Friday, January 6, 2012

BMJ's Ten Commandments for the Ideal Physician

The British Medical Journal's great blogger Richard Lehman has published the following Ten Commandments for excellent clinical practice. These are great rules of thumb for any savvy health care practitioner--but they do require that wee bit of extra work to truly understand the statistics behind the medical literature. 
(Hat tip to Steve Balt, MD, for sending me the link). 

The New Therapeutics: Ten Commandments
  • Thou shalt treat according to level of risk rather than level of risk factor.
  • Thou shalt exercise caution when adding drugs to existing polypharmacy.
  • Thou shalt consider benefits of drugs as proven only by hard endpoint studies.
  • Thou shalt not bow down to surrogate endpoints, for these are but graven images.
  • Thou shalt not worship Treatment Targets, for these are but the creations of Committees.
  • Thou shalt apply a pinch of salt to Relative Risk Reductions, regardless of P values, for the population of their provenance may bear little relationship to thy daily clientele.
  • Thou shalt honour the Numbers Needed to Treat, for therein rest the clues to patient-relevant information and to treatment costs.
  • Thou shalt not see detailmen, nor covet an Educational Symposium in a luxury setting.
  • Thou shalt share decisions on treatment options with the patient in the light of estimates of the individual’s likely risks and benefits.
  • Honour the elderly patient, for although this is where the greatest levels of risk reside, so do the greatest hazards of many treatments.

Thursday, January 5, 2012

On Stephen Colbert, Super PACs, and Industry-Supported CME

The current New York Times Magazine carries a fascinating and quite hilarious profile of Stephen Colbert, of the Colbert Report. Colbert is well known for his parody of a know-nothing rabidly conservative Republican commentator—but according to the article he has taken his comedy into the real world, involving himself directly in those shady instruments of electioneering known as “super PACs.”

For those who haven’t followed super PACs, they are the political equivalent of the CME industry’s Medical Education Communication Companies (MECCs). Super PACs can take unlimited amounts of money from corporations, then turn around and use the money to promote candidates of their choosing—with the stipulation that they are not directly “coordinating” with their favorite candidates, whatever that means.  Analogously, MECCs can take unlimited amounts of money from drug companies, then turn around and use the money to pay doctors to promote the company’s products—with the stipulation that they cannot coordinate their CME courses directly with drug companies, again, whatever that means.

In both examples, a third party is being used by corporations to circumvent an inconvenient regulation. In the case of super PACs, companies can circumvent Federal  Election Commission (FEC) rules that limit campaign contributions to a maximum of $2500 per individual (super PACs can accept millions from individuals). In the case of MECCs, drug companies circumvent ACCME Standards for Commercial Support forbidding direct payments to doctors for CME, by laundering the money in the form of  educational grants to third party CME companies.

Colbert, in an effort to expose how corrupt super PACs are, has actually started his own super PAC, entitled "Americans for a Better Tomorrow, Tomorrow."  As quoted in the Times article, Colbert facetiously defends his and other super PACs by pointing out that they are “100 percent legal and at least 10 percent ethical.”

I’ve never heard a better characterization of industry-supported CME.  Let’s hope that Colbert continues his unorthodox lessons in the ways of money, corporations, and corruption.  For his next project, I suggest he start his own MECC, named, perhaps, “The Institute for Healthcare Education and Prescription Promotion.” 

Wednesday, January 4, 2012

APA Threatens to Sue "dsm5watch" Website

I just read Bernard Carroll's interesting post on the Health Care Renewal Blog about the latest DSM-5 brouhaha. It appears that the American Psychiatric Association has sent a "cease and desist" letter to a website critical of the DSM-5. The site was called "dsm5watch," but the APA argues that using DSM-5 in the blog title is an infringement of their trademark. The owner of the blog, Suzy Chapman, having no funds to tussle with APA lawyers, simply changed the name of her site to dxrevisionwatch, which, she says, has resulted in much less traffic.

Is the APA simply protecting its ownership of a lucrative franchise, or is it engaging in something more insidious, what Dr. Carroll calls the "SLAPP maneuver," an acronym for "strategic lawsuit against public participation"? I'm guessing that APA would have had little problem with the site if it were cheerleading the DSM-5 process. It all seems rather heavy-handed to me. After all, the New York Times appears to have no problem with the anti-Times site called TimesWatch. In a democratic society, healthy dissent and debate is part of the package. It may be annoying, but that doesn't excuse the bullying tactics that the APA has chosen.