Fish organs for sale!

I suppose a Swedish fish libel would be preferable.

Ten reasons for health reform (with asterisks next to what Obama's effort might help with)

1. The uninsured.*
2. The uneven delivery of health care, which varies from hospital to hospital, region to region.
3. The money spent on ineffective care, using resources for the sake of those resources' continuing existence.*
4. The general unsustainability of expenditures.
5. The holes in our systems of preventive care*, care for immigrants, and care for non-English speakers.
6. The overabundance of specialists.*
7. The philosophical and ethical failures of the current medico-industrial establishment.
8. It all costs too much & we can't afford it (repetition of 4. for emphasis)
9. Other countries do it better.
10. If we give veterans, the old, and the poor evidence-based medicine (or at least we're starting to try) why can't we do it for everybody?×

Saving money while improving care

At the Health Care Blog, George Lundberg picks the following sources of savings, where comparative effectiveness research can help save money while guiding us to the most effective treatment. His confidence that screening mammography doesn't improve mortality seems misplaced (the data isn't clear, and the studies are difficult), and his jab at oncologists is impolitic, but otherwise this is a worthwhile list.

1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.


2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.


3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.


4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.


5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.


6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.


7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved.

Australiana

I know a family man
devotee of the Kabbalah
who set out to cure the Chlamydia
that is ravaging the koala.

"All my creatures are precious,"
said the Maker of all people,
"but don't forget your esoterica
in the pocket of the marsupials."

A new bilingual anthology of contemporary Yiddish poetry!

Very exciting, and not just because I am represented (and helped with the translating).

"It is precisely [the] remarkable and idiosyncratic character of Yiddish, which bridges languages, cultures, 'worlds of geography and universal human spaces', that shines through this anthology of contemporary Yiddish poetry. Inspired by Peter Yankl Conzen’s poetry and his deep knowledge of the Yiddish literary tradition, Step by Step. Contemporary Yiddish Poetry brings together the voices of contemporary Yiddish poets from throughout the world."

Buy it here.

God, Doctor, and Patient: The Uncomfortable Hospital Triad

I would never pray with a patient at the bedside. What doctor has time to talk about God? And who knows whether a patient will find the suggestion of prayer offensive, helpful, or rapport-building? Most of us doctors, when we think about prayer at all, keep it as far from our work as possible. I am an observant Jew, yarmulke wearing and Sabbath observing, and I pray three times a day. But never would I mention to my colleagues a word about my daily spiritual practice. We are practitioners of our own esoteric art, which we like to pretend is uncontaminated by outside influence, and our white coats are not cassocks. Even when an appreciation of religion might be of some use, we make an extra effort to keep it at a distance. When patients are about to die, or when our care is serving only to prolong suffering, we delegate the hard questions to highly trained ethicists sharing our worldview. When there's nothing left but to commend a patient's soul to its maker, we murmur something about "medical futility."

Thus the small but growing scientific literature linking prayer to health is discussed by nobody in my circles. It's in the same category as "alternative" medicine (acupuncture, Chinese therapies, ayurvedic medicine, and the like) or, for that matter, most of psychology - areas worth dabbling in but never imagined by orthodox practitioners as primary to the profession. Once organic causes have been thoroughly "worked up" (through appropriate technologies and laboratory tests), then we are free to speculate about the psychological and spiritual realms, usually with a cocked eyebrow or an eye on the clock.

What would it mean for prayer to help the sick? It's a question linked to others great philosophers have plumbed and foundered on: the existence of evil, God's relationship to prayer, the necessity of any belief in God at all when one prays. One might think that the scientific literature shouldn't find the problem as difficult as the philosophers - just find an objective measure of "prayer" and "help." But objective measures of prayer are precisely what are lacking, as psychologists Kevin Masters and Glen Spielmans explained in a review published in the Journal of Behavioral Medicine in 2007: what the field needs are "experimental studies based on conceptual models that include precise operationally defined constructs [and] longitudinal investigations with proper measure of control variables." In other words, we're back to the same issues: what is prayer? And how do we tell what is the effect of prayer, and not merely the nonspecific warmth of human companionship?

God is most relevant to me at work for different reasons. I'm a medical resident in his final year whose routine usually involves others' tragedy. Religion in my practice is usually evident only as a wedge between what I want and what patients - and, more often, patients' families - want. Enveloped by a medical culture which is difficult to step outside, I often catch myself assuming with an unquestioning certainty exactly what should happen in a given case: this person over here is worth treating (from a "medical" perspective - that is, from the perspective of my guild), there is progress to be made here, and we should try to convince the patient and family of this; or, conversely, there is "nothing to treat here," and any protestations to the contrary are due to delusion, illusion, or "cultural differences," a common euphemism which includes religion. Often it happens that religious patients and their families want more care than we doctors want. This is frustrating for me as a religious person: what's the point of all the spiritualism if it only blocks lines of communication between doctor and patient?

As in the case of prayer and health, the issue of end-of-life care for religious patients (and their families) can be illuminated through empirical research where otherwise we might get lost in philosophical byways. In a recent issue of the Journal of the American Medical Association, Holly Prigerson at the Harvard Medical School Center for Palliative Care, together with her colleagues, published a rigorous study of patients who use religious faith to cope with a diagnosis of advanced cancer. Even after controlling for other variables, these patients with "positive religious coping" request and receive more intensive life-prolonging care at the end of life.

In an on-line interview, the authors declined to make recommendations to clinicians based on this conclusion. In the article, however, they observe "because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment, intensive end-of-life care might represent a negative outcome for religious copers." This would certainlly justify doctors' bewilderment when dealing with religiously intransigent families. Such families are arguing their loved ones into more days in the ICU and a death entangled in wires and tubes.
Thinking it about it in another way, though - trying as hard as I can to think like the spiritual person I occasionally manage to be outside of work - a scrabbling after every scrap of life, even as it seems to slip inexorably away, is a perfectly religious path. For many religious people, sick or well, the question is not "Does prayer help?" but "How can I manage to pray?" Prayer has no point; its existence is enough. Similarly, I would not be surprised if many religious families viewed the question of "negative outcomes" as just another barrier thrown up to the achievement of transcendence. Life is life. Clinging on to it has no point; the clinging is enough. These days our art of medicine is always accompanied by debates about the evidence, what it is and how one introduces it into practice. While God and God's adherents frustrate me no end while I am trying to get work done in the hospital, I am vivified by those whose attachment to life is circumscribed by something other than evidence.

"This is Dr. Berger. He is visiting Australia to see what a modern medical system looks like."

I spent the day enjoyably. I gave a talk this morning to the folks at VMA General Practice Training, one of a number of provider training centers throughout Australia. (Recently - within the past decade or so - the Australian government has decentralized the training of general practitioners, formerly under the College of General Practitioners, in order to promote competition.) I had a feeling of being at home among people like those at the primary care program I just graduated from. Now, primary care doctors in the US are (with the addition of philosophical self-consciousness and their own advocacy organization) just like internists, while their equivalent in Australia is the GP. Australia is civilized because about half their practitioners are GPs. What struck me was how little difference there seems to be, on a brief first glance, in outlook and sensibility.

Then this afternoon and evening I have been shadowing the clinicians at Parkridge Medical Centre in Melbourne. Besides the obvious differences (namely, that Australia has a "modern medical system" with universal healthcare coverage) I noted, again anecdotally, a relative reluctance to spring first for the pharmaceutical solution, something I know I did as a resident (mere weeks ago!).

Hacked!

I am sorry if my Facebook account is asking you for money, poisoning your cat, writing Ranolazine prescriptions, or performing other unspeakable activity. It were hacked, I tell you! I am trying to fix things as lickety damn split as I can.

But on one foot, some fun Melbourne activities (your mileage may vary):

Eating vegetarian pizza.

Comparing kosher baked goods.

Listening to my daughter sing songs learned in her (temporary but lovely) kindergarten (which they call "kinder" here).

Playing on the beach while discussing (with various people) Yiddish poetry translation, bioethics, and an anti-realist view of scientific theories.

Appreciating the clang of the trams.

What makes it more likely for new prescriptions to be filled?

Recently, some colleagues and I at NYU looked at factors influencing first-fill adherence to new asthma prescriptions. Lower copay and oral administration were associated with greater first fill. See the abstract below and the full paper here.

Lower Copay and Oral Administration: Predictors of First-Fill Adherence to New Asthma Prescriptions

Background: Nonadherence to asthma medications is associated with increased emergency department visits and hospitalizations. If adherence is to be improved, first-fill adherence is thefirst goal to meet after the physician and patient have decided to begin treatment. Little is known about first-fill adherence with asthma medications and the factors for no-fill.

Objective: The goal of the study was to examine the proportion of patients who fill a new prescription for an asthma medication and analyze characteristics associated with this first-fill.

Methods: This retrospective cohort study linked electronic health records with pharmacy claims. The cohort was comprised of 2023 patients aged 18 years or older who sought care from the Geisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthma medication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescription filled by the patient within 30 days of the prescription order date. Covariates examined included factors related to the patient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office visits, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy co-pay amount. A logistic-regression model was used to determine covariates associated with first-fill.

Results: The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with a copay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients prescribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11).

Conclusions: Several factors associated with failing to fill an initial prescription for asthma can be addressed through simple interventions: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary medications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreasing copay may improve adherence and, therefore, asthma control.

Is medicine a Jewish profession?: quote from a talk in preparation

if it is legitimate at all to say that medicine is a Jewish profession, it is not because that medicine is "more Jewish" than it is Christian/Hindu/African-American/etc. (that would be ridiculous) but because the ethical characteristics of the physician, while universally appreciated and able to be implemented in any culture, conform well with Jewish self-understanding, i.e. that Jews should be bayshanim (humble), rakhmonim (merciful) and goymlei khasodim (performers of deeds of lovingkindness).

Department of Welcome Exaggeration, Melbourne Edition

THE JEWISH CULTURAL CENTER AND NATIONAL LIBRARY KADIMAH

has the pleasure of presenting one of the world's most interesting
and well known lecturers visiting from the United States

DR. ZACHARY SHOLEM BERGER

two lectures will take place in the Leo Fink Hall at the "Kadimah"
7 Selwyn Street Elsternwick at 3 pm. on the following dates

"IS MEDICINE A JEWISH PROFESSION?"
12 July 2009 - lecture .n English

"WHY IS MEDICINE A JEWISH PROFESSION?"

26 July 2009 - lecture in Yiddish

Refreshments will be served.

Smoothing Over

problems pave
the potholes
with blacker
asphalt, so the
problems make
a swift
double bump
Not gone
Not gone

Ten Things I Know About Bellevue Hospital That Will Never Come in Handy Again

1. The closets that are always open across from the chemistry lab have signs that say "THESE DOORS MUST NOT BE LEFT OPEN."

2. Cocaine for sale!

3. There is only so much Valium in the hospital, and in a night with a lot of alcohol withdrawers, Bellevue just might run out. Then - the apocalypse. Or some other benzodiazepine, whatever.

4. What happens on the eighteenth floor, stays on the eighteenth floor.

5. During my intern year I got sick of people mistaking Bellevue, New York's oldest public hospital, for a psychiatric institution. Now I know the truth: Bellevue is a psychiatric institution which just happens to have a lot of medical beds too.

6. Sure you don't need to call an inpatient dermatology consult very often, but when you do, are they ever wrong?

7. No, the patient doesn't speak (Spanish, Chinese) - they're just (Filipino, Indonesian).

8. [insulting comment about a subspecialty or particular nursing station]

9. Sure you put the order in. You have to call too.

10. Now call again.

Evidence-Based Lobbying

Leaders of the medical-industrial complex wonder if the Dartmouth research findings might be a touch overblown. I dunno - maybe. But don't we doctors do a lot else based on much less evidence? What fraction of hallowed medical practice is based on no more than class IIb recommendations?

Heck, I'm ready for New York to get less medical money. I don't think the kinds of places I'd rather practice are the ones that are overspending.

Super Jewish Historical Prediction Game: Female Modern Orthodox Clergy Edition

I. circa 1980

Cathy Conservative: Women can be rabbis!
Joe Modern Orthodox: Pshaw!

II. 2009

Joe Modern Orthodox: Women can...umm...kinda be rabbis!

III. 2025

Joe M.O.: ___________ (fill in the blank)

Evidence based medicine: pragmatic, objective, or authoritarian?

In the spring issue of Perspectives in Biology and Medicine, Maya Goldenberg dissects the contradictions of evidence-based medicine (EBM). (I found the article through philpapers.org, which I didn't know about before.) On the one hand, EBM's commitments to pragmatism

are readily apparent in EBM’s clear allegiance to experimental methods of inquiry that set aside past habitual thinking in favor of purely empirical investigation. Indeed, EBM’s promise of “the application of the best research evidence to medical decision-making” (EBMWG 1992) could have been achieved by strictly pragmatic scientific methodology.

On the other hand, EBM lays claim to the marble statuary of objectivism, which is problematic.

[The] objectivist ontology,where the evidence “speaks” and reliable knowledge follows, presents an occupational hazard to (actual) medical practice. Subjective content muddies up even the most rigorous evidence-based practice by the inescapable layers of interpretation and sociocultural influence that enter in the setting of research agendas (including what projects get funded and why), the production of evidence in primary research, and the selection of which evidence is chosen to inform policy and practice.

But EBM's hierarchy of evidence, with the randomized controlled trial (RCT) at the top, rests on shaky grounds itself:

From a pragmatist perspective, the problem is not so much that the gold standard status is tenuous, but that the RCT’s placement of at the top of the hierarchy is so insistently maintained. It is largely in the interest of avoiding dogmatic theoretical commitments that pragmatists endorse a bottom-up approach to theory construction, where localized beliefs must pass the test of experience in order to be elevated to generalizable knowledge claims.There are numerous experimental scenarios in health research where the RCT would not be the methodology of choice,which suggests that the hierarchy of evidence would not pass the rigors of the bottom-up approach to theory building.

EBM's certainty in its own objectivism leads to a blindness: "[t]he hierarchy of evidence is the point at which evidence-based methodology can be charged with authoritarianism." There are some juicy accusations in this article, which I didn't know before, about the financial relationship between EBM "producers" and the editorial boards of certain journals, e.g., BMJ.

However, in her conclusions, Goldenberg is fittingly pragmatic:

In the interest of better science, I propose that EBM’s pragmatic features are worth keeping. By this, I mean that the open-ended critical inquiry should be encouraged, as should comparative clinical research and problem-specific methodology (which may include uncontrolled methods and even reliance on clinical judgment).The rigid hierarchy of evidence, as we have seen, leads to considerable problems for EBM and should be dismantled.The EBM critics,writing from the post-positivist philosophy of science tradition, have amply demonstrated these problems. But the constructive project of revisioning or perhaps recasting the evidence-based approach to medicine requires that the worthwhile aspects of EBM not be discarded along with its flawed features.

Chasidic Yiddish blogger Katle Kanye on the swine flu

Original here. Translation mine.

The truth is that we Chasidim haven't been so impressed by the swine flu from the beginning. Yes, it's gotten to South America, Europe, and even Israel. But that sort of thing usually doesn't interest a Chasid too much, and a "God have mercy"or a "it shouldn't happen to us!" can take care of it. So folks in New York have gotten it too? I assume you're familiar with the verse "and all the children of Israel had light in their dwellings"! And which cheder pupil doesn't know about the plague of blood when the Egyptians bought water from the Jews - so what's the difference here? ...They said about AIDS that it would eat up the whole world, but like the lice in Egypt it stopped at the Chasidic zip codes. Just like the miracle of the shemittah farmers who clearly see their blessings compared to their neighbors, all the maladies I visited upon Egypt are not seen or found among those who are meticulous in their observance of commandments both major and minor. So much the more so in this case because we don't eat the flesh of pigs - their hoof is cloven but the cud they do not chew - and we're in the month of Iyar, which stands for I, God, am your healer.

The catastrophe is though that - whether it's really true or they're just saying it - two yeshiva students from Mir got it. Oh my teachers and rabbis, death has risen to our windows, come to our palaces and the Angel of Death is attracted to white shirts and black hats too. Now it's a tragedy. I know the experts say that it's easier to get infected on the train than it is from a Chasid's achoo on the other side of the Mediterranean, but what do the experts know? They say the world's getting warm but the kutchme sellers aren't yelling for a bailout. When Chasidic young men get it it's a whole other story. It's our concern now, so we need to get in touch with the Chasidic doctors and move mountains.

Nevertheless, as they say, in all labor there is profit, or as the goyim say, every cloud has a silver lining. A truly God-fearing Jew feels a spiritual satisfaction, a feeling that we're not left out, we're on the guest list too. Leave it to the Jews: if there's something to pick up in the world you can bet that we won't be left behind. We might look different but there's nothing we don't have. We'll get there. We won't just get there, we'll make the whole business our own by giving it a name. Make a mishebeirach, change pig to Mexico, and confuse the devil just like we do on the eve of Rosh Hashanah... from a swine's flu you can make a silk purse, or a shtreimel.

What are we to learn at the bedside? A re-examination of Verghese's essay "Culture Shock"

Abraham Verghese's essay "Culture Shock" (pdf) made a lasting impression when I came upon it last night during a quiet period at work. He writes beautifully about the real patient, with all his spots and signs - as opposed to what Verghese calls the "iPatient," the simulacrum found inside the electronic medical record but nowhere else.

I do realize that we residents, no matter where we train, hone our skills on the iPatient's indices ("The iPatient's blood counts and emanations are tracked and trended like a Dow Jones index, and pop-up flags remind caregivers to feed or bleed") while getting ever farther away from the bedside physical exam done on the real patient. This article makes as powerful a case as any I've read for the re-centering and re-honing of my skills, and it comes at just the right time, when I have the chance to make a transition to be the kind of doctor I want to be. 

But Verghese is confused in his defense of the physical exam - he doesn't know what rationale he wants to focus on, or how he feels about physical diagnosis as justified (or questioned) by evidence-based medicine. Here he is in one place:

If one eschews the skilled and repeated examination of the real patient, then simpl diagnoses and new developments are overlooked, while tests, consultations, and procedures that might not be needed are ordered.

This is the argument from efficiency, or maybe from diagnostic rigor - exceeded somewhat by Verghese's clear affection for the physical exam as a pedagogic and maybe, even, an esthetic, cultural, and moral tool. But it's not clear whether Verghese believes that the physical exam does improve diagnosis or efficiency. Just paragraphs later, Verghese takes another turn:

Younger physicians often argue that physical signs lack an "evidence base." Clearly some signs are helpful, some are not, and we need continued study in this area. But recognizing erythema nodosum or decreased breath sounds and dullness over a larg pleural effusion is worthwhile in and of itself.

The physical exam's actual use in diagnosis is again feinted toward, but without making a real case one way or the other ("we need continued study in this area," the academic physician's classic copout that I know I use at the end of every article I write).

Near the end of the essay, and most confusingly, Verghese takes yet another tack when describing with understandable pride the teaching of the bedside physical exam he coordinates with his chief residents:

We teach that physical findings should be considered biomarkers, phenotypic markers. ... An enlarged spleen, Roth's spots, a Virchow's node, and jugular venous distention are all biomarkers that should be factored in with the high calcium level, the abnormal MRI, and other data to arrive at a true picture of the patient. Failure to recognize these biomarkers is an oversight akin to not seeing a key laboratory value in the chart.

But this comparison is double-edged. If a finding on the physical exam is like a biomarker, then it is like any other diagnostic test, which can be ignored, re-interpreted, or even not tested at all based on the prior probabilities the physician approaches the patient with. Perhaps - given the patient - I might prefer the information given by X-ray to my own physical exam. Or maybe, given the vagaries of varying echocardiography reads, I might privilege my own cardiac exam.

This is why I find Verghese's essay, though moving and personally challenging to my own too-ingrained love of EHRs, to be ultimately unsatisfying. If medicine is a culture, it changes. If the physical exam is to be a practical part of the diagnostic art, and not a relic, it too must change. Let's find out which parts of the diagnostic exam work, and why. We know that no physician does the "head-to-toe exam" for more than a fraction of his or her patients, so which parts should be done when? When is it useful to look for Roth's spots as a diagnostic adjunct rather than as a fascinating bedside pedagogical tool of limited clinical import? (Probably rarely.) Given our limited time with patients, should we not build rapport and understanding by asking more detailed histories at the bedside, rather than indulging in percussion of parts which have no diagnosis to yield up? 

I take Verghese's wisdom and his eloquence but I look for rigor elsewhere, trying to spend my time with the patient in ways that build our therapeutic relationship and find a true diagnosis efficiently.

Activism and Jewish Science

The folks at 36 Under 36 are an accomplished bunch, but The Jewish Week is laboring within a limited definition of Jewish activism: viz., stuff which yields a creative product or institution immediately appreciable by the Jewish lay public. But (with the exceptions of Ethan Tucker and Adam Kirsch) what this definition leaves out is the intellectual effort of Jewish academia, which never got anyone to make aliyah or become a mikvah habitué but - for all that - is of value. I wonder if the assumption might be that activists Act, while pure intellectuals don't. But that would be wrong.

Swine flu on one trotter

1. Even now no one knows how bad it could get. Or even (given that we don't know the real denominator of all cases) whether it's worse than regular old seasonal flu at all.

2. The limits of genetics: you can download sequences of many varieties of influenza A H1N1, but that tells you nothing about transmission and an unknown amount about virulence.

3. A prime example here of how people think of risks: the flu crisis is immediate and scary and thus available to them in a way that less immediate risks are not (car accidents, malaria).