the so called experts in the email - I went to the Library of Congress' web site and searched though the bill in question for myself. 

Kristof provides the reference to where is data come from:  The Robert Wood Johnson funded study by the Urban Instiitute How Does the Quality of U.S. Health Care Compare Internationally? Thus, one need not read my or Kristof's spin. 

As my dad told me as a kid don't believe what people tell you find out for yourself.

SMP

Health Care - Controlling Costs? Control Behavior

When we hear about health care reform and the importance of controlling costs the fundamental problem is that we can't really control costs by legislation.  To control costs we need to do one thing, change behavior.  The billion dollar question, ok it's probably a 700 billion dollar question is whose behavior? The answer everyone's, doctors and patients. 
NPR and PRI's The American Life recently had a series of pieces on the costs of health care.  They have, I believe, laid out the complicated but fundamental problem insimple way.

• Doctor's perform too many procedures that people don't really need. 
• Patient's demand too many procedures that they don't really need (and doctor's cave-in and order or do those procedures
• Advertisements are fueling the demand for costly drugs.  

There are other issues too.

The high cost of drugs.  My own insurance policy changed. In the past we paid 5, 10 or 15 dollars co-pay on a prescription.  Now the co-pays can be higher.  Oh boy can they be higher.  I've had dandruff and the shampoos that one could buy at the supermarket weren't working anymore.   So the dermatologist wrote me a perscription for a shampoo that worked like a dream.  I've used the stuff for 3 years.  It was great, depending on the season using this 1-2 times per week (only approximately tablespoon full) and I was fine.
Well with the change in insurance this shampoo wasn't covered.  The cost...over $300 for a small bottle! By small I'm talking a 4oz bottle!  The pharmacist said that he wouldn't pay that much for shampoo unless it "got him a supermodel."  I've got a different prescription shampoo now.  It's only $125.  Cheap?  Ok, cheaper!  Still the problem was I was completely insulated from the extreme cost of the shampoo.  I would suspect that the vast majority of people using that shampoo were likewise insulated from the cost and thus there was no market pressure to cut the cost.  Think about how much the cost of a band name drug drops once the patent protection runs out and their are generics.  Of course the brand name never gets as inexpensive but it still is cheaper.

American's LOVE brand names.  I remember when I got my first Polo brand shirt.  The little guy on the polo pony was on embroidered on the shirt tail.  Too see the logo one would have to really know where it was to see it.  Now of course it's critical that everyone actually see the logo to know you own a Polo.  I think this is way Tylenol is still one of the best selling drugs, even though one can buy a generic for much less.  People buy expensive brand names when the generic is cheaper. 

Watch and wait - a treatment approach

Image via Wikipedia

The September 22nd issue of the Wall Street Journal has an interesting column by Melinda Beck, "Getting Well: It's About Time."  To make it simple this about about how so much waste is involved in our health care system because we are impatient.  For many conditions one would do best to just wait.  In a previous blog I present an anecdote about Dr. Paul Glasziou using the best treatment for his 2 year old's otitis media, "watch and wait".  Ms. Beck cites a few different doctors who note the value of such a non-treatment approach. 
There are a bunch of great quotes in this piece:

• "Most people's bodies and immune systems are wonderful in terms of handling things—if people can be patient," Ted Epperly 
•  "I have a mantra: You can do more for yourself than I can do for you," - Raymond Scalettar

The estimate is 1/3 of the US expenditures on health care would be saved if we did less, when appropriate.  Ms. Beck presents a list of when one shouldn't wait such as signs of stroke, heart attack, majory injury etc.
 The bottom line is better health care decisions on both patients' and doctors' parts would save us a ton.

"The art of medicine consists in amusing the patient while nature cures the disease."
Voltaire (1692-1778)

SMP

Baseball and health care - evidence based care

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As I hear more debate (or is it partisan rancor - I mean despite obvious lies not one Democrat disrespected the office of the President and yelled to President Bush liar) regarding health care reform I am reminded of a remarkable Op-Ed piece from the NY Times (of course) by the strangest of bed fellows: Billy Beane, Newt Gingrich And John Kerry.  For those who do not know Beane is the VP and General Manager of the Oakland A's, I might be wrong but I figure everyone else knows former Congressman Gingrich and Senator Kerry.

Just brings Garrett Morris as Chico Escuela on SNL- "Baseball be berra good to me"

Why would baseball be a benchmark for health care?  Because baseball is a game of statistics and coaching decisions and in particular staffing decisions are made by using those statistics.  The use of a newer way of looking at baseball statistics is what Beane is known for.  It is called sabermetrics. And the point of this op-ed is better health care is possible if we use the data, i.e. evidence based health care.

SMP

Malpractice 3

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In today's CT Post, Robert A. Levine, MD writes an Op-Ed on health care reform and malpractice. I have to say that when I saw the headline I thought this was going to be another kill the lawyers piece that I see so often. Or maybe another Republican-like plan to restrict the amount of jury awards to people actually harmed by negligent care.
Instead, Dr. Levine presents a cogent argument about what is wrong with our current system and suggested objectives that any reform measure should include.
I would post a link to his article but unfortunately the publishers of the CT Post have never read "What Would Google Do?" (WWGD is a great book by Jeff Jarvis which would argue that the CT Post should put the whole content of the newspaper on-line for free - remember what has Google every charged you? ZERO).
Dr. Levine's five objectives in any system intended to address medical negligence and malpractice are:

1. Decreasing the incidence of negligence and improving quality of care
2. Properly and rationally compensating individuals who have been significantly injured as a result of negligence
3. Removing incompetent physicians from patient care
4. Punishing physicians guilty of negligence
5. Having a process both patients and physicians believe is equitable.

As I've noted in previous blogs about malpractice a large problem isn't frivolous suits but negligent care. Dr. Levine notes that many who are seriously injured never receive any compensation because they don't file suit. Currently too many bad doctors, regardless of the specific profession continue to practice or shall I say malpractice.
Hopefully, any plan to come out of Congress doesn't just limit the amount paid out in malpractice cases for all that will do is ensure that some patients who really need compensation don't get it.
SMP

Swine Poop - Swine Flu & Chiropractic II

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To quote President Reagan "there you go again". Once again a high profile chiropractor is there suggesting in a press release that chiropractic spinal manipulation is part of a reasonable flu prevention strategy. See my previous blog entry on Swine Flu & Chiropractic.

I know I could sit back and wait for the blogosphere of chiropractic critics to appropriately lampoon this press release. But then they would imply the entire chiropractic profession believes this but I won't be painted with that same paint brush.

I'll put it in the simplest language possible. This idea that "nerve interference" somehow leads one to be vulnerable to infection is swine poop. And the idea that one needs to see a chiropractor to make sure that there is no "nerve interference" so that one's children's immune systems will function at their best is swine poop, too.

As Max Planck wrote in 1936:

An important scientific innovation rarely makes its way rapidly winning over and converting its opponents; it rarely happens that Saul becomes Paul. What does happen is that its opponents gradually die out and that the growing generation is familiarized with the idea from the beginning.

Unfortunately, when it comes to chiropractic the opponents of rational thought and the scientific method within chiropractic seem to reproduce er proselytize before they die out. Thus, this pseudo-religious thinking persists within chiropractic medicine. Exposing this pseudo-religious thinking does not appear to force it underground. (1, 2) It seems that the Internet has allowed this form of lunacy to flourish as much as any other form of C.R.A.P. (convoluted reasoning anti-intellectual pomposity)

The most insidious part of this press release is that the writer has a legitimate degree in public health, an MPH. This might give the laity the belief that this is a legitimate idea. Likewise, one of those cited in the press release has an impressive sounding title as president of an organization with an impressive name. None of this provides any evidence that the press release actually presents valid information about the importance of the subluxation.

The fact that the CDC is cited also gives the illusion that this press release has some scientific merit. It only shows that the writer knows how to package this swine poop so it looks good. Or as was used so often in the last US presidential election, he's put lipstick on a pig. The central premise, go to a chiropractor so he/she can remove the subluxation which causes nerve interference which leads to a poorly functioning immune system is still swine poop.

Obviously the writer of the press release is intelligent. But as I noted in an earlier blog ideological immunity is not the domain of the unintelligent.

Now of course the author of the press release might posit that it is I who have the ideological immunity and just can't see the profound value to one's immune function by removing the ubiquitous nerve interfering subluxation. He might be right. Sometimes people with deviant thoughts are right: think the long road to that Drs. Marshall and Warren traveled before the role of H pylori in duodenal and gastric ulcers and stomach cancer was acknowledged.

However, as Carl Sagan wrote in Broca's Brain:

I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence.

Clearly the idea that subluxations cause nerve interference which then reduces the effectiveness of the immune system is an extraordinary claim and it requires extraordinary evidence. I think as with any rational scientist I am willing to be shown to be wrong in my assessment and change my thinking. The growth of scientific knowledge is made by shattering the previous truths. BUT one won't shatter the current state of scientific evidence exclusively with the pronouncements or press releases of a self-professed expert. Show me the beef er the research that subluxations cause nerve interference and that it reduces the effectiveness of the immune system. Since we wrote our paper on the subluxation (3) I've not seen any evidence yet that our assessment was wrong.

Please prove us wrong by providing extraordinary level of scientific evidence (heck how about any valid scientific evidence). I'll tell you if those who believe this swine poop think that the first author on our paper, the late Dr. Joe Keating would be rolling in his grave if the evidence was presented, I'm here to assure you that I know he'd be cheering. Because Joe and the rest of the authors are basically saying put up or shut up. Please put up or shut up!

SMP

1. Mirtz TA. UNIVERSAL INTELLIGENCE: A Theological Entity in Conflict with Lutheran Theology. J Chiropr Humanit. 1999;9(1). free full text here
2. Mirtz TA. The question of theology for chiropractic: A theological study of chiropractic's prime tenets. J Chiropr Humanit. 2001;10(1). free full text here
3. Keating JC, Jr., Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF. Subluxation: dogma or science? Chiropr Osteopat. 2005 Aug 10;13:17. free full text here

The Making of the American Health Care System

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A colleague gave this to me to post anonymously.

October 26, 1943: Healthcare’s Pearl Harbor

Unlike that actual Pearl Harbor attack on Dec. 7, 1941, the health care Pearl Harbor which occurred two years later did not make headlines, was not addressed by President Roosevelt in a joint session of Congress and did not result in massive death and destruction. Indeed, there were probably only a small handful of people who were even aware that some happened on October 26 that affected health care.

But like Pearl Harbor, the events of October 26, 1943, were cataclysmic. They changed, fundamentally, irrevocably and for the worse, the trajectory of the health care system for the next 66 years (and counting). To understand the events of that day we have to back up a few years to beginning of WW II. Within months of our entry into WW II the size or our armed forces swelled from a few hundred thousand to many millions, eventually peaking at 16 million men and women in uniform. Almost all of these 16 million were taken from the existing workforce. This resulted in very severe manpower shortages in industry. As well, the Defense Department (known then as the War Department) consumed huge quantities of natural resources (rubber, iron, coal, gas, etc.). These manpower and resource shortages necessitated the implementation of wage and price controls for the duration of the war.

Private sector industries were desperate for workers but were prohibited from offering high wages to attract them. They were permitted to offer some benefits, health insurance among them, without violating the wage and price rules. It’s worth recalling the state of health insurance (and health care itself) at this time in history. Health insurance in 1941 was an anomaly. Both the Kaiser system and the Blue Cross systems were developed in the 1930s, but these touched very few lives. Overall, more than 95% of the population was uninsured. In 1941 health care expenditures accounted for less than 2.5% of GDP as compared to 17.6% of GDP today. But this data point doesn’t even begin to describe the minimal state of health care at the time. Today we spend $8,300 per capita on health care. In 1941 we spent, in 2009 dollars, $325 per capita on health care. (I spent twice that much last week in one dental appointment.) As compared to the health care industrial complex of today, the health care system was a cottage industry in 1941.

In any case, the wartime health insurance benefit did become a popular and effective means of attracting workers. And then came October 26, 1943. On that date the question was answered: Are employer-based health insurance benefits taxable as income? Until that day there was no answer to this question. Mostly companies offering health insurance did not report this as income, but some did. All these companies wanted a clarification from the IRS.

It is not recorded whether there was any political debate on this question. Were there advocates (perhaps the insurance companies) of tax-free health insurance? We don’t know. Were there opponents of such (perhaps budget-conscious Congressmen)? We have no idea. Were there any discussions of the possible implications of this ruling on our health care system? It’s very unlikely. Certainly given the state of our health care system at that time no one would have thought to utter the phrase, “We have to get our health care spending under control.” This would have been nonsensical. If there was any active consideration of this policy it surely would have been something like, “Health insurance? More people having health insurance is a good thing. Let’s leave it alone.” Or something like that. So, on October 26, 1943, a person, panel, of committee who to this day is unknown and un-named, ruled that employer-provided health insurance is not taxable income. And the rest is history. (In 1954 an act of Congress finally ratified and made permanent this IRS ruling.) Before detailing the mostly deleterious effects of this event, lets’ quickly recount the trajectory of the health care system over the next few generations.

As millions of servicemen and women were demobilized and returned to the civilian workforce the concept of the health insurance benefit had reached a critical mass. In the heavily unionized industries the addition of a health insurance benefit became one the most sought-after benefits of collective bargaining. And in the professional and managerial classes the offering of a health insurance benefit continued to be useful recruiting tool. In 1941 there were fewer than 5 million people in the US who had some sort of medical/hospital insurance. By 1950 that had grown to over 100 million, most of this based on employer-provided insurance. (Interestingly, individually purchased health insurance also increased rapidly during this period and peaked in about 1970 and thereafter steadily shrank as a mode of health insurance purchase.)
Along with this revolution in health care funding came a revolution in health care itself. In 1941 Sulfa drugs were just being introduced. Penicillin and other antibiotics were still several years away from practical use. Insulin to treat diabetes had been in regular use for several at this point and you did have a good chance of surviving appendicitis surgery and basic obstetrical care was probably doing some good as well. And if you had a serious cut or laceration could stitch you up and hopefully avoid infection. But that was about it. Even with the best health insurance plan in existence it would still have been very difficult to find much to spend health care dollars on. And then everything changed. Without belaboring the point there was an explosion of health care technology: New antibiotics, new steroids, new psychoactive drugs, heart surgery, transplant surgery, chemotherapy, radiation therapy (not entirely new), CT, MRI, PET scans, Gamma knives, stents, implants, new hips, news knees, new lenses, cochlear implants…the list goes on and on. (It is another story whether or not all of these advances are in fact advances, but that’s a different story.)

All of this increased health care purchasing power and expansion of medical technology obviously dramatically increased the demand for services and it quickly became clear that our health care infrastructure was inadequate to service this demand. Multiple pieces of legislation were enacted to correct this. Most notably the Hill-Burton act of 1946 provided funding for the construction of new hospital facilities. The goal was to achieve a density of 4.5 hospital beds per 1,000 in all locales of the country. Many other pieces of legislation during this post-war period subsidized and expanded the health care infra-structure including a dramatic expansion of the health care workforce.
Thus there were three forces that drove health care from being a cottage industry to being a Mega-industry:

• Increased health care purchasing power
• Increased health care technology
• Expanded health care infra-structure

Collectively these three forces have produced a 25-fold increase in per-capita health care spending since WW II. The principle engine that drives this explosion of health care spending is employer-based health insurance.

Which brings us finally to the issue of why the October 26, 1943 tax ruling has been so damaging to our health care system:

1. It has tied health insurance to employment. One thing that everyone hates about our health care system is that for most people the only practical way to secure health insurance is through one’s employer. The tax advantage offered by this mode of insurance makes other options impractical or unavailable. And so our health insurance is only as secure as our job and we end up making career decisions based on the effect if will have on our health insurance status. All of this is a stupid, inefficient and arbitrary way to organize both our health care system and our workforce.

2. It has subsidized the purchase of health insurance. In 1943 the idea of subsidizing the purchase of health insurance probably seemed like a pretty good idea. It could hardly be said at the time that we were over-insured. But over the decades those of us who do have employer-based health insurance are typically over-insured. When it is possible to buy $1 dollars worth of insurance for $0.75 (which is the effect of the tax subsidy) we will rationally choose to buy more health insurance that would otherwise be the case. When health insurance was still in its formative years (1945-1965) most insured people had what as called “major medical” insurance, that is, catastrophic insurance. But over time this has become the exception rather than the rule and the insurance subsidy has resulting increasingly lavish and comprehensive insurance policies. The idea of insuring against large and unforeseen health care expenditures has been replaced by the idea of insuring against routine and predictable health care costs.

3. It has separated the purchaser (patient) and seller (doctor, hospital) from the cost implications of health care. In 1965 a threshold was passed: more than half of all health care expenditures were paid by third parties. Prior to the health insurance revolution most health care was paid for as you would pay for anything else—out of pocket. And since 1965 the percentage paid by third parties has continued to rise and has now leveled-off at about 80%. No other sector of our economy is characterized by such a triad (buyer, seller, payer). In this triad the buyer is essentially indifferent to cost and provides no brake on utilization or price. The seller is of course is incentivized to increase price utilization and finds little resistance from the buyer. And the payer tries vainly, and to no one’s satisfaction, to apply some brakes to the system. The buyer’s indifference to cost is further manifested by their indifference to the cost of health insurance itself. The perception on the part of the employee is that their company’s health benefit is “free” or most free depending upon their contribution. In fact the cost of employer provided health care is 100% paid for by employees in the form of lower wages. But this fact is not visible and in fact believed by most even when they are apprised of this fact. (It must be noted that economists have extensively studied this question and there is no disagreement on this issue.) Being indifferent to the cost of insurance employees are only interested in expanding the benefit as much as possible in the mistaken belief that it is free to them and this of course further exacerbates the problem of over-insurance.

4. It has artificially increased the demand for health care services. In 2009 over 100 million advanced imaging studies (CT/MRI) will be performed in the US. One in four Americans will have an imaging study of some sort, some of them, multiple studies. No, not all of them are unnecessary. I imagine there are several million people who will benefit from these studies. But most of these 75 million imagees (is that a word?) will not benefit and the fact that they will not is entirely understood and predictable. This excess (and the excesses of every other procedure, device, drug that is a part of our health care system) is only possible through the artificially pumped-pumped up demand created by subsidized employer sponsored health insurance.

5. It has crowed out other forms of health insurance. If one is employed and if one’s employer offers a health insurance benefit, it would be economically irrational to forgo this benefit and attempt to buy an individual policy with after-tax dollars. There is no possibility of getting as much for your money as you would with your employer’s plan. And so no one acts in this manner and thus the individual and small group insurance market is atrophied and inefficient. To be sure, without the tax incentive, employer-based health insurance would still be a viable option. We do, after all, sometimes get life insurance and disability insurance through our employers without the inducement of tax subsidies. And employer-based health insurance is an effective way to pool risk. But an efficient and effective insurance market needs more than just one viable and practical option.

6. It has ultimately resulted in a positive feedback loop of cost escalation. And so, for the past 67 years we have been caught in an ever accelerating positive feedback loop of health care cost increases. As medical technology and infrastructure expand the need to fund this expansion drives up the cost and the need for health insurance. An anxious public is frightened to death at the prospect of paying for the scan, the surgery, the drugs and this public makes clear to the employers that their health insurance benefit must keep pace with these costs. The employers oblige as best they can and continue to fund premiums which tend to increase at about twice the rate of underlying inflation. And the next round of technology and price increases is thus funded and the process continues. Thus, we spend 17.6% of our incomes on health care, soon to break the 20% barrier.

It would be a vast oversimplification and simply wrong to suggest that all of our health care woes are caused by tax-subsidized, employer-based health insurance. But it is not wrong or an oversimplification to suggest that this is the single biggest factor driving the inefficiencies of our system. And it is, frankly, an easy problem to fix. But it appears that we won’t get this fix. Instead we are being to treated 1000+ page health legislation which will not become law in any case. Let me offer a 39-word health care reform bill that just might do the trick:

The Commissioner of the IRS shall revise the tax code such that from 2010 to 2015 the portion of employer-based health insurance benefits that is treated as taxable income shall increase in a linear fashion from 0% to 100%.

Preventing Deaths From Treatable and Preventable conditions

Image by seiuhealthcare775nw via Flickr

The health care debate rages on and most of the discourse seems to be full of opinions that are bereft of data. A recent NYTimes editorial notes that an Urban Institute study shows that American health care does somethings right and others wrong. The Times editorial highlights the fact that American health care seems to fail at preventing deaths from treatable and preventable diseases.
While the most jingoistic Americans are blind to the quality problems in our health care system, the recognition that the American health care system could do better has been known for a long time. One of the most through studies about quality of American health care was published by the Institute of Medicine over a decade ago.
Crossing the Quality Chasm: The IOM Health Care Quality Initiative

The IOM Definition of Quality is one I think everyone should keep in mind:

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

With so many people complaining that they don't want the government to decide on health care decisions, I wonder why we have assumed that insurance companies, for whom less payments to health care providers means more profit, are some how better than the government without profit motive would do. Whether it is the government or a for profit company making decisions on what health care interventions are appropriate and should be paid for, it would be nice if this definition of quality were foremost in everyone's mind.
SMP

Stupid Until Proven Intelligent - MD & DC Relations

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Around 1986-7 I was the medical director for a track meet at West Point. At that time I was in charge of all medical care for all of the Metropolitan Athletics Congresses events. I must have worked at 40-50 track and cross country events a year.

Whoever was a top US 100m high hurdler fell and hurt her leg. The pain was on the lateral side of her lower leg. A tuning fork test suggested an unusual fracture one of the fibula. The tuning fork test is where one puts a 128Hz turning fork on a bone with a suspected fracture (not right over the site of injury) and the vibration is supposed to irritate the fracture side and cause pain.

I drove this woman to the base hospital and spoke to the admission clerk, reporting a suspected fibular fracture. The attending was standing nearby and overheard me. He said, “don’t you mean tibia?” I replied, “no, fibula.” He asked why I thought fibula. As I said this is not a common fracture.

I said location of pain and a positive tuning fork test. That of course provoked questions about the tuning fork. I said that it was a standard on-field screening test in sport medicine.

MD: “Sports medicine? That’s a specialty?”

Me: “I’m certified” {I was a CCSP (Certified Chiropractic Sports Physician - except due to NYS bizzar rules I was supposed to call myself a Certified Chiropractic Sports Practioner}

MD: “I didn’t know there were fellowships in that?”

Me: “I did post grad training”

He then asked if I could show him how to do it on a woman just brought in by ambulance. She crashed on the base ski run. He had to get a nurse to unlock the cabinet with the tuning forks. They had the box set with every frequency. I took out the 128Hz and showed him how to use it. Later after my athlete’s radiographs came back negative we talked some more. He asked what hospital I work at and then I said, “I don’t, I’m a chiropractor.”

Lindsay Rowe, DC, MD taught me this "technique" to deal with medical prejudice towards chiropractors. He said that to many MDs you are stupid until proven intelligent if they know you are a chiropractor. So prove you are intelligent and then let them know you are a chiropractor. I’ve used it often to great effect.

The example Lindsay gave me was that before he went back to get his medical degree, he used to travel the US. Wherever he was he'd call the local medical school and try to speak to the head of radiology department. On the phone he would introduced himself as a radiologist from NZ with interesting cases. Lindsey is a board certified chiropractic radiologist. {BTW two studies have shown that chiropractic radiologists (DACBR) are as good as anyone else in reading skeletal films.(1, 2)} If he got to meet with the radiologist they'd play what I call, "stump the radiologist."

Then when they were done trying to stump each other he’d reveal he was “only” a DC. Lots of surprised looks. He was invited to give grand rounds a few times and audience was only told what his training was at the end. Most couldn’t believe it because of course we’re all dumb as door-nails.

I've used this technique for many years. Fortunately, I don't run into such overt prejudice as often as I once did. My favorite example was the MD at a cocktail party who upon hearing I was a chiropractor dropped my hand, mid-handshake, spun on his heels and walked away without a single word.

Because of my work with the ING New York City Marathon and the New York Road Runners I often come in contact with MDs and haven't had that kind of thing happen. I guess that means my profession is moving more into the mainstream of health care, but we have work yet to do to be completely in mainstream health-care.

SMP

1. Taylor JA, Clopton P, Bosch E, Miller KA, Marcelis S. Interpretation of abnormal lumbosacral spine radiographs: A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic. Spine. 1995;20(10):1147-54.
2. de Zoete A, Assendelft WJ, Algra PR, Oberman WR, Vanderschueren GM, Bezemer PD. Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists. Spine. 2002 Sep 1;27(17):1926-33; discussion 33.