Wednesday, July 8, 2009

Pop’s up again...

I’ve had a year. Well almost a year since the last post.

Here goes again.

A brief explanation involves describing a move to this Island off the coast of Maine and New Brunswick
~ about 2,000 permanent residents along the 15 or so miles of coastline on the East side of the island (there is no road on the West side), living in 3 or 4 villages (numbers depending on definitions) situated each in a cove that once sheltered fishing boats alas now almost gone (except for lobster and whales-watching tourists), a thriving high school (surprising in a way), a small hospital and nursing home (where I do a little internal medicine - aka geriatrics) and a fabulous bakery (that operates in the tourist season), a tourist season that thrives because of the beauty of the place and ancient migratory bird routes that touch down along the its coasts and archipelago.

In the interim - it’s almost as if I returned from space - we have Obama and hope, Michael Jackson and death, the US moving distinctly to public health care, the Canadian Medical Association moving in the opposite (and self-interested) direction, a continuous stream (perhaps now a river) of revelations of pharmaceutical company driven manipulations of drug trials (doing, analyzing and interpreting and reporting all designed to promote drug benefits and minimize drug harms), and perhaps not much else worth noting.

I did speak at the annual COPE meeting in London earlier this year. COPE (Committee on Publication Ethics) is the brilliant idea started about a decade ago by the Richard’s Smith (BMJ) and Horton (Lancet). The editors were dealing with issues of misconduct - author, publisher, sponsor and had: A) no place to discuss these problems - were they problems? Yes - an B) no UK national organization to deal with them - What does an editor do when he/she discovers an author has fabricated scientific data? For example.

COPE has carried on and is now an international organization with a growing audience and membership. Liz Wager is the current President. Worth checking out if you are a journal editor.

Equator-Network is also working in the same area, but is focused on improving the reporting of research studies. Most published studies - and I mean most - probably well over 50% - are incomplete when published. Incomplete means missing key information that permits the discerning reader (and we should all be discerning or better discerning and extremely skeptical) to determine if the design, methods, results and interpretations are valid. Part of my COPE talk showed how Pfizer published manipulated research on its drug gabapentin (Neurontin) that eventually found its way into national US guidelines for treatment of patients. Work done by Kay Dickerson for the plaintiffs - full report worth reading is at

And to wrap up for today’s post a few observations on medical practice in 2009 vs. medical practice in 1993. Yes 1993, the last year that I saw patients. I went back into practice for a couple of reasons not worth discussing here, but the really striking differences between practice in ’93 and practice in ’09 are:

A) Lots of new drugs - and so many are but minor atom changes on the underlying chemical (i.e. within a class they’re all pretty much the same).
B) But most of them - pretty much all so far that I’ve encountered - are largely ineffective or so mildly effective that patient’s don’t get any better
C) A few new laboratory tests - especially imaging - that produce such exquisite diagnostic information that physicians find test ordering irresistible because of curiosity and, and fear of malpractice suits for ‘missing’ something, usually untreatable.
D) Except in the nursing home where because of age or dementia, patients seem to be diagnostically neglected.
E) Information availability. It is so much fun to be able to look things up - books, recently published papers, systematic reviews, and so on - sitting here in my study. I think I’ll be a better physician, even after the decade long layoff.

More on practice later.


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