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On Excellent Medical Reporting

In an earlier entry, I was critical of what I call the “press release” variety of medical reporting in which the news report is based heavily or entirely on a press release by individuals or institutions who have a financial or other vested interest in shaping the presentation.  In many, if not the majority, of these the difference between informing and marketing is not discernible to me.  It is therefore only fair to give credit for what I think is an example of excellent medical reporting. As described below, I was also impressed at the value added to conventional newspaper reporting by its associated Internet capabilities. The article provides an example of the pre-publication embargo system used by some major medical journals with what I think are both positive and negative implications.

The Article and Report.
On Tuesday, February 8, New York Times reporter Denise Grady published an article, “Lymph Node Study Shakes Pillar of Breast Cancer Care.” My sometimes faulty memory tells me I saw her article Monday evening on the New York Times website. The article Ms. Grady reported on was officially published in the February 9 issue of JAMA, the Journal of the American Medical Association: “Axillary Dissection vs No Axillary Dissection in Woman With Invasive Breast Cancer and Sentinel Node Metastasis, ” by Armando E. Giuliano and coauthors; vol. 305:569, 2011. I received my personal copy of the Journal on Wednesday the 9th.

I spent over two hours studying this seven page paper. It was heavy going for me and would have been largely impenetrable to a layperson. It goes against my grain to be paternal, but there is no way for a layperson to understand the significance of the research or how it might relate to them without help. In fact, even I needed some help to put things in perspective, and I confess some of that help came from Denise Grady.

To summarize the paper in an obscenely brief manner, 891 women with breast cancer that had already metastasized as far as the lower lymph nodes in her axilla (armpit) were randomized to 2 different treatment plans. Half the women went on to what was then the standard treatment of extensive removal of all the lymph nodes in their axilla. The other half had no additional surgery beyond the biopsy of the low sentinel node that showed the metastatic cancer. All of the women had a lumpectomy and radiation to the breast, and almost all had additional adjuvant or prophylactic chemotherapy. The patients were followed for as long as eight years. There was no difference in the survival or cancer recurrence rate in either group. Continue reading “On Excellent Medical Reporting”

Seeing Green in Kentucky: Money in Politics

I read with interest today’s report in the Courier-Journal by Tom Loftus summarizing the lobbying efforts of the Kentucky Optometric Association in promoting a bill that would expand their scope of practice and give their licensure board more freedom to define what other things they can legally do. The administration of medications and the ability to perform laser surgery are among them.

Two things are remarkable to me.   The first is the swift and overwhelmingly bipartisan support for the bill.   The second is the remarkable amount of money spread so widely among legislators of both parties.  The money, also called campaign contributions, was given to 137 of the 138 members of the state legislature and both gubernatorial candidates.   It was good business for the lobbying community as well: at least 18 of them helped to spread the fertilizer. The only legislator who did not receive a contribution was representative David Watkins, who also happens to be a physician of the MD variety.  His position appears to be similar to that of the Kentucky Medical Association and might be paraphrased as, “If you want to practice medicine, go to medical school.” (Disclaimer:  I am a member of the KMA.)

Some $400,000 in political contributions were spread around in the past two years alone. To put things in perspective, the Kentucky (MD) Physicians PAC gave only $70,050 during the same period, and the Ophthalmologic (MD) Physicians pack gave $20,750.   The MDs were obviously outbid by the ODs.  The bill passed out of the Senate by a vote of 33 to 3.  I did not think anything could pass out of the Senate with such cooperation nowadays! Continue reading “Seeing Green in Kentucky: Money in Politics”

Safer to Buy Your Prescription Drugs in Canada?

I clipped an article from the Courier journal in December, 2010 entitled, “Pfizer issues 4th Lipitor recall” that was released by the Associated Press.  Although I had planned to focus on articles from the new year, a subsequent article about a recall of multiple products by Johnson & Johnson made the pair fair game.

The Lipitor recall was the most recent of a series reacting to an “uncharacteristic” odor.  The smell is blamed on a wood preservative often applied to wood pallets that might have been used to transport products.  The article quotes Pfizer that the use of such chemicals in the shipment of its products is prohibited.  (Are we are left to assume that the chemical tainted the pills in some other as yet unknown manner?)

The article goes on to mention that over 360,000 bottles of Lipitor have been recalled so far; that Lipitor is the best-selling prescription drug in the US; that other drug companies such as Johnson and Johnson have had trouble with smelly pills; and that the risk of serious harm from this particular contamination is remote.

The story about Johnson and Johnson is quite interesting.  As reported by Wall Street Journal and other sources,  Johnson & Johnson recalled tens of millions of packages of over 40 different medicines in 2010.     According to Reuters, at least one American Johnson & Johnson manufacturing plant “was closed to fix quality control lapses, including unsanitary conditions.”  The recall has generated citations from federal regulators and criticism by congress because of the “phantom” nature of the recalls.  This is a far cry from the actions of McNeil during the Tylenol poisoning incident in 1982 which brought  the Johnson & Johnson subsidiary praise for its bold and definitive response.

Continue reading “Safer to Buy Your Prescription Drugs in Canada?”

Battles Royale in Louisville

My discussion of the reporting on the extremely high rate of major spinal fusion surgery in Louisville has generated its own follow-up.  On Jan 17, Courier-Journal reporter Patrick Howington contributed a front-page article about the legal battle of five Louisville orthopedic surgeons over an estimated $60 million in royalty fees.

Wow!  The Chamber of Commerce must be proud.  This is the kind of big-time health care and research money on which Louisville’s city fathers, and its business and university communities have pinned their hopes for the future.  So why am I embarrassed over this?  Should I be?  Would I be if the money were coming to me?   I think there is plenty of embarrassment to go around.

It is embarrassing for me as a physician to see other physicians fighting so publicly over money.  While certainly within their legal rights, this dispute over money by these professionals reminds us that even for physicians, the practice of medicine is at its base a business.  There has always been an inherent tension in the patient-physician relationship:  what is best for the patient may not always be what is best for the physician.  The professional ideal resolves any such conflicts in favor of the patient.  As more and more outside players insert themselves between and around the patient-physician relationship, the vectors of tension become more complex and more difficult to resolve.  I predict we will increasingly appreciate such policy difficulties as the structure of our healthcare system changes.  Our debates over capitation, managed care, or physicians as employees provide examples where the nature of the patient-physician relationship has been tested.  During the last year in Louisville, several prominent contract battles between insurance companies, doctors, and hospitals continues to disrupt the vulnerable contract between patients and their physicians. Continue reading “Battles Royale in Louisville”