Former NEJM editor Arnold Relman dies at 91

RelmanSee Storify for updates. 

Arnold Relman, the former New England Journal of Medicine editor, has died. From Bryan Marquard at the Globe: 

Eloquent and forceful on the page or the podium, Dr. Arnold Relman led the New England Journal of Medicine for more than 13 years, raising a sometimes lonely voice to warn about the dangers of for-profit medicine when many in politics and his profession raced to embrace a free market approach.

Dr. Relman also was one of the nation’s foremost writers about the rising cost of health care. Persistent to the end, he received the galleys of his final article just a few days before he died of cancer in his Cambridge home early Tuesday, on his 91st birthday.

 

When he suffered a catastrophic fall last year, he wrote about it in The New York Review of Books:

 

Since then, I have made an astonishing recovery, in the course of which I learned how it feels to be a helpless patient close to death. I also learned some things about the US medical care system that I had never fully appreciated, even though this is a subject that I have studied and written about for many years.

 

What he reported was not flattering to Spaulding Rehab, the hospitals that has won praise for working with so many marathon bombing survivors.

What did this experience teach me about the current state of medical care in the US? Quite a lot, as it turns out. I always knew that the treatment of the critically ill in our best teaching hospitals was excellent. That was certainly confirmed by the life-saving treatment I received in the Massachusetts General emergency room. Physicians there simply refused to let me die (try as hard as I might). But what I hadn’t appreciated was the extent to which, when there is no emergency, new technologies and electronic record-keeping affect how doctors do their work. Attention to the masses of data generated by laboratory and imaging studies has shifted their focus away from the patient. Doctors now spend more time with their computers than at the bedside. That seemed true at both the ICU and Spaulding. Reading the physicians’ notes in the MGHand Spaulding records, I found only a few brief descriptions of how I felt or looked, but there were copious reports of the data from tests and monitoring devices. Conversations with my physicians were infrequent, brief, and hardly ever reported.

What personal care hospitalized patients now get is mostly from nurses. In the MGHICU the nursing care was superb; at Spaulding it was inconsistent. I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.

More on that piece from The NYTimes. 

 

Relman often commented on the influence of money on medicine. In 20o9,  he crashed the inaugural meeting of the Association of Clinical Researchers and Educators (ACRE) “an organization of medical professionals dedicated to the advancement of patient care through productive collaboration with industry and its counterparts.”

So, we asked for his thoughts about the presentations. Here they are:

“I sat through the whole program, which was a sustained diatribe against conflict-of-interest regulations rather than a scholarly, balanced discussion of the issues. There was practically no time for audience questions or comments, but instead an almost unrelenting barrage of ideological and anecdotal criticism of what was said to be a misguided “belief system” that worries excessively over relations between industry and the medical profession. There was an occasional informative and reasonable contribution, but for the most part sarcasm and anger prevailed.
 
The heavily industry-related audience loved the performance, but the obviously biased, self-serving, and often grossly flawed presentations should have embarrassed the organizers. Although neither Harvard Medical School nor the Brigham & Women’s Hospital sponsored or formally endorsed the meeting, the HMS Dean did give the initial welcoming remarks, and the Hospital offered its facilities for the event. One can only hope that they are now having second thoughts.”
More here:

Asking advertisers, journalists and politicians to back up claims #evidence #askforevidence

ssA class at Emerson is working to bring the UK’s “Ask for Evidence” program to the US. The program was highlighted last night at Cambridge Science Festival. (TR was on one of the panels)

The premise behind this project is simple: if politicians, companies, or commentators want us to vote for them, buy their products, or believe their claims, then we should take an active role as responsible citizens and consumers in asking for relevant evidence. This campaign seeks to involve the public, YOU, in your own defense against deceit, by encouraging you to question and investigate marketing, media, or policy assertions that you read or hear. At Emerson College, this project is being incorporated into various Marketing and Communication Sciences and Disorders courses in order to engage students in asking for evidence and to collect data on consumer awareness.

Check it out. 

 

 

Health Leaders Media: What hospitals learned from the Boston Marathon Bombing

From Health Leaders Media

A year after the two bombs went off near the finish line of the Boston Marathon, killing three and injuring scores, the city is making final preparations for the 2014 marathon on Monday, April 21. 

First responders and healthcare workers in particular have learned a number of lessons from the events of April 15, 2013. For example, since the bombing, Boston hospitals have changed the way they receive unidentified trauma patients in the emergency department. Members of the city’s police force are now equipped with military-quality tourniquets.

More lessons, perhaps further-reaching, will come as researchers begin to analyze data on the injuries, surgeries, and outcomes for each of the more than 240 people injured.

Dr King’s Marathon from Tinker Ready on Vimeo.

Over-treatment? There’s an app for that

ss accCritics have knocked the recently updated guidelines  on statins for patients at risk of heart disease. While some heart specialist spent years putting together advice for the high risk, others said the guidelines will result in massive overtreament.

Still, health monitoring apps are hot,. The American College of Cardiology is now offering an iPhone/ iPad risk calculator,  the Globe’s Daily Dose reports. This paragraph from the Boston.com post was cut off the print version of the story.

The app does instruct doctors to have a discussion about the risks and benefits of statins and to consider patient preferences; whether busy primary care providers will make the time to have that discussion, rather than simply prescribing the drugs, remains to be seen. 

The headlines were different as well. 

Print: App Calculates Heart Disease

Boston.com: Heart disease risk app may increase statin prescriptions

Don’t like the ACC app? There are already a handful of others.

NEJM: 80% of arthroscopic partial meniscectomy procedures do little for the knees

Note: Consider BMC for your next knee surgery. You may not need it.

From The New York Times:

A popular surgical procedure worked no better than fake operations in helping people with one type of common knee problem, suggesting that thousands of people may be undergoing unnecessary surgery, a new study in The New England Journal of Medicine reports.

The Finnish study does not indicate that surgery never helps; there is consensus that it should be performed in some circumstances, especially for younger patients and for tears from acute sports injuries. But about 80 percent of tears develop from wear and aging, and some researchers believe surgery in those cases should be significantly limited.

“Those who do research have been gradually showing that this popular operation is not of very much value,” said Dr. David Felson, a professor of medicine and epidemiology at Boston University. This study “provides information beautifully about whether the surgery that the orthopedist thinks he or she is doing is accomplishing anything. I think often the answer is no.”

Globe: BWH surgeon sues BWH over wife’s post-#hysterectomy #cancer diagnosis

The Globe’s play on this story should say something — Metro front rather than 1A.  Malpractice stories are tricky– serious charges and a response penned by a lawyer, not a doctor.  (At 8 a.m., a complete version of the story was lingering on White Coat Notes, outside the paywall.)

Note the Brigham’s carefully worded statement on the link between cancer and  morcellation, the procedure used during a minimally invasive hysterectomy.

The Brigham said in a statement that “while it’s not possible to know what impact the procedure will ultimately have on Dr. Reed’s health, we do know that literature suggests morcellation of malignant tumors increases the chances of mortality. 

Here’s the lead

A Boston surgeon and his wife, an anesthesiologist, are pushing to stop a widespread surgical technique used on thousands of women during hysterectomies, which they say caused her undetected cancer to dangerously spread.

The she said/she said suggest that

Dr. Barbara Goff  president of the Society of Gynecologic Oncology and director of the Division of Gynecologic Oncology at the University of Washington in Seattle says “Morcellation allows many women to have safer hysterectomies with better outcomes than full abdominal surgery, including less blood loss, smaller wounds, and a quicker overall recovery.”

“You try to balance cost and outcomes and doing the best you can for an entire population of women,” Goff said.

But Dr. Bobbie Gostout, chairwoman of obstetrics and gynecology at the Mayo Clinic, said more women should be given the option of a vaginal hysterectomy, where the uterus can often be taken out intact through the vagina, especially because morcellation “is a questionable practice.”

She said morcellating devices are not yet good at capturing tissue or protecting other sensitive organs from rotating blades.

“I don’t want to see [morcellation] go away, but I would like to see it kept in perspective and occupy its necessary place,” she said. “Morcellation is still so far off what it ought to be.”

A round-up: The new and maybe-not-improved statin guidelines

See NYTimes to catch up on the debate over new guidelines from the American Heart Association that would vastly expand the use of cholesterol-lowering statins.  Here’s a Nov. 25 update. 

It was supposed to be a moment of triumph. An august committee had for the first time relied only on the most rigorous scientific evidence to formulate guidelines to prevent heart attacks and strokes, which kill one out of every three Americans. The group had worked for five years, unpaid, to develop them. Then, at the annual meeting of the American Heart Association, it all went horribly awry.

Many leading cardiologists now say the credibility of the guidelines, released Nov. 14, is shattered. And the troubled effort to devise them has raised broader questions about what kind of evidence should be used to direct medical practice, how changes should be introduced and even which guidelines to believe.

The critics of guidelines are Brigham researchers. The initial coverage by Todd Neale at MedPage Today talks about Dr. Ridker’s background conducting clinical trial on one statins and researching the biomarker C-reactive protein as a “marker of subclinical atherosclerosis.”

https://twitter.com/ToddNealeMPT/status/403554561748926464

The NYTimes

Less than a week after the American Heart Assn. and the nation’s cardiologists issued guidelines that would greatly expand the number of Americans taking a statin medication, the guidelines have been faulted for overestimating patients’ risk of heart attack or stroke.

Few authors of the new recommendations had even returned to their clinical practices before learning that an influential Harvard cardiologist and his biostatistician collaborator had taken the guidelines to task, arguing they use unreliable data on Americans’ health to calculate which patients would benefit from taking the medication. 

Dr. Paul Ridker and Dr. Nancy Cook, both professors at Harvard Medical School, estimate that between 13 and 16 million of the 33 million middle-aged adults targeted by the new guidelines for statin therapy do not have sufficiently high odds of having a heart attack or stroke over the next decade to warrant statins’ use.

Gary Schwitzer offers a  round-up within a round-up. His looks at conflicts of interest and link to a very funny cartoon from the Daily Kos, which also ran in the NYTimes week in review.

Some more coverage:

LA Times

In the summer of 2012, two Brigham and Women’s Hospital researchers were asked to review a draft of a major cholesterol treatment guideline. They sent back a pointed critique, declaring that the authors should abandon a proposed heart-disease risk calculator because it overestimated patients’ chances of getting sick.

So they were shocked when they saw the final guideline, which was issued last week by two leading heart groups. The risk calculator remained an integral part of the document and would be responsible for millions more Americans being put on cholesterol-lowering statin drugs to prevent heart attacks and strokes.

“I’m a strong advocate for statin therapy,” said Brigham cardiologist Dr. Paul Ridker. “I just want to see the right patients get treated.”

More from:

Medpage Today

The Lancet

Medscape

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