How Much Of The Medical Literature Is Wrong?

medicalnews2One of my favorite recent articles is a review by Dr Christopher Labos in Medscape describing why what we read in the medical literature is not always correct. If it is reported as published in the New England Journal of Medicine we tend to believe it true. Unfortunately, all studies are subject to errors ranging from flawed assumptions to just plain chance. Ultimately for a study to be accurate it should withstand the test of time and be replicated – which is really the scientific method. However not all studies are replicated. Lobos cites a review of 45 studies in major medical journals; 24% were never replicated, 16% were contradicted by further studies, and in 16% the effect reported turned out to be smaller than originally reported. Some of the associations reported in the past which made headlines and which have turned out to be false include: Coffee consumption increases pancreatic cancer risk, cell phones cause brain tumors, and estrogen replacement prevents heart disease. Something to think about when you read about the next breakthrough.


Until next week.  Dr Ed Taubman, Primary Care Doctor, Olney MD  301-774-5400

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What’s New In The Medical Literature

medicalnewsThis week, rather than delving in depth on a specific topic I thought I would get off my soapbox and summarize some recent literature that is of interest to me as a physician and which may perhaps have impact on health care in the not too distant future.  Let me know what you think of this format!

-A number of articles and an editorial in the New England Journal of Medicine document that even though the media is focused on new and experimental treatments for Ebola that many lives can, and are being saved, with the use of intravenous fluids, attention to oxygen needs, and treatment of secondary infections.  Though such treatments are commonplace in intensive care units such as those in our own community, they are lacking in Africa – which contributes to the high death rate there.  In essence Ebola is a serious viral infection which can be treated with existing known management strategies.

-Previously I have touched on the childhood obesity epidemic.  So how do we get adolescents, for instance, to cut back on the sodas they are drinking?  In a study done by the Johns Hopkins Bloomberg School of Public Health adolescents going to the store were shown how many calories were in the beverages they were consuming vs how many miles they would have to walk to work off a single soda.  The authors reported that “adolescents who were given caloric information associated with a sugar-sweetened beverage in a format they could relate to” ie how many miles they would have to walk to work off a single soda were more likely to purchase a smaller sized soft drink, choose a diet beverage, or forgo the beverage altogether.   Makes sense to me.  Seriously, maybe we should do the same thing on food labels in general.

-So, you’re a drug company and want to test to see if your new drug is better than a placebo (dummy or sugar pill).  To get FDA approval you need to spend tens or even hundreds millions of dollars doing trials to prove your drugs are safe and effective.  Sounds straight forward; but in actuality many people in drug trials are just like everyday patients – they often don’t take their medicines as directed – which means the researchers doing the study may get ambiguous results or need to enroll many more patients to find true differences among different treatments; doing so makes the trials that much expensive to do which ultimately drives up the cost of the new medicines.

As reported in Science some strategies being discussed to deal with this include putting microchips on pill bottles to show how often the bottles have been opened and even inserting microchips into the pills themselves that can radio to monitoring devices that they have actually been ingested!  And finally, researchers have discovered what may be genetic traits that make some people inherently more predisposed to respond to dummy pills or just want to please; in drug trials they may be more prone to report benefits and not report adverse effects.  If too many of those people are in drug trials they could influence the results in a way that makes it hard to tell if a drug was better than a dummy pill;  in the future genetically testing for such traits to limit the number of such people in drug studies might one day increase the reliability of drug studies, reduce the number needed to find a benefit, and ultimately reduce the cost of bringing new treatments to market.

Until next week.  Dr Ed Taubman, Primary Care, Olney MD  301-774-5400

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Where To Get a Flu Shot?

My concerns with the corporatization of health care.

saveflushotJust the other day, I had a case where an elderly woman was in a lot of pain, so I called in prescriptions to the local grocery store pharmacist to help alleviate the pain and make her more comfortable. The next day the family called to say she was on the way to the emergency room because the pain had gotten worse. I asked how many of the pain pills she had taken and was told none—the prescription had not yet been filled by the pharmacy.

Concerned about this woman’s prescription I again called the pharmacy. I asked the grocery store pharmacist why it took a day to fill a prescription that I had personally called in, and he told me that they were way behind in processing prescriptions because they were so busy giving flu shots!

Pharmacists too busy giving shots to fill prescriptions? So here I am, back on my soap box to complain about the corporatization of health care at all levels and the accompanying trivialization of the role of primary care in our society.

In primary care circles, there is increasing talk of the demise of primary care medicine; for this and a multitude of reasons. In my one-person doctor office, for instance, we outlay over 60 thousand dollars a year to stockpile immunizations and injectibles; with a large chunk of that going to seasonal flu shots. Every time a patient goes to the grocery store or pharmacy to get a flu shot, a primary care practice somewhere has to struggle that much more. Every time a patient goes to a walk-in clinic for a sore throat or relatively minor illness, it means that a primary care practice has fewer ways to offset the time spent managing more complicated patients, for which reimbursements are inherently low. And so it goes on and on.

It has become more and more acceptable for patients to get their flu shots at the grocery store or pharmacy lured by discounts at the checkout counter, or to go to the walk-in clinic for a minor illness, or to the emergency room for something a primary care doctor could easily diagnose and treat. No longer is there a caring and knowledgeable primary care physician and staff looking at the big picture. The patient becomes his own primary care provider.  After consulting the internet, said patient refers himself to more and more specialists who, not knowing the patient, order more and more tests. People then wake up one day and wonder how medicine became so costly and fragmented and wonder why it’s so hard to find a good primary care practice.

The answer to that question starts with that grocery store flu shot.

Until next week this is Dr. Ed Taubman Primary Care, Olney MD, where we still give vaccines, draw our own blood, and give people the personalized care they deserve. Call today to book your appointment with the top primary care doctor practice in town, at 301-774-5400; where friendly and helpful people are ready to serve you and the doctor actually picks up the phone to coordinate your care with your other health care providers.

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Medicine, Ebola, And Checklists

check listThe recent case of a Liberian with Ebola virus not being recognized by a Dallas emergency room provides a reason for me to get on my soap box and complain about the transformation of American medicine into a checklist mentality.  While I understand that checklists can play important roles in certain industries – the classic case being pilots making sure flaps are up before takeoff and nurses in operating rooms making sure all instruments are accounted for after surgery – a checklist mentality has now permeated all aspects of medicine.  The problem is there are now so many checklists to be completed that health care workers are too close to the checklist trees; and sometimes miss the big picture.  Once checklist A has been completed, then it’s on to checklist B and so it goes, on and on – all in the name of good care.  The problem is that medicine has a lot of subtleties; it’s not just black and white but lots of greys.  Good clinical judgment cannot be captured by a checklist and good medical care requires great communication. This means people need to talk to each other – which is difficult when one is glued to a computer filling out checklists.  Medicine is an art as much as a science; that’s why to become a doctor takes over a decade.  There aren’t enough checklists in the world to ensure good medical care.

Checklists in medicine evolved initially to keep insurance companies from denying payments for alleged lack of documentation and to help fend off lawsuits.  The problem with checklists is that they are often used as excuses to allow less expensive (and less trained) personnel to provide care.  Moreover, the checklist recepients have become immune to paying attention to the lists due to checklist information overload.   And it’s not just checklists – All day long our fax machine and computer are spitting out voluminous computer-generated notes from doctors’ offices describing five minute visits for minor medical problems.

What we need in medicine is less time checking lists and more time for more qualified people to think and analyze.  People need to get up out of their seats and away from their computers and to communicate the old-fashioned way – by talking.

In Dallas the hospital initially acknowledged that a nurse took a travel history and filled out a checklist, but the information never made it to those responsible for the care of the patient. Their most recent explanation as reported on CNN is “As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record, including within the physician’s workflow,”  In other words blame now is being shifted from the nurse (her job ended when she put the travel checklist into the computer) to the “full care team”.  Using the term “full care team” might be an artful way of saying the patient wasn’t actually seen by a doctor, but rather by a nurse practitioner or physician assistant.

Regardless of who saw the patient it is tempting to try to put the blame on the nurse, or the doctors, or conclude that their computer system just needs an upgrade to better flag alarming issues.  The real problem is the electronic checklist mentality which is overtaking medicine.  And though the bean counters would like us to believe that good medicine can be quantified and accomplished by more and more computerization, this should serve as a wake-up call to the contrary.

Until next week this is Dr. Ed Taubman primary care Olney MD 301-774-5400 where friendly and helpful people are ready to serve you and the doctor hasn’t forgotten how to pick up the phone to coordinate your care with your other health care providers.

New Treatments For Congestive Heart Failure On The Horizon

ChronicHeartFailureCongestive heart failure can be a serious ailment leading to shortness of breath, fluid retention, and early death.  About 2% of adults are diagnosed with this condition; and for those 65 and over 6-10% are affected.  The most common causes are heart damage due to heart attack and blocked arteries but other conditions such as leaky valves, viral infections, and inherited conditions can also be causative.  As a damaged heart continues to pump its undamaged tissue can get overworked and eventually wear out.  As a result congestive heart failure tends to get worse with time.  Treatments for this condition date back to over two hundred years ago with the introduction of digitalis, a derivative of the foxglove plant. Although digitalis was the mainstay of treatment for centuries, modern studies have shown that digitalis, while making patients feel better, did not prolong longevity.

Over the last 30 years there has been incremental progress in the treatment of this condition as researchers have gradually better understood the underlying mechanisms contributing to worsening heart failure. The addition of drugs such as ACE inhibitors and ARB inhibitors, which are widely used to treat hypertension, and diurtetics such as spironolactone have proven useful in extending life and reducing symptoms. Mechanical devices like resynchronization pacemakers and automatic defibrillators, which shock the heart out of fatal irregular heart beats, have found their places in the management of congestive heart failure as well. More recently beta blockers, a class of drugs which had been avoided for years in heart failure because of concerns that they would weaken the heart, are now widely used; studies have shown that they can actually help protect the heart from further damage. Heart transplantation has proven to be an imperfect solution given the growing numbers of people with congestive heart failure and the considerable challenges to perfecting a safe and effective mechanical heart have yet to be overcome.

A new study reported last week in the “New England Journal of Medicine” reports on a new drug, LCZ696, part of a new class of medicines collectively known as angiotension receptor-neprilysin inhibitors. Combined with a traditional ARB drug valsartan, this new drug was studied in a group of over 8000 patients with heart failure; half received the new combination and the other half received standard treatments. Over a study period of more than two years, there was a 13% decrease in death, a 21% decrease in hospitalizations, and an accompanying significant improvement in symptoms. This study is a tribute to the international collaboration of researchers and the participating patients and will likely usher in a new era in the treatment of this ailment.

Dr. Ed Taubman Primary Care Olney, MD 301-774-5400
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