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The Power of Anecdote

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The morning papers are filled with relevant health reform stories, but two stand out. They weren’t reported by journalists, but were experience-based opinion pieces offered by people on the front lines of delivering and insuring health care.

The first comes from the Washington Post, where a family practice physician reports on the battery of tests he received after checking into the local emergency room for excruciating eye pain while on vacation. Despite an ultimately accurate self-diagnosis of shingles, he submits to his physicians’ orders for an ever escalating battery of tests. My takeaway lesson from his story is that if a skilled physician cannot resist orders for expensive tests and unnecessary drugs, there is no chance that individual consumers, even if they have more skin in the game, will be more successful. 

The second story comes from an op-ed in the New York Times, where a Texas regulator, who served on that state’s ill-fated attempt in the 1990s to set up an insurance exchange for small businesses, concludes either a strong public plan or very tight regulations are needed to make exchanges work. Otherwise, he states, insurance companies will cherry pick the insurance pool and doom those with high-cost employees and family members to unaffordable plans.

It’s telling that I found those stories much more compelling than the best journalism in today’s papers. There was a solid Post story about how the U.S. lags in preventing deaths that could be prevented through health care interventions. There was also a Times take out on insurance exchanges, which included a brief sidebar on a Utah exchange aimed at small businesses that sounds suspiciously like the failed Texas model.

It’s not that the good reporters who wrote those stories couldn’t deliver powerful pieces. But the sad truth is that quick turnaround stories based on studies, or overviews based on numerous telephone calls to policy wonks, the thin gruel now offered by ever-shrinking newsrooms, will never have the power of well-reported, anecdote-driven stories that can only be produced by reporters spending serious time on the ground with real people and practitioners. 

via gooznews.com

The key here is whether the anecdote illustrates a broader, true dynamic, or an anomaly. Here we’ve the former.

Posted via web from David Dobbs’s Somatic Marker

Medicine

Our screwed-up malpractice system. Whose fault is that? Let’s try ‘nobody’.

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A few years ago, a friend of mine gave birth to a daughter, her second child. A few weeks into the child’s life, it became apparent she was suffering from cerebral palsy. Not long after, my friend, whom I’ll call Carol, bumped into her ob/gyn doctor on the street and told him about her daughter’s diagnosis. In a good world, the moral and legal context of such a conversation would encourage the doctor to express sympathy. But the doctor, looking stricken, and clearly terrified about being sued, immediately said, “Well I hope you don’t think it was because of anything I did.” Carol, who was sharing information about her baby — and, frankly, hoping to hear a sympathetic response to the person who’d helped her bring that and a previous child into the world — felt cut to the quick, and I imagine the doctor didn’t feel too good about the exchange, either. Yet it’s precisely the sort of relationship the current malpractice system encourages when things go badly.
This corrosion of the doctor-patient relationship is just one of many reasons to change our present malpractice system. Unfortunately, none of the tweaks being considered in the healthcare reform debate address it — or any of the malpractice system’s other central problems. The focus has been on the extra costs costs created by high malpractice insurance premiums and expensive, unnecessary defensive medicine. But this debate, as David Leonhardt notes in a recent Times post, this debate isn’t really getting us anywhere. It exaggerates the scale of the problem, overlooks many of its central dynamics — and never drifts anywhere near a sensible fix. And while Obama’s proposed tweaks would help a bit, but wouldn’t fix the fundamentals.
‘Twas much the same four years ago, amid what was then the third U.S. “malpractice crisis” of rising premiums. At that point I wrote in Slate about a ‘no-fault’ fix that has great promise. But even now, with the wonkish Obama administration in office, this isn’t getting much play, perhaps because it’s from Europe. Instead we get the usual rumble and noise. Then as now, I wrote, this debate “amounts to bickering about how to fix a machine of spectacularly bad design.”

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Medicine

Swine flu vaccine ‘nightmare’ — and neither flu nor vaccine is even here yet

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I’ve wondered many times, including out loud in Slate, why it’s not common in the U.S. to give flu vaccinations at schools, so they could efficiently be given to the population (children) whose inoculation most effectively prevents epidemics or pandemics, as well as to anyone else who wanted one. Same place, procedure, and personnel every year. It would simplify and speed things immensely, and save scads of money.
This story in the Times has me asking the question anew. Instead of a single date (or a few dates) in which people can line up and get their shots in an orderly, efficient process, the entire primary care system is scrambling and overwhelmed — and that’s before either vaccine or shot arrives.

The federal Centers for Disease Control and Prevention released the first doses of vaccine on Monday. But many doctors, especially pediatricians, say they know little about the program and have been deluged with questions.
At the same time, the pediatricians are struggling to figure out how to administer perhaps thousands of doses quickly in small offices with limited staff, while still dealing with other illnesses.

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Medicine

Neuron Culture’s Top Ten from September

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Never know what’ll top the charts. Top post was a post I put up in January, “Pfizer takes $2.3 billion offl-label marketing fine.” That post reported the news (via FiercePharma) that Pfizer had tucked away in its financial disclosure forms a $2.3 billion charge to end the federal investigation into allegations of off-label promotions of its Cox-2 painkillers, including Bextra. (Lot of money … but it didn’t quite wipe out the company’s 2008 net income.) The company had set aside the money as part of a deal it was negotiating Justiice. Finalizing the deal, however, took until September. At that point, the Dept of Justice announced it in a splashy press conference. Because my post was was one of the few things already on the interwebz before Justice held its news conference, the Google rush shot it toward the top of the search results. Sometimes big news is 8 months old.

Other hits of the month:

Embargo? Embargo? The case of the missing swine flu paper
How Pfizer’s $2.3B criminal settlement proves Obama wants to ‘federalize’ healthcare
PTSD: Two new programs; two big ignored questions
Morning Dip – Depression doubles; swine flu packs for a move north
53-inch penises, other self-destruction, & viruses bad & good
We’re Number 37 – The “Rock Tank” analysis of the healthcare reform debate Very entertaining. You should watch it again.
What the Public Thinks of Public Schools
Neuroskeptic: Trauma Alters Brain Function… So What?

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Crushed that pitch: Announcer goes yard with pre-game homer prediction

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Ruth may or may not have called his. But former player and Mariners announcer Mike Blowers, asked before the game for his prediction of the game, predicted a rookie player would hit a homer — his first in the bigs — into the second deck in left-center in his second at-bat on a 3-1 fastball. Man did it.

Medicine

Flu roundup cont’d

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Lots of flu news out there. Here’s my short list for the day:

Helen Branswell reports that WHO is unpersuaded by the unpublished paper showing seasonal flu vaccine may raise chance of getting swine flu. (Anomalies are usually anomalies.) Canada has been thrown into quite a bit of confusion by this report, with some provinces holding off on seasonal flu vaccines.

Meanwhile, an OB notes an extraordinary death toll of H5N1 among pregnant women.

Greg Laden has an extremely short post suggesting how difficult these two bits of news are when you (or your wife) are actually pregnant. The gist: The possibility that the seasonal flu vaccine could increase risk of contracting swine flu, says Laden, “concerns me quite a bit, as my wife is 8 months pregnant, flu is a very serious risk for pregnant women and their babies, she teaches in a high school, and got her seasonal flu shot last week..”  

One can hope, fervently, that the swine-flu vaccines, which start getting punched into people in the U.S. today, find their way very rapidly to a flu clinic near Laden’s better half.

Meanwhile, Revere, changing his mind, decides that mandatory swine-flu vaccines for healthcare workers would backfire.

An on the treatment end, here’s a front-line report from an ER doctor in Columbus. (h/t Avian Flu Diary)

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On the reading table lately

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Been a while, so these cover a span of reading.

I’m in the midst of my friend Adrienne Mayor’s The Poison King: The Life and Legend of Mithradates, Rome’s Deadliest Enemy, and can report that Mr. M is quite a poisonous but complicated handful — a dark and deadly echo of his hero and model, Alexander — and this reconstruction a splendid read.

A few weeks ago I finished Thomas Ricks’ The Gamble, an excellent account of the surge in Iraq. Ricks — who earlier wrote Fiasco, a devastating indictment of the run-up to the war, makes three things quite clear:

  1. The surge was not about more soldiers, but soldiers doing different things — protecting the populace rather than hunting the enemy. They killed fewer enemies — but reduced even further the number of new enemies made.
  2. This made things safer for both Iraqis and Americans, but didn’t necessarily solve any long-term problems.
  3. We’re going to be there a long long time.

While researching a feature I wrote that will be appearing soon in a major magazine near you, I read:

Deborah Blum’s Love at Goon Park: Harry Harlow and the Science of Affection. First-rate history of science here, and a fascinating look at Harry Harlow, a monkey researcher whose powerful but sometimes disturbing experiments in the middle decades of last century helped replace a cold behavioralist view of infancy and childhood with the theories of attachment and bonding that still rule today.

The 10,000-Year Explosion: How Civilization Accelerated Human Evolution, by Harry Harpending and Gregory Cochran. “The Beak of the Finch (a favorite of mine), but this time about us.

And amid those I read Cormac McCarthy’s No Country For Old Men, which went through me like a bullet. Withering. Beautiful.


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Dipstick: religious brains, more school, more meds, states rights, and dancing with the unwilling. Plus Ardi, free

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Notables from the last 24:

Over at Gene Expression, Razib casts a skeptical eye on a study of the neuroanatomical variability of religiosity.

The brain areas identified in this and the parallel fMRI studies are not unique to processing religion [the study states], but play major roles in social cognition. This implies that religious beliefs and behavior emerged not as sui generis evolutionary adaptations, but as an extension (some would say “by product”) of social cognition and behavior.

May be something to that, Razib says — but it would be nice “get in on the game of normal human variation in religious orientation (as opposed to studies of mystical brain states which seem focused on outliers).”

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Flu roundup: A marked (and tweeted) acceleration

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You have to move fast these days to keep up with the flu. Or outrun it.

A quick roundup from the last 24:

From the invaluable H5N1:

  • Mexico: 4,000 H1N1 cases in 7 days

  • Spain: 31,322 cases and 6 deaths in one week

  • US: 15 states could run out of hospital beds

  • Scotland sees it Worst week yet for swine flu, with new cases running at 2,000 a day

  • Toronto catches the wave.

Meanwhile, Helen Branswell reports that Dutch researchers find mutation linked to greater virulence in swine flu virus — but so far it doesn’t appear to be the big upgrade in nasty we’ve been fearing. Effect Measure gives it a good look.

A sad story about Ground zero of Canada’s flu crisis, about a village in WInnipeg that asked for sanitation supplies — and got body bags.

The WSJ Blog asks whether Pregnant Women Will Get the Swine Flu Vaccine. Avian Flu Diary looks at why they might want to.

Avian Flu Diary look as well at another study showing the swine flu does its worst when it goes particularly deep into the lungs.

And a couple doctors tweeting from Dell Children’s Hospital in Austin, where they set up tents to handle the overflow, record a remarkable surge there. No links, but tweets tell a sort of shouted story of acceleration, starting last Friday, Sept 25:

Fr 9/25:

setonh1n1: Flu patient volume continuing to build up at Dell. Approximately 341 patients last 24hrs! Majority with ILI or flu.

setonh1n1: 343 patients at Dell yesterday, majority with flu or flu like illness. Tentatively planniing on opening flu tents tomm

setonh1n1: Yesterday a whopping 68% of patients tested by our flu research group with ILI symptoms tested positive for type A flu. A new high rate.

Sun 9/27: setonh1n1: Wow! 365 patients at Dell in the past 24hrs! 7am today there are already 40 waiting to be seen. Possibly time for a new plan.

Mon 9/28:setonh1n1: Last 24hrs at Dell Children’s volume was 386! Majority with flu illness. With continuing rise in cases when will it peak and start to taper? Tue 9/29: setonh1n1: Extremely busy again, 353 patients. Over 70% with flu or ILI. Second tent treatment area opens today with an extra doc or nurse practitioner

Wed 9/30: setonh1n1: 404 patients at the Dell ED yesterday! The highest yet. We keep hoping the flu has peaked in children but no solid sign of such yet.

Thu Oct 1, 7:50pm (CST): setonh1n1: 3 more tents arrived at Dell. Decision if, when, where, to deploy will depend on volume across the network. Still mostly just kids sick.

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H5N1: Canada: “An epidemic of confusion”

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September 30, 2009

Canada: “An epidemic of confusion”

Via the Globe and Mail, Caroline Alphonso writes: Provincial flu strategies all over the map. Excerpt:

Two provinces and a territory have split ranks with the rest of Canada’s health authorities in their fall immunization plans, sowing public confusion and raising questions of whether Canadians are being offered the safest options. 

The hodge-podge of vaccination strategies comes after a controversial, unpublished study suggested that people under 50 are twice as likely to contract the H1N1 virus if they have received a seasonal flu shot compared to unvaccinated people. 

With no data revealing the optimal way of rolling out vaccines against the looming double threat of seasonal flu and the pandemic swine flu virus, the abrupt changes by provinces and territories could create disarray in inoculation programs, with fewer people turning up for either shot, potentially resulting in more cases of severe illness. 

“We’ll know who’s smarter at the end of the flu season,” said Ross Upshur, director of the University of Toronto’s Joint Centre for Bioethics and a primary care physician. 

“What we assuredly have is an outbreak of unpublished research which is causing an epidemic of confusion.”

Non-Canadians may not understand that our provinces–in some areas–are effectively sovereign states. Education and health are two of those areas, where the federal government provides some money and guidance, but the provinces set their own terms.

In some ways this is just fine. But in the present emergency, we do look like Canadian humorist Stephen Leacock’s gallant knight who dashed out of his manor house, leaped on his horse, and galloped off in all directions.

via crofsblogs.typepad.com

Posted via web from David Dobbs’s Somatic Marker