Category: Physicians

Disclosure isn’t enough

published date
November 30th, 2006 by

Disclosure isn’t enough

Most cancer patients in clinical trials don’t care if their doctor has financial ties to the trial’s sponsor, according to a study decribed in the Washington Post. The article says the survey

undermines “full disclosure” as a central tenet of clinical research.

The authors think that patients may be too overwhelmed by their disease to think critically about such conflicts. That may be true. However, I’m not surprised that disclsoure doesn’t work. It reminds me of the situation in financial services, where equity analysts with clear conflicts of interest wrote bullish reports on the companies they covered. Those conflicts were often disclosed but it didn’t stop investors from treating the reports as objective. More likely, the investor or patient assumes the analyst or doctor will bend over backwards to ensure objectivity once disclosing the conflict. That’s a bad assumption.

The pornification of the medical profession

published date
November 21st, 2006 by

The pornification of the medical profession

What does this sound like?

As she delivered her thoughtful patient presentations to me and the other attending doctors, it was hard not to notice her low-cut dress.

A Harlequin romance? A soft-core film? Nope. It’s from an essay in the New York Times (When Young Doctors Strut Too Much.)

Among older and middle-aged physicians (like myself), tales of salacious and sloppy trainee attire abound. One colleague commented that a particularly statuesque student “must have thought all her male patients were having strokes” when she walked in their exam room wearing a low-cut top and a miniskirt… One Midwestern medical school dean reported that her school instituted a formal dress policy after administrators noticed students revealing too much flesh while sunbathing on a small patch of grass outside the school building, directly below patients’ hospital room windows.

Patients, especially older ones, won’t take doctors as seriously and may not be as open with them when they fail to show up for work dressed as expected. Smutty novelists and film makers may also have to take things up a level to differentiate themselves. Is it all part of the pornification of America?

Testing, testing, 1, 2, 3

published date
November 14th, 2006 by

Testing, testing, 1, 2, 3

From the Wall Street Journal:

Worried that unnecessary diagnostic tests are adding to the nation’s soaring medical costs, federal health-care officials are moving to shrink loopholes that let doctors profit from referring patients for MRI scans and other costly medical tests.
Medical imaging is one of Medicare’s fastest-growing costs, rising an average of 20% a year since 1999. In 2005, the federal health-insurance program for the elderly paid $7 billion for imaging scans. Some studies have shown that doctors with a financial interest in big-ticket machines for magnetic resonance imaging or other tests are more likely to order those tests.

It is not surprising that doctors will order more tests if they profit from testing. However, even if doctors get no profits from tests a huge problem remains – doctors are ordering tests using “other people’s money” and have little incentive to economize. Spending due to tests being seen as costless is likely to be much greater than spending due to doctors profiting from testing.

This is not a simple problem to solve, but financial incentives to patients and medical professionals to save money by economizing on tests will get doctors to spend more time thinking and looking things up and less money testing.

Non-financial initiatives can work as well, such as educating patients about the dangers of radiation exposure from too many CTs and about the harm that can result when a false positive on an unneeded blood test is followed up with increasingly invasive tests.

The diagnostic crisis in child psychiatry

published date
November 12th, 2006 by
The diagnostic crisis in child psychiatryThanks to Mickey for his perspective on the chaos in diagnosis in child psychiatry, described in yesterday’s New York Times. (What’s Wrong with a Child? Psychiatrists Often Disagree):
At a time when increasing numbers of children are being treated for psychiatric problems, naming those problems remains more an art than a science. Doctors often disagree about what is wrong.

A child’’s problems are now routinely given two or more diagnoses at the same time, like attention deficit and bipolar disorders. And parents of disruptive children in particular — those who once might have been called delinquents, or simply “problem children” –— say they hear an alphabet soup of labels that seem to change as often as a child’s shoe size.

Psychiatrists have no blood tests or brain scans to diagnose mental disorders. They have to make judgments, based on interviews and checklists of symptoms. And unlike most adults, young children are often unable or unwilling to talk about their symptoms, leaving doctors to rely on observation and information from parents and teachers.

““Psychiatry has made great strides in helping kids manage mental illness, particularly moderate conditions, but the system of diagnosis is still 200 to 300 years behind other branches of medicine,”” said Dr. E. Jane Costello, a professor of psychiatry and behavioral sciences at Duke University. “On an individual level, for many parents and families, the experience can be a disaster; we must say that.”

The main problem is that these diagnostic labels are findings, not diseases. A good example of this problem is attention deficit disorder, which in many families seems due to a single autosomal dominant gene. Despite this genetic simplicity, people with attention deficit disorder typically have other disorders too, including oppositional defiant disorder, conduct disorders, as well as affective, anxiety, learning disorders and even poor handwriting. This is not surprising – being overwhelmed with sensory input, as occurs in attention deficit disorder, could easily produce these multiple symptoms.

All these labels are based primarily on symptom checklists. According to the American Psychiatric Association’s diagnostic manual, for instance, childhood problems qualify as oppositional defiant disorder if the child exhibits at least four of eight behavior patterns, including “often loses temper,” ““often argues with adults,”” ““is often touchy or easily annoyed by others” and ““is often spiteful or vindictive.”

Dr. Darrel Regier of the American Psychiatric Association, who is coordinating work on the next edition of the associationՉ۪s diagnostic manual for mental disorders, due out in 2011, said that researchers would focus on drawing distinctions among several childhood disorders, including bipolar disorder and attention deficit disorder.

““We wouldn’t disagree that criteria for these disorders currently overlap to some degree,” Dr. Regier wrote in an e-mail message, “and that a significant amount of research is under way to disentangle the disorders in order to support more specific treatment indications.”

The Chinese Restaurant Menu approach used in the diagnostic manual is part of the problem since it combines rigidity and ignorance. A statistical pattern matching approach would be an improvement, but major progress will require new knowledge. Once we start to make progress the pace of advances will increase: once we have gene tests for a few diseases, progress in other diseases will also accelerate since the bin of undiagnosed patients will become simpler.

From which disease will the first advances come? Attention deficit disorder should be an early success because it often has such simple inheritance. Why don’t we have an attention deficit disorder gene yet? One difficulty may be that many single genes can cause attention deficit disorder and this heterogeneity on a population level messes up positional cloning studies. Another problem is that it can be difficult to make the diagnosis of attention deficit disorder in females, leading to data too messy for positional cloning studies.

If genetic heterogeneity is the problem a more promising strategy may be to test candidate genes in small families in which all patients share the same problem gene. This can work if you understand the biology, but since the presumption that dopamine transmission problems underlie attention deficit disorder has not borne fruit it would not be surprising if a dopamine disorder is the wrong hypothesis.

It sounds like we are in a rut, but there are enough MDs with basic science experience floating around and the cost of sequencing a gene is getting so low that someone is going to hit the bulls-eye with a good hunch on a different candidate gene.

PSA at 40?

published date
November 7th, 2006 by

PSA at 40?

Prostate Specific Antigen (PSA) is a widely-used screening test for prostate cancer. Unfortunately these tests cause a lot anguish: an elevated PSA doesn’t usually mean prostate cancer (only 25-30 percent of cases with elevated PSAs are prostate cancer), but it often means a biopsy and a lot of angst.

According to the National Cancer Institute:

Using the PSA test to screen men for prostate cancer is controversial because it is not yet known if this test actually saves lives. Moreover, it is not clear if the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatments. For example, the PSA test may detect small cancers that would never become life threatening. This situation, called overdiagnosis, puts men at risk for complications from unnecessary treatment such as surgery or radiation.

So I was a little surprised to read that the authors of a new study are advocating starting PSA testing even earlier: at age 40 rather than age 50. It’s counterintuitive, but the reasoning is that if a patient has a longer baseline it will be easier to tell from the PSA whether they in fact have cancer. For example, as I read in the Wall Street Journal (Beginning Prostate-Cancer Screening At Age 40 Holds Benefits, New Data Show):

[A] 40-year-old man who has a PSA of 0.8 at 40 and then a score of 2 a few years later likely is at high risk for aggressive cancer. But if he has a score of 2 and no prior PSA test, he likely would be told he’s at low risk. By the time his PSA score reaches 4 and doctors decide to intervene, it might be too late to save him.

Meanwhile a 50-year-old man with a PSA of 4 likely will be told he needs a biopsy. However, if that man at the age of 40 had a PSA of 2, the 10-year trend suggests he likely doesn’t have cancer or at least not an aggressive cancer.

“It’s the same threshold of 4,” says Dr. Carter. “But the two people got to that threshold at much different rates. I see this as a way to decrease the men who have biopsies and identify the men with lethal disease.”

The logic sounds good, but it makes me nervous. I’m turning 40 next year and I think I’ll wait till I turn 50 to start testing. (I’ll see what my doc thinks before deciding.) I don’t have any of the prostate cancer risk factors and I’m as scared of having a false positive as I am of prostate cancer itself. In 10 years, when I’m 50 maybe there will be a better test and it won’t matter that I don’t have baseline PSA data.