Author Archives: jpwmd

On May 12th, 2022, I posted a blog regarding our nation’s cockamamie physician reimbursement policies (“Physician Reimbursement Askew).  I pointed out that primary care physicians average net incomes about two-thirds that of subspecialists.  The difference lies in procedures—interventions such as colonoscopies are valued way out of proportion to the cognitive work of diagnosis and care for chronic conditions such as hypertension and diabetes.  Geriatricians are in the “cognitive” category. 

A recent article in the Journal of the Medical Association about geriatricians amplifies the problem of training physicians with expertise in the care of the aged.

Geriatricians 

Geriatricians, typically graduates of residency programs (i.e., the training medical school undergraduates undertake after medical school) in Internal Medicine and Family Medicine, undergo further training in the field of geriatrics.  This discipline involves care for the elderly, with emphasis on the care of patients with multiple medical problems, unwieldy pharmaceutical regimens, functional debility, cognitive decline, and much more.  Crucially, geriatricians gain expertise in discerning whether symptoms betray disease or whether they are a normal part of aging. Training in interdisciplinary team care is also a crucial part of the curriculum.

The number of board certified geriatricians in the US is declining.  In 2000, there were 10,270, and in 2022, the number was 7,413.  The number of young physicians engaging in advanced training in geriatrics in 2022 fell to 177.  In the most recent census, 16.9 percent of the US population was 65 years of age or older, a figure expected to increase to 22 percent in 2050.

Family doctors and internists currently supply most of the primary care for the elderly.  They need to develop their expertise on their own, as neither medical schools nor residency training programs have geriatric specific curriculum requirements.  Many argue that, rather than worry about the lack of physicians specifically trained in geriatrics, there should be greater emphasis on clinical training in primary care residencies specifically aimed at care of the elderly.  On the other hand, there is plenty of data that demonstrates the superiority of geriatricians’ care of the elderly.

At any rate, it is clear there is not, nor will there be, a sufficient number of geriatricians to meet the need of a burgeoning elderly population.  They will continue to fill a crucial role in advocacy for old patients, training of primary care physicians in the clinical care of the elderly, and research.  But they make a financial sacrifice for their efforts–compared to general internists and family doctors, geriatricians earn less than if they had simply gone into practice without another year of training.

Reality

Of course a sensible doctor person power policy would target the increasing lack of physicians who can provide great care for the elderly.  The need for doctors who prioritize care of the elderly is currently marked and will only get bigger.  But there are obstacles to plugging the gap.  One, taking care of the elderly is hard.  Patients typically have an array of problems that require much more time to address than corporate medicine typically allots.  In fifteen minutes, primary care doctors and geriatricians are supposed to address problems like hypertension, diabetes, sleep disorders, arthritis, and the possibility of cognitive decline.  And these only scratch the surface of problems.  A gastroenterologist  can make make three times the amount of a primary care doctor in a morning of performing colonoscopies–without concern for all of the other problems a patient may have. 

In a rational physician person power policy, money would be poured into compensating primary care doctors and geriatricians.  This is not going to happen.  Our nation has no overarching physician person power policy.  The market drives the amount of subspecialty doctors, and medical school graduates continue to flock to these highly paid, procedure-oriented specialties. A physician advisory commission, an influential body that advises Congress on physician reimbursement policies, is composed of two-thirds procedure oriented doctors.  Guess what it prioritizes in terms of physician compensation.

The US has a looming crisis in care for the elderly.  What are we doing about it?  Nothing. 

The word is out about the benefits of exercise.  Some recent publications (e.g., US Department of Health and Human Services: “Physical Activity Guidelines for Americans”) have put some numbers to it.

First, some definitions.  The guidelines speak to “moderate physical activity” and “vigorous physical activity.”  The former includes brisk walking and everyday activities such as mowing the lawn, carrying groceries, easy bike riding, etc.  The latter refers to more vigorous activity such as jogging, running and fast biking.  The key is to do something that increases heart rate and makes breathing a bit harder.  How do you know which is which?  If you can talk while exercising, but not sing, you are probably doing moderate activity.  There is a spectrum of activity, and the more you do, the better.  Two minutes of moderate activity equals approximately one minute of vigorous activity, and whatever is done should include some resistance training at least twice a week (i.e., anaerobic work), such as weight lifting.

The Numbers 

Numerous observational studies that include millions of individuals demonstrate rather dramatic data.  One meta-analysis (i.e., a paper that combines research from several similar studies) demonstrated a 60% reduction in all cause mortality in people who did about 150 minutes per week of moderate activity compared to people who did little or no exercise.  Even 10 to 15 minutes of activity per day resulted in a 45 to 50% reduction in mortality.  A trial of previously sedentary people who undertook moderate activity achieved a 20% reduction in mortality compared to those who remained on the couch. 

It goes on and on, and data show that any level of activity, in terms of reducing risk of a multitude of causes of death, is superior to just sitting around.  The sweet spot is 150 minutes per week of moderate activity or 75 minutes of vigorous activity per week, but benefit accrues on a continuum that starts with something as simple as standing rather than sitting (you burn almost 25% more calories while standing).  So the elderly and/or infirm can benefit from exercise even if 150 minutes of activity per week is impossible.  And there appears to be no upper limit–the more you do, the greater the benefit. 

Finally, what if you cannot do exercise every day?  Can you cram your 150 minutes into, say, the weekend, and still achieve the benefit?  Resoundingly, the answer is YES.

Comment

The benefit of exercise is so striking that I wonder how it compares to statins.  I would love to see a trial that compares statins to exercise (Pause here while pharmaceutical executives pick themselves up from the floor).

At any rate, the benefits of exercise are even more amazing, and manageable, than I knew.  In the words of the late, great Cubs announcer, Harry Caray, “Holy Cow!”

Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig’s Disease) is a uniformly fatal disease that attacks the nerves that control all of the muscles in the body.  Patients diagnosed with this disease slowly lose the use of their muscles, including those that are needed to breathe, and die on average two to five years after being diagnosed.  

In 2013, two undergraduates at Brown University concocted a pharmaceutical (they called it Amylyx) that they hoped would help patients with Alzheimer’s and Parkinson’s.  It consisted of a drug that included an acid found in bear bile, a mainstain of Chinese medicine.  They knew little of what it takes to test a drug and bring it to market, but they found a prominent researcher who thought that a trial for patients was warranted–only for ALS, not for the other two neurological afflictions.  The students pivoted to focus on ALS, and the researcher had the wherewithal to conduct a clinical trial of the novel drug. 

A small trial appeared to show that patients who got the drug lived, on average, five months longer than those who got placebo.Patients, and their advocates, jumped all over this and importuned the Food and Drug Administration (FDA) to approve the drug.

Enter the FDA

The FDA found the clinical trial wanting and declined to approve the drug.  It felt the trial was poorly designed and that the statistical analysis was convoluted to the point of obscurity.  This resulted in a fusillade of criticism that centered on the FDA’s apparent reluctance to approve drugs that showed promise, but were unproved by standard clinical trials.
ALS Advocacy groups had learned a lot from the HIV/AIDs advocacy groups in the 1980s.  In fact, the ALS people capitalized on the experience of these groups to learn how to pressure Congress and regulatory agencies for approval of drugs.  These lobbying efforts often force science to take a back seat to promotion efforts straight out of marketing curricula.  

Eventually, FDA was pressured into bestowing an “accelerated-approval pathway” for Amylyx.  This is a way to legalize pharmaceuticals pending definite proof of effectiveness.  Large trials for the ALS drug are ongoing in Europe.  

In the meantime, sales of the drug have skyrocketed and today sales of the Amylyx will reach $400 million per year.  The drug costs  privately insured patients $158,000 per year, typically with a copay of $30,000.  People on Medicare and Medicaid are expected to pay the whole freight.  Regardless, few people can afford the drug, and, like so much in America, the poor stand to lose out.

Conflicting Interests

Patients with ALS are desperate.  Many feel that the FDA has prioritized science over compassion.  The FDA’s mission, on the other hand, is to ensure the safety and efficacy of the drugs available to Americans.  The FDA suspects that Amylyx has gained currency through emotional appeal of afflicted patients and a transcendently good marketing campaign.  Patients, and their advocates, on the other hand, are determined to try anything that may extend their lives, regardless of the science. 

And then there is the proprietary interest of the company that manufacturers the drug.  Once definitive studies are completed, will the company simply withdraw the drug as promised if it is shown not to work?  Insurers are also enmeshed in the situation:  They legitimately do not want to pay for drugs that have not been proven to work.

Commentary

This blog entry springs from a recent article in The New Yorker.  The piece does not state whether the Brown undergraduates had any scientific background, but it does say that they had no idea how to navigate the drug approval process.  Then they stumbled upon a researcher in ALS who became interested in the drug, but not for dementia and Parkinson’s for which it was originally created.  It was like, what the hell, let’s try it for ALS.  All three diseases have completely different pathophysiology (the process that causes diseases), and therefore it stands to reason that effective drugs would differ for each condition.  But no, trials proceed, drug sales are in the multi millions, and science lies in the wake.  And skeptics fear that ALS patients are being victimized (some say “robbed”), perhaps at the expense of “legitimate” science.  The fear is that patients on Amylyx will forgo participating in important trials of drugs for ALS that are the product of scientific based research.

All parties in this situation have understandable goals.  Patients are desperate and are willing to try anything that holds a shred of promise.  The FDA’s mission is to help ensure the safety and effectiveness of pharmaceuticals, and it feels political pressure diverts it from this mission.  Putting emotion into the approval process is beguiling, but it can be ultimately counterproductive and harmful.

Regular readers of The Medical Beat (“medicalbeat.net”) know that I do not hesitate to criticize healthcare in the United States.  But a recent opinion piece in the American Journal of Medicine made me reflect on genuine progress in many areas of medicine.  The long term editor of this prominent journal, Dr. Joseph Alpert,  reflected on advances in healthcare, listing “the ten most noteworthy developments in clinical medicine” over his fifty-plus year career as a practicing physician.  Here are some highlights.

Myocardial Infarction (i.e., heart attacks)
Around 1970, the 30 day mortality for patients with a heart attack was about 30 percent.  Today, it is six to seven percent.  This is all the more remarkable as victims of heart attack are now much older.  Reasons for the improvement include reperfusion therapy (i.e., mechanical and pharmaceutical opening of blocked arteries that cause the heart attack), statins, advances in treatment of heart failure, the creation of intensive care units, and many more.  And these factors do not even speak to the decrease in the prevalence of heart disease that is preventable with lifestyle changes.

HIV/AIDS
When I was a young doctor in the early 1980’s, I treated many young patients with a strange pneumonia that was impervious to conventional therapy.  I witnessed many terrible deaths that introduced the HIV era of medicine.  In the beginning of the scourge, the disease was uniformly fatal for hospitalized patients.Now HIV/AIDS is an entirely treatable disease.  The remarkable, and fast, recognition of the cause and eventual development of safe and effective therapy is one of the great achievements of modern medicine.  With effective pharmaceutical intervention, HIV/AIDS is now a chronic disease, much like diabetes.

Inflammatory Bowel Disease
In the beginning of Dr. Alpert’s clinical career, he was taught that ulcerative colitis (one form of inflammatory bowel disease, along with Crohn’s Disease) resulted from psychological distress, often related to adverse relationships with one’s mother (!).  Advances in the genetic and molecular understanding of the disease has resulted in modern pharmacological therapy that has made this a highly manageable disease.  Total colectomy (surgical removal of the colon), the treatment of choice back in the day, is now almost unheard of.

Personal Favorites in the Hit Parade
In addition to Dr. Alpert’s list of the top ten advances in medicine, I have many other personal favorites. 

 
According to the Center for Disease Control, cancer mortality in the US decreased 27 percent from 2001 to 2020.  The reasons are multifactorial and include tobacco cessation, vaccines such as one for hepatitis B (a cause of liver cancer), screening tests (for example colonoscopic screening for colon cancer), and other-worldly cancer treatments that attack mutations or use the immune system to find and kill cancer cells.

 
Prosthetic joints, especially for the elderly, are increasingly common and, though they have no demonstrable effect on life span, have resulted in vast improvement in the quality of life for millions.  Studies on knee and hip replacement have consistently shown improvement in psychological well-being and functional capability.  As a senior citizen, I can see the remarkable improvements from these procedures in many of my friends and relatives.*

Hospice care also deserves a place in the pantheon of notable advances in medicine.  As a young doctor, I too often witnessed the inappropriate and futile aggressive treatment of the dying elderly.  Hospice care, simply stated, is designed exclusively to give comfort care for terminal patients.  This intervention has resulted in the provision of comprehensive at-home care, allowing for dignified, comfortable deaths that too often eluded terminal patients in the past.  Patients, and families, now better understand that end-of-life treatment decisions are in their own hands.  People increasingly opt for terminal care with hospice over the use of aggressive, painful, useless interventions.

Finally, of all the benefits modern healthcare has bestowed, public health is the crown jewel (see my blog on December 19, 2002).  Vaccinations, education (for instance, the dangers of smoking), and maintenance of a safe food and water supply are but a few ways that public health programs have had an immensely positive effect on the population.  Much of what public health accomplishes tends to fly under the radar, but it is nevertheless critical to the well-being of all Americans.

The Future
The future of healthcare in America is precarious.  The cost is outlandish, care is impossibly fragmented, all providers are venal, and special interests will maintain the status quo for the foreseeable future.  On the other hand, we have somehow made staggering progress in many areas.  It seems that we should be able to create a coherent healthcare system, and make the types of advances I have detailed.

*Note: Decisions regarding joint replacement surgery should be undertaken with care.  It is a rare replacement that results in restoration of perfect function, and complications, while unusual,  increase with age.   

The Supreme Court has lately been very active in matters that affect healthcare in the United States.

Covid Issues

The Court invalidated restrictions on religious gatherings in New York and California during the height of the pandemic.  These rules were the result of scientific studies that showed large group gatherings presented a high risk of disease transmission.

The Occupational Safety and Health Administration ordered large businesses to either require vaccinations against Covid or routinely test employees.  This rule was interdicted, and scientists predicted 6,500 lives could have been saved and 250,000 hospitalizations averted if these rules had been permitted.

Environment

Last year, the Court invalidated the Clean Power Plan, a measure that would have required power plants to install energy efficient devices and show progress toward sustainable energy.  The decision rested upon the belief that “major questions” must be explicitly legislated.  Critics of the decision felt that this emasculates regulatory agencies such as the Environmental Protection Agency in their missions to protect public health, as they need some degree of discretion to fulfill their missions.   

Firearms

The Second Amendment has enjoyed a heyday with the current conservative majority on the Supreme Court.  It  recently invalidated a New York law that required a person to show cause for a license to carry a gun outside the home.  This overturned a precedent established in 1911.

The Supreme Court is not alone in its apparent zeal to promote guns.  For instance, the Fifth Circuit of Appeals ruled unconstitutional a federal law that banned gun possession by people who are under restraining orders due to domestic violence.

Women’s Rights

The court overturned a 50 year constitutional right, when it decided that abortion is not protected by the US constitution.  The implications are protean, not the least of which are the ambiguities that resulting state laws have created.  For instance, does emergency medical care include abortion services?

On the Docket

Other cases with important implications for health may soon come before the Supreme Court.  Education is a major determinant of health, and observers believe that the court will invalidate affirmative action plans.  At present, Medicaid recipients can challenge in court state denials of federal benefits.  A pending case would deny enrollees the right to do this.  The Supreme Court may soon rule on the FDA’s long standing approval of abortion pills.      

Summary

I lifted most of the content of this blog entry from a “Viewpoint” published in the May 9, 2023 edition of the Journal of the American Medical Association.  It ends as follows:

The Supreme Court’s six conservative justices are bringing vast changes to the public health legal landscape.  The Supreme Court is impairing the government’s ability to act in the public interest and undermining safeguards for groups that have been historically marginalized.  Yet far from affecting only a subset of US individuals, the justices are weakening public health with health and equity on the line.

The piece is obviously left leaning, but, regardless of the politics, it is clear that, especially on matters pertaining to health, the judiciary in the US is tending toward intervening in matters that have profound consequences on the health of Americans.

Some years ago, I wrote a letter to the editor regarding the meaning of single payer health insurance.  I recently read of a politician who erroneously conflated “Medicare for all” (one way to implement single payer health insurance) with socialized medicine.  I feel the need to once again explain what single payer health insurance is.  

Single payer insurance refers to the way health insurance is funded.  It is not socialized medicine.  Socialized medicine occurs when the government owns the entire health care system.  The US Veterans Administration health system is an example.  The VA owns and operates all hospitals and clinics in the system, and employs all personnel, including doctors and nurses. 

With single payer health insurance, the government is the exclusive insurer.  Doctors work independent of the government and bill for their services.  Hospitals are also independent.  No one gets a free ride–the best and most successful doctors and hospitals will earn incomes in proportion to the amount and quality of the work they do.  The free market is intact.

There are many and varied challenges to implementing single payer health insurance in the US.  The supposed threat of “socialized medicine” is not one of them. 

I knew a doctor who worked for a large healthcare organization in the Chicagoland area.  As part of the group practice, he was subject to evaluation, which was partly based on patient satisfaction surveys.  One of the questions patients were asked about their physicians was whether he or she saw them in a timely fashion.  These evaluation instruments were important, as they helped determine bonuses and supposedly provided feedback regarding performance.  The idea was to improve patient care.  However, this physician’s schedulers once booked him for four patients at one time.

In a similar vein, healthcare organizations are evaluated by the Joint Commission on Accreditation of Healthcare Organizations.  The JCAHO mandated some sort of patient satisfaction surveys, so a hospital that I worked for in the 1990s engaged a well known firm to perform the task.  The product was a shiny tome that drew all sorts of inferences, but the response rate was 19%.  This is laughably inadequate–to avoid skewed information, the response rate should be at least 80%, preferably 90%.  Moreover, while the hospital had a significant Hispanic population (about 25%), the surveys were in English only.

Are These Surveys Useful?

Of course no one can object to the idea of evaluating quality.  But, at least in healthcare, as shown above, they are of questionable value–and they may even be counterproductive.  For instance, a famous study found that patients for whom more tests were ordered gave higher satisfaction scores.  This fact of course incentivized physicians to order unnecessary tests.  And, crucially, the patients who got more tests had a higher mortality rate.

The evaluation instruments used today are also outdated, and are very sloppy in terms of statistical conclusions.  A physician who provides exemplary care may get an unfairly low overall score, because one patient who doesn’t like the weather gives poor ratings.  Such flawed information can have a devastating effect on physicians, and some studies on physician “burnout” implicate the satisfaction surveys as a cause of depression in doctors and even early retirement.

W. Edwards Deming is the father of the quality initiatives in industry.  Even he, however, recognized the pitfalls.  He wrote:

…the merit rating system nourishes short-term performance, annihilates long-term planning, builds fear, demolishes team work, and nourishes rivalry and politics.  It leaves people bitter, crushed, bruised, battered, desolate, despondent, dejected, feeling inferior, some even depressed, unfit for work for weeks after receipt of rating, unable to comprehend why they are inferior.  It is unfair, as it ascribes to the people in a group differences that may be caused totally by the system they work in.

It’s Everywhere

The obsession with evaluation is not confined to healthcare.  After buying toothpaste at a large chain drugstore, I find an email regarding how my experience was.  At the end of a phone call for which I was on hold for five minutes, and got entangled in an endless loop, I am asked how I enjoyed the experience (duh).  Leaving a restroom, I am presented with three buttons to rate the cleanliness of the facility.  It goes on and on.  And I am skeptical that any action is taken on these surveys.

Why?

I suspect that all of the evaluation movement is a way to bestow the illusion that organizations are really pursuing quality.  The contrary may be true–and haphazard evaluation may even be harmful.  At the root of the problem is the reliance on things that can be easily measured.  You can easily count the number of colonoscopies a physician orders, but rating empathy is another level.  Until someone figures out an effective way to objectively measure some of the most important subjective qualities of a physician, the satisfaction ratings as they are currently constituted should be trashed.

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Dear friends, 

Thank you for being a subscriber to The Medical Beat.  It is now a year and a half old, with a couple of new features.  You can now access all the posts by clicking the “Blog Archive” on the home page, then scrolling backwards to the first entry on September 5, 2021.  Also, the invitation to subscribe is now at the top of the home page.

I am ever interested in more readership, so I urge you to tell friends and family about the blog.  The address is “medicalbeat.net” and, as mentioned above, subscribing is easy.  You can assure people that subscribing will not put them on any list that will produce email clogging ads.

Your readership is important to me and I particularly enjoy comments, even contrary ones.  At best, the blog could spark an on-line dialogue about issues that do not receive sufficient attention in popular media.

Cheers, 

Jim

Dr. Don Berwick, who founded the Institute for Health Improvement, is a prominent figure in American healthcare.  He recently wrote an opinion piece in the Journal of the American Medical Association that sounds the alarm about creeping “kleptocapitalist” behaviors in medicine that threatens the quality of medical care in the US.  The litany of financial depredations is impressive.

The Brief

Profiteering afflicts all areas of medicine from administration to practice.  

Drug companies’ behaviors are well known–they raise prices indiscriminately and preserve a monopoly on drugs with legal legerdemain that insures profits beyond normal expiration periods for patents.  Only recently has the government been able to overcome the powerful pharmaceutical industry’s lobby (over $350 million spent in 2022) to begin to cap drug prices that are insupportable for average patients.  Nethertheless, a major hospital in Chicago billed a patient $73,800 for two doses of Lupron, a treatment for prostate cancer.  In the UK, the drug is available for $260 per dose.

Health organizations can be relentless in pursuit of medical debt (see the November 28, 2022 posting on The Medical Beat for more information).  58% of all debt collections are for medical bills.  In Massachusetts, for example, 13% of the adult population owes more $10,000 in medical bills, causing 46% to forgo, or unwisely reduce, medical care.

Hospitals are complicit too.  Consolidations of healthcare systems result in closing of hospitals that don’t produce.  Even not-for-profit systems close hospitals in poor neighborhoods in favor of opening new ones in wealthy suburbs.  

CEO salaries in healthcare are staggering: according to Dr. Berwick, the CEO of Oak Street Health, an organization with a chain of primary care sites, has a salary and benefits package that totals $568 million.  That organization has three of the top ten paid corporate executives in the US (not just healthcare).

Insurers have gotten on the gravy train through, for example, participation in Medicare Advantage (MA), an option for Medicare beneficiaries that was ostensibly designed to provide better care than traditional Medicare.  Almost 50% of seniors now get healthcare under this plan.  This was supposed to save money and provide better managed care, but over the next eight years, MA will cost $600 billion more than traditional Medicare.  The “advantage” is profit for major insurers, not improvement in medical care. 

How do companies manage these greater profits?  The answer lies in behaviors that are on the edge of legality, or frankly illegal.

Here Is How It Works: Upcoding and Unbundling

Upcoding occurs when a healthcare provider (e.g., a physician, hospital, etc.) bills for a service that inflates reality.  For instance, a hospital consultant may legitimately bill for a comprehensive evaluation and treatment of a complex patient (an appropriately well reimbursed activity), but, on follow-up, may continue to bill as though other comprehensive evaluations have taken place when the followup visit may have taken only a few minutes.

Or billing for something that simply did not take place.  A psychiatrist billed Medicare for 30 to 60 minute visits, when he was only doing 10 to 15 minute reviews of medications (he had to reimburse Medicare $400,000 and lost his participation in both Medicare and Medicaid).

Unbundling is the practice of fragmenting a service for which there is normally a comprehensive fee.  A hospital, for instance, may get an inclusive set fee for a cardiac procedure.  This includes blood tests, anesthesia, hospital rehab, etc.  Breaking out each billable element of the process, however, results in a far greater reimbursement.  This is illegal, but very hard to detect.

These practices cost the healthcare system an estimated $11 billion from 2002 to 2011.

The Purpose of Healthcare

Dr. Berwick is one of the most respected physicians in the US.  He has a string of accomplishments few can match, and his well reasoned and insightful commentary deserves attention.  He has essentially called out organized medicine to examine its goals: does healthcare have a mission to improve the health of the population or is it another industry organized solely to prioritize profit?

In the late 1990s, the respected British medical journal, The Lancet, published a report that linked vaccines to autism.  This was met with a fusillade of objections from credible sources, followed by study after study that proved there was (and is) no association between vaccines and autism.

Nevertheless, the fuse on the already significant anti-vaccination movement was lit.  And irresponsible commentary fed the fire.  For instance, US Senator Rand Paul, a physician, told of a friend with a child who was vaccinated for measles, mumps and rubella, and then, presto, contracted autism.

Measles

In 2000, due to an aggressive public health campaign, measles was declared eradicated in the US, with a few cases being documented from unvaccinated US citizens who had traveled in countries with high rates of measles.   

Measles can be much more than an irritating skin rash.  It carries a death rate that is small (one or two per one thousand cases), but still results in serious complications such as pneumonia and encephalitis.  In 2011, for instance, 40% of people with measles were hospitalized, almost all of  them unvaccinated.  In the last 10 years, the incidence of measles in the US has been as low as 18 per year  and as high as 1,274, almost all of it in unvaccinated individuals.  Worldwide, before 1963 (the year measles vaccines became widely available), there were 2.6 million deaths per year from measles.  Since then, with widespread measles vaccination initiatives, the yearly mortality averages about 140,000.  A two stage vaccination for measles results in a 97% protection rate against the disease. 

Medical Reports Gone Astray

Recently, The Economist, a popular and highly regarded British magazine for lay people, published a piece by a health journalist entitled “Fake research is influencing medical care.”  Without citing specific instances, the author points to studies that contain allegedly fabricated data, which then eventually find their way into “many, if  not most,” clinical treatment guidelines for physicians.  The writer also presents information that editors are slow, or even resistant, to correcting errors.  

I think, or hope, that the import of the article is overstated, but I too am suspicious of a lot of the medical literature.  When, while perusing a medical journal, I see the heading of an article that may interest me, I immediately look to see how the study was sponsored.  If it was funded by a pharmaceutical company, I may not go any further.  I know the proprietary interest drug companies have in finding that a medicine is safe and effective, and I understand how data can be fudged to fit the “right” conclusion.  I also know that the authors of such studies are often compensated, or even employed, by the company manufacturing the product.

But even studies done by authors without “skin in the game” face great challenges in executing research with integrity.  The gold standard for clinical studies is randomization, that is, study subjects have to agree, prospectively, to be assigned to either the intervention group or the placebo group.  At the heart of this is “informed consent.”  Patients are supposed to understand randomization, “blind” analysis of results, etc.  Can someone in the throes of a heart attack really make an informed choice regarding entering a study that will randomize him/her to, say, cardiac angioplasty (i.e. opening heart arteries mechanically) versus the usual approach to care?  

Unequivocal Fraud

It took 11 years, but The Lancet withdrew the study on autism, when fraud was conclusively proven.  Mistakes, honest mistakes, occur in medical research all the time, and this is acceptable.  Outright fraud is not acceptable, and the case of the autism publication is exhibit A for the harm such lies can do.  The article is still at the root of much of the anti-vaccination movement, and it could be argued that the deceitful author is responsible for the loss of millions of lives.