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Coffee And Stroke: Another Study The Media Got Wrong

Here we go again. Headlines across America blaring lines like, “Coffee may reduce stroke risk.”

It was a big study, but an observational study. Not a trial. Not an experiment. And, as we say so many times on this website that you could almost join along with the chorus, observational studies have inherent limitations that should always be mentioned in stories. They can’t prove cause and effect. They can show a strong statistical association, but they can’t prove cause and effect. So you can’t prove benefit or risk reduction. And stories should say that.

USA Today, for example, did not explain that in its story. Nor did it include any of the limitations that were included in, for example, a HealthDay story, which stated:

“The problem with this type of study is that there are too many factors unaccounted for and association does not prove causality, said Dr. Larry B. Goldstein, director of the Duke Stroke Center at Duke University Medical Center.

“Subjects were asked about their past coffee consumption in a questionnaire and then followed over time. There is no way to know if they changed their behavior,” Goldstein said.

And, he noted, there was no control for medication use or other potential but unmeasured factors.

“The study is restricted to a Scandinavian population, and it is not clear, even if there is a relationship, that it would be present in more diverse populations. I think that it can be concluded, at least in this population, that there was not an increased risk of stroke among coffee drinkers,” he said.”

When you don’t explain the limitations of observational studies — and/or when you imply that cause and effect has been established — you lose credibility with some readers. And you should. Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Ibuprofen-Parkinson’s Study: Few News Organizations Report On It Accurately

We’re delighted to see that USA Today, Reuters, and WebMD were among the news organizations that included what an editorial writer said about an observational study linking ibuprofen use with fewer cases of Parkinson’s disease. All three news organizations used some version of what editorial writer Dr. James Bower of the Mayo Clinic wrote or said:

“Whenever in epidemiology you find an association, that does not mean causation.”
“An association does not prove causation.”
“There could be other explanations for the ibuprofen-Parkinson’s connection.”

Kudos to those news organizations. And some praise goes to the journal Neurology for publishing Dr. Bower’s editorial to accompany the study. His piece is entitled, “Is the answer for Parkinson disease already in the medicine cabinet? Unfortunately not.”

And unfortunately not all news organizations got that message. Because many don’t read the journals, so they certainly never get to the editorials. Instead, they rewrite quick hits off a wire service story. As a result, we end up with some of the following:

A FoxNews.com story was particularly deaf to Bower’s caveat, stating: “That bottle of ibuprofen in your medicine cabinet is more powerful than you may think.”

A CBSNews.com story never addressed the observational study limitation, instead whimsically writing: “Pop a pill to prevent Parkinson’s disease? A new study says it’s possible, and the pill in question isn’t some experimental marvel that’s still years away from drugstore shelves. It’s plain old ibuprofen.” Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Why Science Should Override Celebrity

Dr. Barron Lerner has written a book about breast cancer: “The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America.” And he’s written a book about celebrity patients: “When Illness Goes Public: Celebrity Patients and How We Look at Medicine.” He wed the two topics in a blog post on the New York Times health blog entitled “Suzanne Somers, Cancer Expert.” Excerpts:

“Earlier this week, NBC’s “Dateline” devoted an entire hour on Sunday evening to allow the actress Suzanne Somers to express her rather unconventional beliefs about cancer.

It is not the first time a major media outlet has given air time to Ms. Somers, whose journey into the medical realm has been featured on a variety of news programs, talk shows and entertainment channels. A few years ago, Oprah Winfrey invited Ms. Somers on her show to share the secrets behind her youthful appearance — a complex regimen of unregulated hormone creams and some 60 vitamins and supplements.

But is it entirely outrageous that respected media organizations continue to give the “Three’s Company” sitcom star a platform to dispense medical advice? Not really, in a world in which celebrities have become among the most recognizable spokespeople — and sometimes experts — about various diseases.

…patients — especially those who want to explore every possible avenue — have the right to know that there are unorthodox cancer therapies that some people believe are helpful.

But not without several caveats, and that is where Ms. Somers, and many of those in the media who discuss her books and views, have failed. Ms. Somers says she is promoting hope, but false hope benefits no one.

Many people with end-stage cancer are, understandably, desperate, and thus potentially vulnerable to a sales pitch — even an expensive one. But here is a case when an informed patient may truly be a wiser patient. Perhaps if doctors were more willing to address the fact that these nontraditional treatments exist, and share what we do and don’t know about their effectiveness, an actress like Ms. Somers would have less influence, and science would override celebrity.”

There’s been quite an online response to Dr. Lerner’s blog post. One reader wrote, succinctly:

“From Thigh Master to Snake Oil.”

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Faces Of Medical Error: The Story Of Michael Skolnik

I was very sad and quite angry after watching a powerful video this weekend entitled ”The Faces of Medical Error: From Tears to Transparency.” It’s the story of Michael Skolnik. His mother, Patty, gave me the video when I met her recently. Michael had what may have been unnecessary brain surgery in 2001 and died three years later.

The Skolniks worked on this video as part of an educational campaign on medical error, and they created an organization now named Citizens for Patient Safety. Here’s a trailer to the video:

You can also watch a Today Show segment that profiled the Skolniks from a few years ago:

While much of the message is about medical errors and malpractice, the Skolniks also promote a message of the “critical need for shared decision-making.” In fact, I met Patty at a shared decision-making conference.

If you haven’t heard Michael Skolnik’s story, you should. And if you’re like me, you’ll need a tissue box close by for the sadness, and something else to help with the ensuing anger.

Thanks to Patty Skolnik for sharing the story and the video with me.

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Why Negative Medical Studies Are Good

This is a guest column by Ivan Oransky, M.D., who is executive editor of Reuters Health and blogs at Embargo Watch and Retraction Watch.

One of the things that makes evaluating medical evidence difficult is knowing whether what’s being published actually reflects reality. Are the studies we read a good representation of scientific truth, or are they full of cherry-picked data that help sell drugs or skew policy decisions?

That question may sound like that of a paranoiac, but rest assured, it’s not. Researchers have worried about a “positive publication bias” for decades. The idea is that studies showing an effect of a particular drug or procedure are more likely to be published. In 2008, for example, a group of researchers published a New England Journal of Medicine study showing that nearly all — or 94 percent — of published studies of antidepressants used by the FDA to make approval decisions had positive results. But the researchers found that when the FDA included unpublished studies, only about half — or 51 percent — were positive.

A PLoS Medicine study published that same year found similar results for studies long after drugs were approved: Less than half — 43 percent — of studies used by the FDA to approve 90 drugs were published within five years of approval. It was those with positive results that were more likely in journals.

All of that can leave the impression that something may work better than it really does. And there is at least one powerful incentive for journals to publish positive studies: Drug and device makers are much more likely to buy reprints of such reports. Such reprints are highly lucrative for journals. Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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