June 30, 2009
Hypertension and dementia
A friend forwarded a commentary on a study on BP variability and its connection to dementia. This was a poster presentation at a conference, so the numbers are not available to us. As presented in this commentary, it raises more questions than it answers, which is the purpose of these kinds of studies.
Previous studies have shown a statistically significant (but not meaningful) increase in dementia with increased pressure. This study does not even show statistical significance. Rather, the variability in pressure is statistically signficant (again, we do have enough information to say whether this is meaningful). But the ranges of variability are much wider than the difference between the ranges.
The big question is, clinically, does treating BP (or worse, attempting to treat) cause greater variability leading to greater dementia? Have we worsened the dementia problem with our treatements (of BP, or cholesterol, or whatever)? Have we first done harm?
| By Robert Maddox | 9:08 PM | Comments (0)
April 7, 2009
Society's agent
This issue of JAMA, April 8 (301, 14 p. 1482-4) contains a commentary by Kirch and Vernon on Social Justice in medicine. They contend that the first three pillars of the foundation of medical ethics (beneficence, non maleficence and respect for autonomy receive plenty of attention, but that justice is underemphasized. In discussing autonomy, they quote an article by Kluge, a Canadian ethicist, that the physician "is society's agent and as such has delegated authority in matters of health care delivery."
In light of the constitutional prohibition on titles of nobility, Herb Titus has argued persuasively against state licensure. This concept of being society's agent is flatly unconstitutional.
Further, it is contrary to reason. What is society? If one means the civil government, than say so. But the civil government is force, not reason. If one means the local community, that is more reasonable, but contrary to the force of the state.
More importantly, this view ignores the fact that Jesus reigns in Heaven and on earth. I am obligated to obey him, to be his agent. That, of course, does not preclude a temporal authority as well. But that temporal authority must also be obeying Jesus. So it is not the desire of society, or the patient, or the doctor, that is the main consideration, but of Jesus.
It is no wonder that the ethicists and policy makers find confusion amongst the options of models. Only the model of mutual servanthood can solve these dilemmas. I am a servant of Jesus and of his creation. I advise and treat fellow servants (even those that rebelliously reject or deny the Master). There is no autonomy, there is no abstract justice, there is no way to determine good or harm apart from his standard.
| By Robert Maddox | 9:39 PM | Comments (0)
March 17, 2009
Quality care
Yesterday, the latest issue of JAPS arrived. It contains an article by Dr. Terrell published posthumously. It will give readers unfamiliar with his work just a taste of the stupendous wisdom, wit and insight of the man. I happened across a discussion on-line of the concept of quality care, and found some good comments by Dr. Centor. But unfortunately, even this excellent discussion misses Dr. Terrell's main concerns. Knowledge of data is helpful, but not the main concern in medicine. This is because diagnoses are not discoveries, but decisions. Individuals should not be lost in the data. Quality medical care cannot be measured and standardized if the individual's suffering is the main point of concern. There are too many competing issues to standardize.
This article deserves wide, careful and repeated reading by anyone who has medical problems, or in the medical fields.
| By Robert Maddox | 4:21 PM | Comments (0)
March 10, 2009
Cramdown
Dr. Ed O'Boyle, a former business professor and now research analyst, has written an excellent summary in the local paper of the reaction of doctors to the various types of cramdown that have been problematic in medicine for decades. His wife is a pediatrician and he knows whereof he speaks. This is as concise a summary as I have seen of the personal level business decisions doctors have to make.
In order to preserve primary care, it seems that Obama will be forced to make that final socialist step making all primary care doctors employees of the State. Hitherto, under our current fascist system, we are being made employees of corporations controlled by the State. Currently, that control is exercised by reimbursement, increasingly out of the hands of the patient. In order for a single payor system to work, these various responses to cramdown will have to be limited.
| By Robert Maddox | 6:40 AM | Comments (0)
February 28, 2009
Flu vaccine
There has been plenty written for and against the flu vaccine. I have been seeing a fair number of flu cases and more people who think they have it but have a negative test. So I find the study comparing the intranasal live vaccine with the inactive interesting on account of the cases of pneumonia and influenza prevented by the vaccine. As I read it, over a three year period there were about 8 cases per 1000 person-years in the vaccinated group, and between 10 and 19 cases in the unvaccinated group. So the NNT varies from 90 to 500. I am not sure how to average that. But in a bad year for flu/pneumonia, 90 people are vaccinated to prevent one case. Not one death but one case. Those that I have seen this year have not been terribly ill, not much more ill than many who don't have the flu. Think of the cost, the time, the worry.
And how does one know if one has the flu? The Positive predictive value of the test is less than a coin toss. That is, even if one tests positive, one cannot be sure one has the flu. This is a result of the poor specificity (15% false positives) and the low prevalence. The Negative predictive value is much better. So why do the test? You tell me.
| By Robert Maddox | 5:09 PM | Comments (0)
Help for Obama reforming health care
JAMA also reports (in the March 4 issue - this is amazing that I received it before it was published, that I have read it, and that I have access to a computer to write this) on the Obama transition team community meetings to discuss health care. (Either I was not invited, didn't know about it, was busy doing important things with the family, didn't think Obama's team cared what I thought, or didn't think it would make a difference.) The White House Office of Health Reform is using volunteer labor to compile "synthesize comments into a manageable document" to deliver to Obama tomorrow. Interestingly, there is "no consensus on its (health care system) biggest problems and possible solutions to fix it."
Apparently, the transition team gave a list of acceptable answers to each of seven questions. I suspect that the answer to the biggest problem question did not allow the answers "hubris" or "idolatrous expectations."
One professor highlighted in the article is quoted to summarize the article, "There's this fundamental metric that's missing from our discourse -- what do individual patients value in a health care setting? We need to shift perspectives; we assume to know what value is, what the patient wants, but we make that assumption without any data."
I might agree with Dr. Corvera, if she were to go on to say that such a metric is noncollectable, and that therefore government, or other third-parties have no right or responsibility to make such decisions. But if she presumes that such a metric can be obtained and systematized for a single or third party payor, she will top the hubris charts.
| By Robert Maddox | 4:45 PM | Comments (0)