NYT: Holding Doctors Accountable for Medical Errors

From the article:

"Q. Has this erosion of trust had a detrimental effect on the patient-doctor relationship?

A. The chaos of everyone doing things their own way is incredibly dangerous, and it is that chaos which gets in the way of the relationship. You can make health care better, safer and less expensive while strengthening the core of the patient-doctor relationship. You can standardize certain parts of care based on clear evidence, which will free up doctors to focus on those pieces of the health care puzzle where there is no data — those issues that are uniquely human and that require judgment, expertise and empathy.

The challenge, though, is to standardize care in a way that will improve safety while retaining the parts that make medicine human. The last thing we want to do is to regiment empathy or to create something so regulated that doctors cannot do something nuanced or innovative for patients.

Q. What are the roles of patients and of doctors in the patient safety movement?

A. If I were a patient or a loved one, I would do what everyone recommends — have a loved one by your side, look for signals that a hospital is safe, check that a physician is board certified. But I am also intensely ambivalent about how responsible patients should be for safety and the prevention of error. Medical mistakes are our bad. Why should patients bear the responsibility to receive the right medication or to have the correct leg amputated? When I get on a plane, I don’t worry about safety and errors.

As for doctors, patient safety can’t happen if physicians aren’t smack in the middle of it. We can either facilitate safety or we can stand its way. We will stand in its way if we embrace our historical approach to these problems, if we instinctively engage in finger-pointing, if we aren’t willing to listen to others.

We have a huge role in creating the kind of environment where people will feel comfortable questioning anything that seems strange or out-of-place and where doctors are open to different opinions from others.

As doctors, we have to admit first that we don’t deliver care that is of the quality and safety our patients deserve. Then we have to get past our professional arrogance. We don’t have the answers to all of these issues, and we have to be open to others who may have the answers or who can approach it from different angles."

Link

Patient Empowerment in Medicine

Many medical professionals are often years behind in their reading; understandably they don't like empowered patients.

Some doctors don't like patients who challenge them. Such patients take time and make a doctor work hard. Most doctors want to be considered the authority - even if it kills you.

If you see annotations in your medical file - "patient is getting information from the internet" - it is probably time to move on for the sake of your health and wellness.

Link

Pristiq for Menopause?

If you are a middle-aged woman and your primary care physician or endocrinologist is offering you antidepressants for symptoms, this article
on the marketing of Pristiq may explain why.
Make sure you have your thyroid checked... menopause troubles may be myxedema.

Teenage Children and Other Abnormalities - Laughable Excerpts from Actual MD Notes

Teenage Children and Other Abnormalities - Laughable Excerpts from Actual MD Notes

This list is reproduced from MDs' actual writings on charts, published in the Mpumalanga Hospital Register (South Africa), courtesy of Veven Bisetty.

It contains a memorable thyroid notation.

1. The patient refused autopsy.

2. The patient has no previous history of suicides.

3. Patient has left white blood cells at another hospital.

4. Patient’s medical history has been remarkably insignificant with
only a 11 kgs weight gain in the past three days.

5. She has no rigors or shaking chills, but her husband states she was
very hot in bed last night.

6. Patient has chest pain if she lies on her left side for over a year.

7. On the second day the knee was better, and on the third day it disappeared.

8. The patient is tearful and crying constantly. She also appears to
be depressed.

9. The patient has been depressed since she began seeing me in 1993.

10. Discharge status: Alive but without my permission.

11. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.

12. Patient had waffles for breakfast and anorexia for lunch.

13 She is numb from her toes down.

14. While in ER, she was examined, X-rated and sent home.

15. The skin was moist and dry.

16 Occasional, constant infrequent headaches.

17. Patient was alert and unresponsive.

18. Rectal examination revealed a normal size thyroid.

19. She stated that she had been constipated for most of her life,
until she got a divorce.

20. I saw your patient today, who is still under our car for physical therapy.

21. Both breasts are equal and reactive to light and accommodation.

22. Examination of genitalia reveals that he is circus sized.

23 The lab test indicated abnormal lover function.

24. Skin: somewhat pale but present.

26. Large brown stool ambulating in the hall.

27. Patient has two teenage children, but no other abnormalities.

Note: This information may not have been evaluated by the FDA.

What Exactly Are They Teaching in Medical School?

What Exactly Are They Teaching in Medical School?

Dateline: 05/05/97
In the May/June issue of Health magazine, there's a familiar but frightening story. The article by Barbara Bailey Kelley describes a woman who had constant fatigue, constipation, constantly feeling cold and difficulty swallowing. According to the article, this group of symptoms had the woman "hopping from doctor to doctor. None could identify a medical problem." Three years after her symptoms appeared, the woman was checked into a hospital, where a coterie of specialists -- an allergist, heart specialist and psychiatrist -- examined her. The psychiatrist wondered if she was suffering from depression. After a battery of tests which, WHEW, finally included a thyroid-stimulating hormone (TSH) test, they FINALLY discovered that she was very hypothyroid, in fact, her thyroid had almost shut down completely.

Okay, calling Dr. Kildare! Marcus Welby! The entire staff of St. Elsewhere, Chicago Hope and ER! Where are the doctors who recognize thyroid disease's symptoms quickly?

On an AOL chat a few weeks ago, a group of us were speculating what would happen if a woman with a basketball-sized goiter walked into the ER at "ER." We decided she'd be told she was stressed out, and sent home with a prescription for Prozac, AND a big fat bill from the emergency room (that her insurance company would probably deny!!!) Now how bout that storyline for dramatic tension? (Of course we all agreed we'd keep the goiter if it meant George Clooney'd be our endocrinologist!)

In any case, doesn't it seem like anyone who's spent more than five minutes reading anything about thyroid disease would have a problem recognizing the familiar litany of symptoms the poor woman in the article described? In fact, I sometimes have to watch about becoming too evangelical myself when friends say, "you know, I've been feeling a bit tired and run-down lately, and..."

"COULD BE YOUR THYROID!!!" I announce.

Continues at Link

Planetree: Patient-Centered Care

Patient-Centered Care Awareness Month

"Patient-Centered Care Awareness Month is an international awareness-building campaign that occurs every October to commemorate the progress that has been made toward making patient-centered care a reality and to build momentum for further progress through education and collaboration. Hospitals and health care organizations around the world are encouraged to celebrate by empowering patients, strengthening their patient-centered practices, and publicly proclaiming to their patients and communities their commitment to patient-centered care.

For the past two years, health care organizations around the United States, Canada and the Netherlands have celebrated Patient-Centered Care Awareness Month. In addition, fourteen state governors commemorated the month signing proclamations officially recognizing the importance of patient-centered care to their states’ citizens.

What is “Patient-Centered Care”?

Although the phrase “patient-centered care” is defined and used in a variety of ways, the essential theme is the importance of delivering healthcare in a manner that works best for patients. In a patient-centered approach to health care, providers partner with patients and their family members to identify and satisfy the full range of patient needs and preferences.

Organizations practicing patient-centered care recognize that:

A patient is an individual to be cared for, not a medical condition to be treated.

Each patient is a unique person, with diverse needs.

Patients are partners and have knowledge and expertise that is essential to their care.

Patients’ family and friends are also partners.

Access to understandable health information is essential to empower patients to participate in their care and patient-centered organizations take responsibility for providing access to that information.

The opportunity to make decisions is essential to the well-being of patients and patient-centered organizations take responsibility for maximizing patients’ opportunities for choices and for respecting those choices.

Each staff member is a caregiver, whose role is to meet the needs of each patient, and staff members can meet those needs more effectively if the organization supports staff members in achieving their highest professional aspirations, as well as their personal goals.

Patient-centered care is the core of a high quality health care system and a necessary foundation for safe, effective, efficient, timely, and equitable care."

Link - at the bottom of the pagte you can download their patient-centered care Toolkit.

DHEA, Adrenals and the Thyroid

DHEA is an endocrine hormone necessary for the function of adrenals. If thyroid is given without taking this into consideration, an adrenal crisis may result.
Does your endocrinologist know and understand DHEA?
Link
Link

Thryoid Awareness: The Akita

A new American film based on the story of a loyal dog may help raise awareness of human thyroid problems. Dogs of this breed, the AKITA, frequently have problems with low thryoid, resulting in health and temperament problems.
http://www.petpublishing.com/dogken/breeds/akita.shtml

Just as the dog Hachiko waited faithfully for his master, human thyroid patients often wait a long time to get help from the doctors they rely on. Let us hope that their long wait will not be in vain.

Memory Loss and Thyroid Function

From Great Smokies Diagnostic Laboratories

Memory Loss and Thyroid Function
Every cell in the body, including cells in the brain, contains receptors for thyroid hormones. Thyroid hormones can stimulate and change the structure of particular regions of the brain, such as the hippocampus, the area primarily responsible for learning and memory.1,2 They also modulate enzymes that regulate the metabolic rate of brain cells.

Temporary memory loss is a classic symptom of hypothyroidism, a condition arising from inadequate production of hormones by the thyroid gland, or from decreased peripheral conversion of the thyroid hormone thyroxine (T4) into triiodothyronine (T3) in the kidney or the liver.

Fortunately, memory loss caused by thyroid hormone imbalances can often be effectively treated. As a recent case study illustrates, proper diagnostic testing is crucial, because memory loss may be the only symptom of thyroid insufficiency, and may occur without any other physical signs of thyroid imbalance.3

Even sublinical thyroid imbalances can affect mental ability. Evidence indicates that as levels of thyroid hormone thyroxine decrease, cognitive function generally declines.4 Researchers from the Karolinska Institute in Stockholm, Sweden found that levels of thyroid stimulating hormone (TSH) correlate with episodic memory performance in healthy men and women over the age of 75.5 They speculated that TSH may actually help the brain encode and store memory. Another study reported that memory loss was the only cognitive symptom of subclinical hypothyroidism in a group of female patients with goiter, and was effectively alleviated with thyroid hormone treatment.6

For these reasons, optimizing thyroid function is considered an important tool for anti-aging therapies designed to safeguard memory and cognitive function.7

Link

On GDSL thyroid assessment
http://web.archive.org/web/20060328012531/www.gsdl.com/home/assessments/thyroid/index.html

The company has changed its name to Genova Diagnostics and the site is
here.

Justice - a course at Harvard

Kirkus Review: A Harvard law professor explores the meaning of justice and invites readers on a journey of moral and political reflection, “to figure out what they think, and why.” Does a veteran suffering from post-traumatic stress disorder “deserve” the Purple Heart? Should the U.S. government formally apologize and make reparations for slavery? Is it wrong to lie to a murderer? Following the taxpayer bailout of the company, are executives at insurance giant A.I.G. still entitled to their bonuses? Should a professional golfer afflicted with a severe circulatory condition be allowed to use a golf cart during tournaments? Are you obliged to surrender your criminal brother to the FBI? Although Sandel (The Case Against Perfection: Ethics in the Age of Genetic Engineering, 2007, etc.) concedes that answering the many questions he poses, bound up “with competing notions of honor and virtue, pride and recognition,” is never easy and inevitably contentious, it’s necessary for a healthy democracy. “Justice,” he writes, “is inescapably judgmental.” Using three approaches to justice—maximizing welfare, respecting freedom and promoting virtue—the author asks readers to ponder the meaning of the good life, the purpose of politics, how laws should be constructed and how society should be organized. Using a compelling, entertaining mix of hypotheticals, news stories, episodes from history, pop-culture tidbits, literary examples, legal cases and teachings from the great philosophers—principally, Aristotle, Kant, Bentham, Mill and Rawls—Sandel takes on a variety of controversial issues—abortion, same-sex marriage, affirmative action—and forces us to confront our own assumptions, biases and lazy thought. The author has a talent for making the difficult—Kant’s “categorical imperative” or Rawls’s “difference principle”—readily comprehensible, and his relentless, though never oppressive, reason shines throughout the narrative. Sparkling commentary from the professor we all wish we had.

Link

Evaluation of Thyroid Function in Health and Disease

Evaluation of Thyroid Function in Health and Disease

Canada's Health Care System - Poor Value for Tax Dollars

Are you more impressed by your physician's clothes and car than by his/her healing skills? Something to think about - your taxes are paying for this. From the Fraser Institute

A Country Doctor - Short Story by Kafka

Many patients find that their experiences with physicians are nightmarish or Kafkaesque.
In this story, a doctor undergoes torment.





Strip his clothes off, then he'll heal us,
If he doesn't, kill him dead!
Only a doctor, only a doctor.

Then my clothes were off and I looked at the people quietly, my fingers in my beard and my head cocked to one side. I was altogether composed and equal to the situation and remained so, although it was no help to me, since they now took me by the head and feet and carried me to the bed. They laid me down in it next to the wall, on the side of the wound. Then they all left the room; the door was shut; the singing stopped; clouds covered the moon; the bedding was warm around me; the horses' heads in the open windows wavered like shadows. "Do you know," said a voice in my ear, "I have very little confidence in you. Why, you were only blown in here, you didn't come on your own feet. Instead of helping me, you're cramping me on my deathbed. What I'd like best is to scratch your eyes out." "Right," I said, "it is a shame. And yet I am a doctor. What am I to do? Believe me, it is not too easy for me either." "Am I supposed to be content with this apology? Oh, I must be, I can't help it. I always have to put up with things. A fine wound is all I brought into the world; that was my sole endowment."

Dunning-Kruger: Does your doctor suffer from this condition?

"Kruger and Dunning set out to test... hypotheses on human subjects consisting of Cornell undergraduates who were registered in various psychology courses. In a series of studies, they examined self-assessment of logical reasoning skills, grammatical skills, and humor. After being shown their test scores, the subjects were again asked to estimate their own rank, whereupon the competent group accurately estimated their rank, while the incompetent group still overestimated their own rank. As Dunning and Kruger noted,

Across four studies, the authors found that participants scoring in the bottom quartile on tests of humor, grammar, and logic grossly overestimated their test performance and ability. Although test scores put them in the 12th percentile, they estimated themselves to be in the 62nd.

Meanwhile, people with true knowledge tended to underestimate their competence. A follow-up study suggests that grossly incompetent students improve both their skill level and their ability to estimate their class rank only after extensive tutoring in the skills they had previously lacked.

They won Ig Nobel Prizes in Psychology in 2000 with their report Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments."

Link
Also see Downing Effect

A Doctor's Rx for CEO Decision Makers

A Doctor's Rx for CEO Decision Makers
by Jerome Groopman, MD

From the essay:

Doctors, like business leaders, make mistakes. Some errors are purely operational. A pint of blood is mistakenly transfused into Joan Smith rather than Jane Smith, and Joan goes into shock. A young doctor writes an incorrect dose of chemotherapy on an order sheet, and a woman with breast cancer dies from the toxic effects of overtreatment. A neurosurgeon operates on the wrong side of the brain because an X-ray was mislabeled as "right" rather than "left." These kinds of errors make headlines, trigger lawsuits, and terrify patients and their families; in the academic world, such mistakes prompted the Institute of Medicine to publish the landmark article "To Err Is Human" in 1999. Leaders in health care took the IOM recommendations to the business world for solutions. Lessons learned in high-risk industries such as air travel and nuclear energy were applied to hospitals. Anyone who has recently had a medical procedure or treatment has benefited from the checks and double checks that have become routine. To ensure that the right patient receives the intended care, health care professionals, like airline pilots, now follow strict protocols.

However, operational mistakes account for only a small percentage of medical errors. The overwhelming majority reflect poor thinking. In fact, 15% to 20% of all medical conditions are misdiagnosed. A middle-aged man's indigestion, treated with antacids, turns out to be a heart attack; a child's chronic headache is due not to "family stress" but to a brain tumor; a grandmother's fading memory is not early Alzheimer's disease but vitamin B12 deficiency. Such diagnostic errors reflect shortcomings in physicians' thinking rather than technical mistakes. In 2007, a national conversation began in the medical field about how best to address these errors of judgment. Business practices were not the solution this time; in fact, CEOs and other senior managers would do well to adopt the strategies that physicians are pursuing.

Senior doctors, like CEOs, traditionally have cast themselves as confident, autonomous decision makers; they take pride in their rapid analyses and sure-footed recommendations. Their judgments filter through the hierarchy in much the same way that decisions in a company are disseminated from the corner office. However, in sharp contrast with most businesses, hospitals convene regular meetings where all faculty and trainees—from the chief to the beginning medical student—revisit cases that had poor outcomes. At these forums, participants are beginning to dissect doctors' misguided thought processes, not just discuss bodily organs. This shift has required that even the most esteemed physicians acknowledge their fallibility in an effort to teach others and to improve themselves.

Medicine is drawing on the work of cognitive scientists—particularly Amos Tversky and Daniel Kahneman, who three decades ago explored the benefits and risks of heuristics, or shortcuts in thinking. Heuristics help to explain the 15% to 20% of cases where we get it wrong. My extensive research on misdiagnoses shows that even the most seasoned physicians are highly susceptible to anchoring error, or seizing on the first bit of clinical information that makes an impression. Similarly, all doctors recall dramatic past cases of theirs and mistakenly apply them to the case at hand, a so-called availability error. Another cognitive trap is attribution error, whereby a physician relies on a stereotype to which he attributes all of his patient's complaints. Menopause, old age, and stress are common categories that physicians glibly invoke as explanations for vague symptoms without digging more deeply for other causes. Contrary to the image of the doctor as authoritarian, dismissive of criticism, and resistant to self-analysis, physician leaders are starting to welcome the insights of cognitive science to help them avoid errors of judgment, in part because they have recently seen the benefits of rectifying operational errors. By making themselves vulnerable, physician leaders have now begun to encourage those lower down in the hierarchy to question decisions more freely and think more broadly.

"...hospitals convene regular meetings where all faculty and trainees—from the chief to the beginning medical student—revisit cases that had poor outcomes..."
We wish...

Link

MTBI Rehabilitation: The Patient's Perspective

A useful article for those who are putting their lives back together after medical error.

MTBI Rehabilitation: The Patient's Perspective
by
Constance Miller, MA
October 27, 1998

A Presentation made to the
Consensus Development Conference on
Rehabilitation of Persons with Traumatic Brain Injury
National Institutes of Health
Bethesda, MD

My interest in Mild Traumatic Brain Injury, MTBI, grew out of my own MTBI in a 1982 car accident. Prior to that life changing event I enjoyed a full, rich lifestyle that included women's rights and health care advocacy as well as a brief career as a university professor.

On that fateful day in 1982, I bumped my head in a car crash and my world turned upside down. When I came to I felt as though I had been disembodied, disconnected from myself and my past. The sensation was one of being outside of my body; viewing myself from afar. It was as though my head was in the clouds and my feet were planted in some strange yet familiar place.

There were blank spots in my memory and gaps in my consciousness. Words eluded me and my thoughts were frequently out of control. Sounds were muffled and sometimes irritating, and worst of all, nothing made sense. I thought to myself, this is spooky, suddenly for some unknown reason the world had become a strange and scary place.

Instinctually, I felt that something was very wrong although I was hard pressed to get others to confirm my impressions. I desperately needed answers. Much to my horror, the answers that were offered were the wrong answers. It did not take long for me to realize that my very life was at stake. In the blink of an eye I had been transformed from a vital, mid-career professional to one of the undead.

Essentially, life as I had known it no longer existed for me. I had become a mere shadow of my former self. Yet something in myself propelled me onward as I launched into the task of creating a new self and a new identity out of the wreckage of my life. Fortunately, my pre-injury accomplishments enabled me to unlock the mystery of MTBI, and create a new life for myself.

I was relieved to find that the answers to the mysteries of MTBI were known to medical science. I applied what I learned to restoring myself and to selecting and educating my doctors and lawyers. Then, I put everything into a self-help guide called From The Ashes. Then I founded the Head Injury Hotline to advise people on the syndrome, on good care providers, on legal options, and on social and career services available to them.

Continues at Link
Brain injury checklist symptoms may match those of thyroid problems.

TED Talks: Our buggy moral code

At TED, Dan Ariely talks about people who cheat - and why they do.

With all the information coming out about faked and ghostwritten medical papers, we know that Ariely's thoughts and observations have relevance in health care. Any patient who has been given short shrift by a doctor - getting less than their due in a fifteen minute appointment - knows this is true. This link discusses people in the medical profession who take advantage of patients who have brain injuries.

Is your doctor cheating you?


URL link - http://www.youtube.com/watch?v=nUdsTizSxSI

Tardive Dyskinesia and missed diagnosis

"Miracle Drugs" Cause the Worst Plague
of Brain Damage in Medical History

(This is taken from Chapter 4 of Peter Breggin's book, Toxic Psychiatry.)
. . . antipsychotic drugs have been termed "neuroleptics," in that these drugs' actions imitate a neurological disease. - American Psychiatric Press, Textbook of Psychiatry (1988)
It is also clear that the antipsychotic [neuroleptic] drugs must continue to be scrutinized for the possibility that their extensive consumption might cause general cerebral dysfunction. - Unpublished paper coauthored in 1978 by Igor Grant and others, including Lewis Judd; comment expurgated from published versions

Every violation of truth is not only a sort of suicide in the liar but is a stab at the health of human society. - Ralph Waldo Emerson

Roberta had been treated for several years with the "miracle drugs," neuroleptics such as Thorazine, Haldol, Mellaril, and Prolixin. My medical evaluation described her condition:
Roberta is a grossly disfigured and severely disabled human being who can no longer control her body. She suffers from extreme writhing movements and spasms involving the face, head, neck, shoulders, limbs, extremities, torso, and back - nearly the entire body. She had difficulty standing, sitting, or lying down, and the difficulties worsen as she attempts to carry out voluntary actions. At one point she could not prevent her head from banging against nearby furniture. She could hold a cup to her lips only with great difficulty. Even her respiratory movements are seriously afflicted so that her speech comes out in grunts and gasps amid spasms of her respiratory muscles.
Roberta's current psychotic disorder is most probably also a product of neuroleptic-induced brain disease. Her inappropriate affect - giggling and superficial smiling while in great distress - is typical of brain damage. Roberta may improve somewhat after several months off the neuroleptic drugs, but she will never again have anything remotely resembling a normal life.

Tardive Dyskinesia and Tardive Dementia
Roberta had an unusually severe case of tardive dyskinesia (TD), a disease frequently caused by the neuroleptics. The term "tardive" means late developing or delayed; "dyskinesia" means abnormal movement. Tardive dyskinesia is a movement disorder that can afflict any of the voluntary muscles, from the eyelids, tongue, larynx, and diaphragm to the neck, arms, legs, and torso.(1) On rare occasions it can occur after a few weeks or months, but usually it strikes the individual after six months to two years of treatment.

Any of the neuroleptics can cause tardive dyskinesia. The total dosage probably affects the likelihood of this happening, but the dose relationship is not easily demonstrated, and any amount must be considered dangerous. While some symptoms improve or even disappear after removal from the offending medications, most cases are permanent. There is no known treatment for tardive dyskinesia.

Often the start of disease goes unnoticed, because the drugs that cause it also tend to suppress the overt symptoms. Thus the disease percolates out of sight, finally breaking through with uncontrollable twitches, spasms, or writhing movements. Whenever possible, patients should try to stop the drugs periodically to check for abnormal movements.

Roberta also had tardive dementia, a global deterioration of her mind and mental faculties caused by the drugs. While tardive dyskinesia is a firmly established disease, tardive dementia remains more controversial within the profession, although evidence for its existence seems incontrovertible.

Had She Seen a Different Doctor ...

Roberta was a college student getting good grades, mostly A's, when she first became depressed and sought psychiatric help at the recommendation of her university health service. She was eighteen at the time, bright and well-motivated, and a very good candidate for psychotherapy. She was going through a sophomore-year identity crisis about dating men, succeeding in school, and planning a future. She could have thrived with a sensitive therapist who had an awareness of women's issues.

Instead of moral support and insight, her doctor gave her Haldol. Over the next four years, six different physicians watched her deteriorate neurologically without warning her or her family about tardive dyskinesia and without making the diagnosis, even when she was overtly twitching in her arms and legs. Instead they switched her from one neuroleptic to another, including Navane, Stelazine, and Thorazine. Eventually a rehabilitation psychologist became concerned enough to send her to a general physician, who made the diagnosis. By then she was permanently physically disabled, with a loss of 30 percent of her IQ.(2)

More "Mild" Cases of Tardive Dyskinesia

Most cases of tardive dyskinesia are labeled "minimal" or "mild," compared to "moderate" or "severe." But imagine how you would feel if your mild case of tardive dyskinesia made you stick out your tongue periodically in front of other people, or if you had to blink your eyes spasmodically or crane your neck oddly, or if your voice screeched a little out of control, while others were watching or listening.

Link

Any of these psychotropic medications can cause TD - Tardive Dyskinesia.


When thyroid and other physical diagnoses are missed by physicians and psychotropics are prescribed, the result may be a loss of quality of life or permanent disability.

How Big Pharma controls doctors and medical education

Some links...

NPR - Medical schools and drug firm dollars

Pharma lobbying contributions

How the drug industry gets its way

WSJ: How pharma relies on doctors to sell its products

J. Moncrieff - An unholy alliance - psychiatry and the influence of the pharmaceutical industry

How the drug companies keep tabs on doctors

How the drug industry uses nonprofits to push its agenda

Blind Faith: What happens when drugs, science and money mix?

Big Pharma reaping profits from disease mongering


"One of the first duties of the physician is to educate the masses not to take medicine."
~ Sir William Osler

The Blindmen and the Elephant

by John Godfrey Saxe

It was six men of Hindustan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind)
That each by observation
Might satisfy the mind.

The first approached the Elephant
And happening to fall
Against his broad and sturdy side
At once began to bawl:
"Bless me, it seems the Elephant
Is very like a wall".

The second, feeling of his tusk,
Cried, "Ho! What have we here
So very round and smooth and sharp?
To me 'tis mighty clear
This wonder of an Elephant
Is very like a spear".

The third approached the animal,
And happening to take
The squirming trunk within his hands,
Then boldly up and spake:
"I see," quoth he, "the Elephant
Is very like a snake."

The Fourth reached out an eager hand,
And felt about the knee.
"What most this wondrous beast is like
Is mighty plain," quoth he;
"'Tis clear enough the Elephant
Is very like a tree!"

The Fifth, who chanced to touch the ear,
Said: "E'en the blindest man
Can tell what this resembles most;
Deny the fact who can,
This marvel of an Elephant
Is very like a fan!"

The Sixth no sooner had begun
About the beast to grope,
Than, seizing on the swinging tail
That fell within his scope,
"I see," quoth he, "the Elephant
Is very like a rope!"

And so these men of Hindustan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right
And all were in the wrong.

So oft in theologic wars,
The disputants, I ween,
Rail on in utter ignorance
Of what each other mean,
And prate about an Elephant
Not one of them has seen!

Has your doctor or medical team seen and read your ENTIRE file?

PR: Let's Speak for Ourselves

"The role of PR is important because the question of sincerity helps you decide whether to trust their bacon in the future.
If standard PR tactics are being unfurled, it's harder to know....
Firms may put words in client's mouths, vet their ideas and advise on whether to speak at all. A huge number of Canadian journalism grads end up in PR. Some go directly; others have distinguished careers first, then switch. And a depressing quantity of news stories, especially in areas such as medicine, now come from well-produced PR packages sent on behalf of pharmaceutical firms and the like. Caveat viewor."

Link

Patient advocacy best-practice resources are in our Links column.

NYT: When patient handoffs go terribly wrong

"Handoffs are supposed to mitigate any issues that arise when doctors pass the responsibility for patient care to a colleague. “But that requires investing time and effort,” Dr. Arora said, “and using handoffs as an opportunity to come together to see how patient care can be made safer.”

Most of the time, however, handoffs are fraught with misunderstanding and miscommunication. Physicians who are signing out may inadvertently omit information, such as the rationale for a certain antibiotic or a key piece of the patient’s surgical history. And doctors who are receiving the information may not assume the same level of responsibility for the care of that patient. “Handoffs are a two-way process,” Dr. Arora observed. “It’s a complex interplay.” Missed opportunities to impart important patient information result in more uncertainty for the incoming doctor. That uncertainty leads to indecision which can ultimately result in significant delays during critical medical decisions."

Proper assessment and diagnosis should not be rushed through like a Triage situation. When your "specialist" sees you without having read your record and for a mere 15 minute consultation - as per "hospital policy" - your life can be ruined.

Article here

Tyee: To Save Big Health Dollars, Put Doctors on Salary

A Canadian nurse says that to reduce medical costs and waste, we need to put doctors on a salary. Link

"As a retired nurse who has seen first hand the health system's inner workings, I propose a different reading of rising costs, and a different way to cut them:

Let's take the business out of medicine and put the doctors on salary.

I offered this same advice last year when the provincial government conducted a "Conversation on Health" survey, during which many people voiced their opinions and solutions. Here is my logic.

Pulling in patients

The Ministry of Health itself points the finger at the rising costs of rates paid to physicians and the increased usage of lab and x-rays services. Such costs rose by a whopping seven per cent in 2007, and have continued to escalate at an alarming rate.

Having worked in a medical clinic, I saw the physician spend an inordinate amount of time and energy figuring out how to get paid more from MSP. It seemed to me that if the business were removed from his practice, his time would have been spent practicing medicine, and everyone would benefit from it.

Needless to say, my voice is barely a whisper in the grand scheme of things. We need someone who has the courage and vision to face down the Canadian and American Medical Associations and save our health care system from extinction. Where is Tommy Douglas when we need him?"

Bill Moyers on the Health Care Industry

Money-Driven Medicine.
Not just in the USA, either. Pity...
Link and Transcript http://www.pbs.org/moyers/journal/08282009/transcript1.html

Times of London: What's the Canadian word for 'Lousy care'?

Canadian health care costs a fortune - $40B per year in Ontario alone. People in Canada should be the healthiest in the world. What's gone wrong? Link

Merck Manual: Euthyroid Sick Syndrome

Link
Asking your doctor
to explain this
should be fun.

Why is health care so hazardous? What needs to be done to improve safety?

Statement of Lucian Leape, M.D.
Member, Quality of Health Care in America Committee
Institute of Medicine
Adjunct Professor, Harvard School of Public Health

Concerning Patient Safety and Medical Errors

Before the
United States Senate
Subcommittee on Labor, Health and Human Services, and Education

January 25, 2000

"Good morning, Mr. Chairman and Senator Kennedy, and members of the committee. My name is Lucian Leape and I am a faculty member at the Harvard School of Public Health. I practiced as a pediatric surgeon for much of my career, but in recent years have focused my attention on research into medical errors. I am here today representing the Institute of Medicine's Committee on the Quality of Health Care in America which recently released the report To Err is Human: Building a Safer Health System.

In my testimony today, I will address two questions: 1) Why is health care so hazardous? 2) What needs to be done to improve safety?

Why is health care so hazardous?

Findings from several studies of large numbers of hospitalized patients indicate that each year a million or more people are injured and as many as 100,000 die as a result of errors in their care. This makes medical care one of the leading causes of death, accounting for more lost lives than automobile accidents, breast cancer or AIDS. While these findings are not new, and some hospitals have improved their error reduction activities, clearly a much greater effort is needed to make health care safe.

No physician or nurse wants to hurt patients, and doctors, nurses, and other health workers are highly trained to be careful and take precautions to prevent mistakes. They are held and hold themselves to high standards. Paradoxically, it is precisely this exclusive focus on the individual's responsibility not to make mistakes, reinforced by punishment, that makes health care so unsafe.

The reason is that errors are seldom due to carelessness or lack of trying hard enough. More commonly, errors are caused by faulty systems, processes and conditions that lead people to make mistakes. They can be prevented by designing systems that make it hard for people to do something wrong and easy to do it right. Safe industries, such as aviation, chemical manufacturing, and nuclear power, learned this lesson long ago. While insisting on training and high standards of performance, they recognize these are insufficient to insure safety. They also pay attention to factors that affect performance, such as hours and work loads, work conditions, team relationships, and the design of tasks to make errors difficult to make. They create safety by design. Health care must do likewise.

Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes."



Link

Wikipedia: Congenital hypothyroidism, PAX8

Congenital hypothyroidism is the most common preventable cause of mental retardation. Few treatments in the practice of medicine provide as large a benefit for as small an effort.

Congenital hypothyroidism

PAX8

Ultrasound Images of Thyroid Dysgenesis and More

Link
Osler didn't have this fancy technology; doctors should be able to tell if half of something isn't there by sight and touch.

ICD Codes for Thyroid Disorders

http://www.icd9data.com/2009/Volume1/240-279/240-246/
Thyroid disorders
http://www.icd9data.com/2009/Volume1/240-279/240-246/243/default.htm
Congenital hypothyroidism
Myxedema

Resource: Werner and Ingbar's THE THYROID

Werner and Ingbar's THE THYROID is online at Google Books. This link leads to the chapter on Hypothyroid conditions.

BMJ - Genetics of Congenital Hypothyroidism

From the abstract:

Journal of Medical Genetics 2005;42:379-389; doi:10.1136/jmg.2004.024158
Copyright © 2005 by the BMJ Publishing Group Ltd.
REVIEW
Genetics of congenital hypothyroidism
S M Park1, V K K Chatterjee2

1 Department of Clinical Genetics, Addenbrooke’s Hospital, Cambridge, UK
2 Department of Medicine, University of Cambridge, Addenbrooke’s Hospital

Correspondence to:
Correspondence to:
Dr S M Park
Department of Clinical Genetics, Box 134, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, UK; soo-mi.park@addenbrookes.nhs.uk
Congenital hypothyroidism is the most common neonatal metabolic disorder and results in severe neurodevelopmental impairment and infertility if untreated. Congenital hypothyroidism is usually sporadic but up to 2% of thyroid dysgenesis is familial, and congenital hypothyroidism caused by organification defects is often recessively inherited. The candidate genes associated with this genetically heterogeneous disorder form two main groups: those causing thyroid gland dysgenesis and those causing dyshormonogenesis. Genes associated with thyroid gland dysgenesis include the TSH receptor in non-syndromic congenital hypothyroidism, and Gs and the thyroid transcription factors (TTF-1, TTF-2, and Pax-8), associated with different complex syndromes that include congenital hypothyroidism. Among those causing dyshormonogenesis, the thyroid peroxidase and thyroglobulin genes were initially described, and more recently PDS (Pendred syndrome), NIS (sodium iodide symporter), and THOX2 (thyroid oxidase 2) gene defects. There is also early evidence for a third group of congenital hypothyroid conditions associated with iodothyronine transporter defects associated with severe neurological sequelae. This review focuses on the genetic aspects of primary congenital hypothyroidism.

Abbreviations: ERSD, endoplasmic reticulum storage disease; NIS, sodium iodide symporter; PHP, pseudohypoparathyroidism; PPHP, pseudopseudo-hypoparathyroidism; PTH, parathyroid hormone; TPO, thyroid peroxidase; TRH, thyrotropin releasing hormone; TSH, thyroid stimulating hormone (thyrotropin)

Keywords: congenital hypothyroidism; candidate gene

Link to abstracthttp://jmg.bmj.com/cgi/content/abstract/42/5/379



Link to pdf

Hypothyroid and Alzheimer's - a connection?

Hypothyroid can not only cause dementia; this study suggests it is linked to Alzheimer's disease too.
http://pt.wkhealth.com/pt/re/clen/abstract.00003033-200012000-00012.htm;jsessionid=KBLSHYLsQBp2mqrqJ8Ttm4tsQXLVfpLc6kcfNyXXPVyXXGlL1YQT!-444506849!181195629!8091!-1
Given reliance on flawed American Thyroid level testing rather than on how the patient feels, prompt and appropriate treatment may not be delivered.

Peatfield was a general practitioner in the British National Health service who came to America and trained at the Broda Barnes Institute. He returned to England and started a thyroid private practice. His book summarizes over 25 years of clinical diagnosing and treating thyroid illness. One section of the book is devoted to the question, "Why thyroid blood tests can be unreliable".

Here is what Dr. Peatfield says:

"Anxiety in the medical establishment about rules and dogma has led to a slavish reliance on blood tests, which are often unreliable and can actually produce a false picture of the true situation"

"I have sadly come across very few doctors who can accept the fact that a normal, or low TSH, may still occur with a low thyroid."

"as a result of this test (TSH), thousands are denied treatment"

Peatfield lists several reasons why thyroid blood tests are flawed:

1) They measure hormone levels in the blood. What we really want to know is tissue levels, not blood levels.

2) The blood tests do not measure cellular receptor hormone resistance.

3) The blood tests do not measure conversion block. Some patients cannot convert their inactive T4 to active T3.

4) The thyroid tests do not account for adrenal insufficiency.

5) Paradoxical low TSH may occur with a low thyroid function.

These sentiments are shared by the teachings of Broda Barnes MD, and the Broda Barnes Foundation. However, Peatfield's book elaborates beyond the classic teachings of Broda Barnes by including chapters on the adrenal as well as a chapter on iodine supplementation. I found this book excellent, and it belongs in every medical library dealing with thyroid disease.

http://www.amazon.com/review/RSKEFGC2G8IZO

Thyroid Transcription Factors and Congenital Hypothyroidism

THYROID TRANSCRIPTION FACTORS AND CONGENITAL HYPOTHYROIDISM

Introduction
Primary congenital hypothyroidism (CH) is the most frequent endocrine-metabolic disease in infancy, with an incidence of about 1/3-4000 newborns. In about 85% of the cases, CH is caused by an alteration in the morphogenesis of the thyroid (thyroid dysgenesis, TD) (2). In 5-16% of cases TD it is associated with other major birth defects, mostly cardiac (Table 1) (3).
Most of the critical events in thyroid morphogenesis take place in the first 60 days of gestation in man or the first 15 days in mice. For this reason, thyroid developmental abnormalities result from morphogenetic errors during this period.
The regulation of formation, migration and proliferation of the thyroid gland are still largely unknown. Several genes, including those encoding thyroid specific transcription factors (TITF1, TITF2, PAX8), thyrotropin (TSH) and its receptor (TSHR), and/or other genes, have been demonstrated to play a role (1). Alterations in any of these genes can be responsible for thyroid dysgenesis.
Mutations in the genes involved in thyroid development give rise to animal models with TD, and mutations in the same genes have been identified also in a small number of patients with congenital hypothyroidism associated with TD.

In this review we will briefly describe the role of thyroid transcription factors and their involvement in the pathogenesis of TD.

NKX2-1/TITF1
NKX2-1, also known as TITF1 (Thyroid Transcription Factor–1) is a homeodomain transcription factor that was initially identified in a rat thyroid cell as a nuclear protein able to bind to specific sequences in the Tg promoter. TITF1 belongs to the Nkx2 class of transcription factors and is encoded by a gene, located on chromosome 14q13 (Table 1). The gene is formed by at least 3 exons and encodes for 42 kDa protein that is phosphorylated. During human development, the gene is expressed in the ventral diencephalon and in the telencephalon; in the lung bud and in the thyroid primordium (1, 4).
Studies in mice demonstrated that Titf1 is required for the survival and subsequent differentiation of the cells.

Link

Interesting... this is not a rare disorder. If an endocrinologist who mainly treats children cannot recognize this in adults, how will s/he recognize it in the young persons in his/her care?

Congenital Hypothyroidism - Diagnostics and Treatment

THYROIDAL CONGENITAL HYPOTHYROIDISM

B1. Ontogeny of the Thyroid Gland

The thyroid gland is the first endocrine gland to appear during embryonic development. The gland develops from a median endodermal thickening in the floor of the primitive pharynx. This placode (median anlage) develops into a diverticulum that grows caudally. By seven weeks of gestation, the human thyroid gland has usually reached its final site in the neck. Experiments with knock-out mice show that the transcription factors NKX2.1, FOXE1 and PAX8 are crucial for thyroid development. [76] Hypoplasia caused by inactivation of the TSH receptor is a later phenomenon.[77]

Defects in NKX2.1

The transcription factor NKX2.1 (TTF-1) is a member of a protein family essential for developmental processes. The NKX2.1 gene is localized on chromosome 14q13 and is expressed in thyroid, lung and several structures of the forebrain. Mice missing the NKX2.1 gene are stillborn, lack the thyroid gland, the pituitary gland, lung parenchyma, and show extensive defects in brain development.[78] Mutations in the NKX2.1-gene are not a frequent cause of CH but result in a syndrome combining a variable degree of congenital hypothyroidism, choreoathetosis, muscular hypotonia and pulmonary problems. [79] [80] [81] [82] The unfavorable outcome of these patients probably does not reflect the hypothyroid state but is most likely due to impaired NKX2.1 expression in the central nervous system. In mice NKX2.1 haploinsufficiency results in hypothyroidism caused by the concomitant reduced expression of the TSH-receptor. [83] Hypothyroidism can range from thyroid agenesis with severe hypothyroidism to a moderate hypoplastic gland with mild hypothyroidism to complete euthyroidism.

Thyroidmanager.org - U of Chicago course

Lyme Disease Conflicts of Interest Uncovered

http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/R807A2F1.GIF
Note: Deer ticks carrying Lyme Disease do not turn back at the US border.

Patient advocates and physicians concerned with the treatment of chronic Lyme disease finally had their voices heard at a July 30 2009 hearing mandated by a legal settlement between Connecticut's Attorney General and the Infectious Diseases Society of America (IDSA). More than a year after an investigation by Atty. Gen. Richard Blumenthal into the 2006 IDSA Lyme Guidelines' development revealed conflicts of interest by members of the IDSA guidelines' panel, a new panel heard testimony on whether the guidelines required revision. Insurance companies use the current highly restrictive treatment guidelines to deny patients reimbursement for medical care. "This dialogue would not have happened without the strong vision and leadership of the CT Attorney General Richard Blumenthal, who investigated this controversy, uncovered the facts, and called for this review," said Diane Blanchard, Co-President of Time for Lyme. "We hope it sets the stage for further dialogue."

Link
Webcast - available through August 2010

Could it be that evidence of use of a "flawed" test has been hushed up and permitted at "world class" Canadian hospitals to shore up denial of insurance claims in the USA? Cdn "national security" Lyme tests.
Discussion

"You may never need another thyroid test again"

Listening to the patient. Empirical medicine. Sir William Osler would approve....

From the page:
“These blood tests – they don’t work for you. They didn’t help you over the last 15 years you’ve been having problems, even when your problems became worse over the last two. It is because these thyroid antibodies variably bind up the hormones you have. There is no way to tell how much thyroid hormone you need based upon blood tests.”

Michelle’s eyes were rolling back into her head and her mouth was sagging open.

She obviously needed more of an explanation. “Let’s try another analogy. When a traffic helicopter flies overhead, it sees all the cars on the road – and says, ‘There’s plenty of transportation to take people around the city.’ But what if a meter maid noticed they didn’t pay their parking tickets and put a red parking boot on some of them. They wouldn’t be able to go anywhere. In order to have enough transportation for the city – you might need twice as many cars. Unfortunately – there is no way to know how vicious that meter maid is – we just know that she is there. There is no way to know how much of a negative effect those thyroid antibodies are having, we just know that they are there. The presence of thyroid antibodies throws off every thyroid test, including the TSH.”

Michelle was exasperated. Slumping back in her chair, “Then how will I ever know how much medicine to be on?”

“You forgot, there is one more type of testing that will be most effective for you.” Michelle became interested again and leaned forward. “We should test the effect that thyroid hormones have on your body. With hormone resistance, it is often easier and more effective to test the function of the hormone, not the actual level. This idea isn’t new. In Type II Diabetes, we know there is insulin hormone resistance. We don’t check insulin levels – we check what it does by monitoring your blood sugar levels. There are many different types of thyroid hormone resistance. In addition to the Reverse T3 phenomenon and Thyroid Antibodies, some people are deficient of essential fatty acids or other vitamins, limiting thyroid hormone’s ability to get into the brain or other cells to have its full effect.9,10 We just have to check what thyroid hormone does in your body.

“Though active thyroid hormone is needed to lower cholesterol and blood pressure, to raise blood sugar when hypoglycemic, and to convert beta-carotene into Vitamin A, there is no specific blood test to show whether thyroid hormone is working properly or not. Dr. Broda Barnes, MD, PhD, who wrote one of the first books on hypothyroidism, ‘Hypothyroidism: the unsuspected illness,' described a simple temperature test using a mercury thermometer.11 Mercury thermometers are more accurate than digital ones, and because they are hard to find nowadays, I’ll sell one to you for a dollar (that’s all they cost me). Here is a handout to describe how to do the test.

“Lastly, I want you to take this sheet of paper that has ten, 10-point scales on it. I want you to write down the ten things most important to you. For the first line, fill in ‘Energy Level.' Zero will be where you can’t get out of bed, ten being where you are excited about travel and are planning a fun trip. If you are spending money you don’t have, you might be at a twelve. Please call me before they take away your credit cards.” Michelle smiled. “Fill in the other nine items with the things most important to you: weight, skin, and mood are three things you’ve already mentioned. Many people also put down constipation, hair growth/loss, nail quality, and cold/heat intolerance, menstrual periods, and libido. Lastly, there are checkboxes at the bottom for ‘Palpitations’ (sensations of your heartbeat) and ‘Anxiety.' If you feel like you have too much coffee or caffeine in your system, you might be getting too much medication. Every so often, scale yourself. If you are getting better – then we know you are on the right track.”

“I think I finally understand these tests, so what do we do now? You said I would have options in choosing my own care.”

Link

Sir William Osler tailored treatment for optimum patient wellness.

Mental status symptoms and thyroid

Illustration - low thyroid/hypothyroid/myxedema

If you look like the lady in this image and feel terrible -
but your doctor says you are endocrinologically "stable",
ask your doctor whether s/he treats lab tests - or people.

If your thryoid is not functioning well and your physician fails to recognize the source of your symptoms, you may be set for years of bad health and altered mental status.

Many psychiatric disorders and symptoms are related to thyroid hormones. Both underactive (hypothyroidism) and overactive (hyperthyroidism) thyroid hormone blood levels can trigger panic attacks. In approximately 1/3 of patients with depression, borderline personality disorder, panic disorder, bulimia, alcoholism in remission, and anorexia nervosa the pituitary gland does not properly increase blood levels of TSH when signaled to do so by the hypothalamus. This can cause "hypothyroidism" with "normal" blood values. "Normal" is a statistic referring to the middle 96% of the population - it does not mean that "normal" is normal or healthy for you. "Normal" cholesterol by the middle 96% technique includes cholesterol levels of 300, whereas the middle statistically is 220, and the goal is less than 200.

From Low thyroid and mental illness
Also see Thyroid and Schizophrenia
Hypothyroidism and Psychiatric Illness
Treatment of hypothyroidism
Myxedema Madness
Myxedema Madness PDF
Anxiety and Thyroid Disease
Anxiety and endocrine disease
Efficacy of T3
T3/T4 Combination in Bipolar
29 Medical Causes of Schizophrenia


Getting locked into a position due to outdated information can be fatal for doctor and patient.

More on this issue to come...

"To get the best care, you have to go out and get it"

he desire to be seen as a person is a common complaint among cancer patients caught in a system that seems overwhelmed by waiting lists and swamped by test results, where phone calls tunnel through to voice mail and a busy doctor may have mere minutes to explain the most complicated, heart-stopping medical information.

Lynda Coghill recalls how her doctor barely spared a few seconds to deliver a curt death sentence. The Newmarket, Ont., school teacher was diagnosed with ovarian cancer at 39. At an appointment after surgery and radiation, she told her oncologist she was still bleeding. He did a quick exam, announced she had a new tumour, and said bluntly: “Your chances are slim to none.” He told her to wait a few weeks for the results of a biopsy, then left to treat a patient down the hall.

“I looked at the nurse in sheer disbelief,” Ms. Coghill says. “The doctor had proceeded to tell me, in less than 30 seconds, that I was going to die. He didn't seem to care that I had three small children.”

She cried for days, unable to eat or sleep. She and her husband planned her funeral. At last, she contacted the sympathetic nurse from the doctor's office and persuaded her to call for an “unofficial” biopsy report. The tumour was benign. Eight years later, Ms. Coghill remains angry about having been treated “like a numbered object on an assembly line.”

To get the best care, patient advocates say, it's not enough to wait passively in an appointment room. You have to go out and get it.'

From The Globe and Mail - Link

This article does not, we think, apply just to cancer patients...and it is telling that physicians dread falling ill, because then they would be cast in the role of... patients.

From the drama/film WIT with Emma Thompson. This patient was too good, and paid the ultimate price.
It's good to be patient - but not too patient...

Illuminations from THE RUNAWAY BUNNY by Margaret Wise Brown.

ACRE--A High Powered Harvard Stealth Pharma Front Group

Image inspired by Charles Pachter

ACRE--A High Powered Harvard Stealth Pharma Front Group
Saturday, 25 July 2009
ACRE's mission is to persuade physicians that MORE rather than less industry involvement in Continuing Medical Education programs is good for patients--much as industry's "Harry and Louise" ads were aimed at convincing the public that universal healthcare was BAD for them.
Daniel Carlat, MD , is Associate Clinical Professor of Psychiatry Tufts University School of Medicine Publisher and Editor The Carlat Psychiatry Report Co-chair, CME Committee Massachusetts Psychiatric Society. Above all, he is an independent psychiatrist whose informative blog contains fascinating information about powerful, financially compromised groups such as the APA Task Force that is currently engaged in further expanding psychiatry's diagnostic / practice guide, the DSM-V . Their perspective--given their financial stake--is in sync with Pharma's market expansion agenda.

ACRE is Pharma's latest, powerful, mostly Harvard-based front group: it is spearheaded by Harvard professor, Thomas Stossel, MD. ACRE's mission is to persuade physicians that MORE rather than less industry involvement in Continuing Medical Education programs is good for patients--much as industry's "Harry and Louise" ads were aimed at convincing the public that universal healthcare was BAD for them. Both attempt to confuse. ACRE poses as the Association of Clinical Researchers and Educators.

ACRE held its charter conference earlier this month at Harvard Medical School.l Its steering committee consists of physicians from Harvard Medical School, the State University of New York Downstate and the Mayo Clinic. Dr. Jeffrey Flier, Dean of the Harvard Medical School, introduced this high powered Pharma-physician conference, which was managed by Rockpointe, a science-based medical communications company that produces "educational programs" for doctors most often sponsored by pharmaceutical companies.

Below we post the financial ties uncovered by Dr. Carlat: the ties that bind ACRE steering committee to Big Pharma--ties that were undisclosed on the ACRE website. Of course, it would be most instructive to learn the secret dollar amount that Harvard Medical School--and its affiliated hospitals--rake in from these unabashed marketing promos masquerading as CME courses! Dr. Carlat dubbed the organization, “Academics Craving Reimbursement for Everything.” PharmaGossip renamed ACRE: Forum for University Corporate Kickbacks in Education as Determined by University Professors:

Why is ACRE very ripe for satire? As Dr. Carlat explains, because "it consists of rich doctors complaining that they want more money from drug companies, and such an organization lacks any inherent credibility, and seems, frankly, absurd."

Dr. Carlat noted that "In all the hoopla and excitement of forming a new organization such as ACRE, certain minor details are easy to overlook. One of these details is a listing of financial disclosures, which is conspicuously missing from the ACRE website."

Below are two of Dr. Carlat's ACRE posts--one about the undisclosed financial ties of the speakers and the post describing the flavor of the ACRE conference:

"...the eeriest presentation came from one J. Michael Gonzalez-Campoy, an endocrinologist who was flown out on the ACRE-jet from Minnesota. His job was to convince everybody that Minnesota’s 1993 physician payment disclosure law (the first in the nation) was an awful mistake. His tactic, theoretically, was a good one. “The law has been terrible for patients,” he declared, speaking in the ominous tones of a doctor notifying you of grim laboratory results.

“Oh boy,” I thought, pen poised, “finally, some data on the effects of transparency laws on patient outcomes.” But alas, Dr. Gonzalez-Campoy’s evidence base amounted to a single patient, a 73 year old man with severe diabetes. “Do you know what drug he was on?” He asked incredulously. “The cheapest drug money will buy—Glyburide….When I asked my patient why he was on that drug, I was appalled by his answer. He told me that his PCP said it is the most cost-effective drug.” It got worse: the patient had apparently been reading newspaper articles saying bad things about the newer diabetes drugs, like Avandia. The kicker was when he told Dr. Gonzalez-Campoy that “I’ve read that doctors are getting brain-washed by drug companies to prescribe these drugs.” Don’t you see what the Minnesota disclosure law has wrought? Patients getting prescribed generic medications. Patients reading the newspaper. Patients questioning the morals of their physicians.
The ACRE conference, it would appear was "full of sound and fury signifying nothing."
Posted by Vera Hassner Sharav
Link

Harvard Medical Students Rebel Against Pharma-Ties
Tuesday, 03 March 2009
200 Harvard Medical School STUDENTS are confronting the administration demanding an end to pharmaceutical industry influence in the classroom.
A front page report in the Business section of the New York Times should bestir some of Harvard Medical School alumni. 200 Harvard Medical School STUDENTS are confronting the administration demanding an end to pharmaceutical industry influence in the classroom.
"The students say they worry that pharmaceutical industry scandals in recent years - including some criminal convictions, billions of dollars in fines, proof of bias in research and publishing and false marketing claims - have cast a bad light on the medical profession. And they criticize Harvard as being less vigilant than other leading medical schools in monitoring potential financial conflicts by faculty members."
Harvard received the lowest grade--an F--from the American Medical Student Association, a national group that rates how well medical schools monitor and control drug industry money. Harvard Medical School's peers received much higher grades, ranging from the A for the University of Pennsylvania, to B's received by Stanford, Columbia and New York University, to the C for Yale.

The revolt began when a first year medical student "grew wary" when a professor promoted cholesterol drugs and "seemed to belittle a student who asked about side effects." He later discovered that the professor, a full-time Harvard Medical faculty member, was a paid consultant to 10 drug companies, including manufacturers of cholesterol drugs.
Link

What happens when drugs, science and money mix at Canadian institutions of learning today? Blandishments and mis-education may well lead to a dangerous lowering of the standard of care.
Read Blind Faith here.

Whatever would Dr. Osler say?

Suggestions for an Approach to the Management of Thyroid Deficiency

http://thyroid-disease.org.uk/index.php?option=com_content&task=view&id=18&Itemid=31

SUGGESTIONS FOR AN APPROACH TO THE MANAGEMENT OF THYROID DEFICIENCY

by Dr Barry J Durrant-Peatfield M.B., B.S., LR.C.P., M.RCS. Approved Civil Aviation Medical Examiner

From the article:
"The clinical syndrome of thyroid deficiency is very much more common than is generally realized; (Dr. Broda) Barnes, in several publications, drew attention to this in the last two decades, as has the present writer more recently. One reason for this, is a tendency to think of hypothyroidism and myxoedema as one of the same thing, when this is quite wrong. Myxoedema, as doctors were taught in medical school, is the end result of a progressive disease process resulting in more or less total absence of thyroid hormone; whose symptoms and signs are no doubt perfectly familiar. But this state of deficiency has to start somewhere, winding down over a variable period to the terminal state of myxoedema. Symptoms and signs will naturally vary according to the extent of the level of deficiency reached. Clearly, a 10% loss may have little to show for it; whereas a 25% loss may have several very definite symptoms and signs; and a 40% loss even more so. Furthermore, patients show very individual response to any given level of dysfunction; while one may complain of excessive fatigue and weight gain, another may be more troubled by depression and menstrual problems.

That the diagnosis is all too frequently missed, is an inevitable result of this fundamental misunderstanding, and is commonly the result of an incomplete clinical appraisal in favor of the standard thyroid function tests. These tests are the real problem in diagnostic failure since there are inherent problems in interpreting blood levels of thyroxine and/or thyroid stimulating hormone (TSH) when blood levels may differ widely from tissue blood levels. Since the diagnosis may very properly, and easily, be made clinically, unreliable blood levels should NOT take precedence over clinical judgment.

Equally unsatisfactory is the acceptance by doctors and patients alike of poor response to thyroid replacement.

The present writer has been constantly alarmed and dismayed by hypothyroid patients who for years, all too often, have been obliged to accept a much less than satisfactory amelioration of their illness, being taught to expect no more than some improvement. It is perfectly possible that complete and long lasting remission should be obtained, and neither doctor nor patient should accept anything less. Further, the response should be monitored, not just by the doctor, but by the patients themselves. Since there often is a dynamic situation, the patients should be educated and taught to monitor themselves, making their own adjustments to dosage. In this connection, frequent monitoring by blood tests may be quite misleading and unhelpful. Surely it must be more satisfactory for the physician to ask the patients how they feel; and guide the informed patient in establishing the right dosage levels of replacement therapy."

We are sure Dr. Osler would agree. But if our physician does not listen but instead turns us out of his office after a woefully inadequate fifteen-minute appointment, and our lives are ruined as a result, what then?

Signs of the Times

Osler computer wallpaper, with neither the great doctor nor a patient anywhere in sight...
These days it seems doctors want to be like "Doogie Howser MD" - a sort of precocious Peter Pan physician.
HOUSE MD, another popular medical television show, features a disabled hero who is friendless and addicted to drugs. Neither character is a proper role model for healers.



When you hear physicians talking together in your hospital, are they discussing health or holidays, medicine or mortgages? If perks and a big salary represent your physician's most precious goals, maybe it's time to hand him a golf ball and tell him to Tee Off.