It’s an AMSA Rodeo, and you’re invited!

Upon arriving to Houston for the 2012 AMSA convention and learning that there is, in fact, a straight-up rodeo in town, my first thoughts turned to the concept of rodeo clowns, and then to clowns more generally.

Harsh? Perhaps. This is, however, the organization of medical students that:

 

• Denounce drug companies and urge physicians and medical schools to cut ties with them, while allowing drug and device companies to buy exhibitors’ booths to reach our innocent medical student eyeballs;
• Advocates for changes in policy on issues from healthcare reform to resident work-hours based mainly on emotive appeals, and whose policy “leaders” don’t seem to have the best sense of the subject matter they’re lobbying about, and;
• Unabashedly supports quacks and quackery… practices that are harmful to patients, and not in keeping with the professional and scientific heritage of the medical profession that their members will soon join.

Sounds a bit clownish to me. That’s what makes it fun to watch. So for the second year in a row, your intrepid blogger will brave the ghastly Houston weather (and jet lag!) and suffer the slings and arrows of those conference attendees who can’t bear disagreement.

Follow my postings to this blog and to Twitter (under the #amsaconv12 hashtag) to get a bug’s-eye view of the goings-on at the 2012 annual convention of the country’s largest association of medical students.

AMSA Follies: Swagalicious

I’ve alluded to AMSA’s… interesting choices regarding who they will and will not take money from (or at least, who they will claim not to take money from). Here’s the long-promised photographic evidence: the swag I collected from conference exhibitors.

What you’ll find below the cut includes:

• A pamphlet, a bag, and some pens from Medical Protective, a professional liability insurance company owned by Berkshire Hathaway.
• A Merck Manual (yes, that Merck… the one that makes all these ”pharms” of which AMSA claims to be ”free”).
• Materials from various academies of quackery (as seen earlier).
• A pen, a magnet, and some other swag from the FDA.
• Application forms for various forms of insurance/consumer credit provided by or through AMSA.
• Some stuff from banks.
• Swag NOS.

AMSA Follies: The Duck Pond

Q: What’s bipedal, featherless, and quacks like a duck?

A: The quacks representatives of the Association of Accredited Naturopathic Medical Colleges.

That’s right… AMSA sold them a booth at the 2011 convention, to say nothing of the smattering of naturopathic students in attendance as participants.

AMSA won’t quite take pharm money (more on that tomorrow), but they have no problem selling out to pseudoscience (that term is far too generous).

I went up to the booth and feigned ignorance as to what naturopathy is. I was told that they are “primary care physicians” who treat the “whole patient in a holistic way.” I pushed harder and harder, and for the longest time they continued to maintain that they’re “just like MD physicians.” Finally, one of their reps cracked, and poured forth the litany of quackery to which they subscribe: homeopathy, herbalism, acupuncture, therapeutic touch, and all sorts of other nonsense.

Fortunately, their written materials were more straightforward about their quackishness, though there were also some materials to recruit MD students for “integrative medicine” training at “Bastyr University“ in the Pacific Northwest (of course). Too bad they’re competing with AMSA’s own summer pseudoscience academy, whose flyers I also picked up.

For an organization that professes to support evidence-based medicine in other realms, and that ostensibly represents those students who are training to become applied scientists, this is really sad. The political gripes I might have with AMSA are one thing, but legitimizing quackery of this sort is truly beyond the pale. A poll of an unrepresentative convenience sample indicated that this is a non-partisan issue. “Open-mindedness” and “tolerance” are great, but when it comes to practices that don’t work, that mislead patients and that cast a pall on scientific medicine, organized medicine (AMSA included!) shouldn’t hesitate to take a stand.

If AMSA could be a forceful voice against pseudoscience much as they are a forceful voice for a variety of health policies with much less evidentiary support, they would be doing medicine, science, and patients a great service indeed.

***

I almost forgot, at the other end of the exhibition hall was the ayurvedic quack booth. I hope these pictures speak for themselves.

 

 

 

 

 

AMSA Follies: Marketing Misadventures

[My efforts at live-blogging/tweeting have been foiled by the fact that this conference occurs two levels below ground where there is no connectivity of any sort. I guess this means the hotel has me on tape delay…]

The first talk of the morning was by a second-year medical student (Shahram Ahari, UC Davis)who spent some time as a sales rep for Eli Lilly after graduating from Rutgers. He went into sales because he thought it would be an opportunity to connect with clinicians at an intellectual level and discuss the science. Because that’s what a private-sector sales job is all about. Needless to say, he was somewhat disillusioned, especially upon finding that most of his salesforce colleagues weren’t scientists, but… salespeople. Go figure.

The presentation wasn’t irrationally hostile to pharm companies, though I might have caught the suggestion at the end that physicians have an “obligation” to vote the interests of their patients. He explained the many ways in which pharm sales people use the same techniques employed by salespeople in any industry: appeals to emotion backed up by data about the client that is never overtly mentioned.

The discussion was focused almost entirely on the prescriber-marketing interface; I was hoping for some evaluation of the appropriate nature of researcher-industry relationships, which is where (in my view) the controversy is much hotter. Nonetheless, it was an entertaining talk that explained the psychological basis behind all sorts of marketing techniques such as giving away free stuff…

Oh, right! Free stuff! AMSA might claim to be pharm-free, but a quick visit through their exhibition hall revealed a whole host of characters whose money AMSA was more than happy to accept in exchange for a booth. Some of these groups are more savoury than others.

Details to come… truly extraordinary.

 

Les Douleurs de la Demagogue

I’ve blogged before about the conflict-of-interest issues raised by the various ways in which physicians interact with pharmaceutical and medical device companies.  Since starting my medical training at SUMS, I’ve had the opportunity to think about these issues further, especially since SUMS has taken their approach to the issue to an extreme level of demagoguery that I had previously thought impossible outside the realm of parody.  To wit, the first-years were recently subjected to a presentation on the school’s COI policy from a “researcher” who proudly described himself as an “anti-pharma zealot” [the Z-word is 100% verbatim].  The official reply letter to be sent to any vendor* with the temerity to send a holiday gift reads like a mix between a legal filing and a letter home from a high school principal outlining the sins of the schoolchild.

There is a very defensible (I would say persuasive) case that reactions such as SUMS’ go too far.  Perhaps the best exposition of this side of the argument comes from Richard Epstein, an NYU law professor whose writings on the topic can be found here and here.  The crux of his argument is that these regulations of COI are ostensibly designed to advance a goal, and that they should be considered in light of how well they advance that goal, not in terms of how well they stick it to the drug companies.  His argument is that the most extreme reactions — those on display at SUMS, for instance — do more to retard the goal of human progress in the medical field than they do to advance it.

This is perhaps best encapsulated in this snippet from a Vanity Fair piece (h/t John Goodman) decrying the practice of “outsourcing” drug trials to countries with weaker regulatory oversight.

Many U.S. medical investigators who manage drug trials abroad say they prefer to work overseas, where regulations are lax and “conflict of interest” is a synonym for “business as usual.” Inside the United States, doctors who oversee trials are required to fill out forms showing any income they have received from drug companies so as to guard against financial biases in trials. This explains in part why the number of clinical-trial investigators registered with the F.D.A. fell 5.2 percent in the U.S. between 2004 and 2007 while increasing 16 percent in Eastern Europe, 12 percent in Asia, and 10 percent in Latin America. In a recent survey, 70 percent of the eligible U.S. and Western European clinical investigators interviewed said they were discouraged by the current regulatory environment, partly because they are compelled to disclose financial ties to the pharmaceutical industry. In trials conducted outside the United States, few people care.

I see two evils here, and have a pretty good sense of which one I feel to be the lesser.  I wonder how many lives SUMS’ local “zealot” would be willing to sacrifice on the altar of anti-corporate ideological purity…

—

* – Given that I’m paying tuition to SUMS in exchange for an education, I can’t help but wonder if I should consider them to be my “educational services vendor,” and if this COI business holds for the vendors to my vendor.  All those verboten food baskets have to go somewhere…

 

Around the Mediverse: July 8, 2010

Fun tidbits, health-related and otherwise, from around the ‘tubes:

• OpenTable for physicians?  It does exist, apparently.  Be sure to click the link for HelloHealth to find out how that firm is bringing the power of the Internet to enhance patient care.

• As debates about research enter the public consciousness more and more often these days, Megan McArdle gives us a timely reminder of what “peer review” of publications means, and more importantly, what it doesn’t mean.  In a similar vein, Dr. Rich tries to get at the real reason for some of the outcry directed at the results of the recent JUPITER trial (statins for primary prevention in healthy adults).
  

• Some questions have emerged about Supreme Court nominee Elena Kagan.  Reason asks if she would ban books.  Bloggers at the Volokh Conspiracy touch on what is arguably Kagan’s political manipulation of a medical specialty society’s statement on abortion.  It should be said that the American College of Obstetrics and Gynecology comes out looking worse than the nominee.

• New York State voted to outlaw short-term housing rentals, dealing a blow to those seeking cheap Manhattan accommodations.  Prior to the vote, this situation prompted a Reason blogger to note wryly that owning property seems to be “a mug’s game.”  Relatedly, one of his colleagues argues that property rights have more importance than is often ascribed to them.

• How the response to the Gulf spill has been hampered by protectionism and inflexible environmental regulation:  the saga of the skimming Dutchmen.

• Though the response to the Deepwater Horizon spill has arguably been insufficiently aggressive, here are two commentators who argue that children should be taught to better express and receive aggression.

• What is a “scientific consensus?”  Reason’s Ronald Bailey takes on this issue.  Along the way, we stumble onto this gem of a web page explaining the relationship between animal models of carcinogenic toxicity and the actual exposure of humans to those substances.  Much more non-technical than I made it sound.  Do give it a read if only to attenuate your own “cancer panic” over some of those chemicals.

• Greg Mankiw asks what will happen to markets for life insurance and annuities given new advances in genetic testing and identification of markers for longevity.  Genetic discrimination?  An adverse selection death spiral?  Or something in between?

• As befits someone with an economics degree and a medical school acceptance agreement, I want to showcase some recent commentary on doctors and dollars.  A contrarian voice at Slate argues that drug companies should be allowed to buy physicians’ lunches.  The comments section of that article is surprisingly informative and thought-provoking.  An excerpt from the recent documentary The Vanishing Oath shows that many people think that doctors are in the profession ‘just for the money.’  Shadowfax argues that under some circumstances, fee-for-service is exactly the right way to pay physicians, whereas Dr. Wes thinks they should be paid by time, like lawyers (though I don’t know if he knows that there’s a movement among some lawyers towards flat fee payment structures).  He also presents pro and con arguments for what he terms “the corporate practice of medicine.”  Whatever choice you make, however, don’t make a mistake!  You will be crushed by a giant green Tyrannosaurus Rex.
  

• David Williams at the Health Business Blog reminds everyone that hospital visits should be BYOMD.

• Via Mark Perry comes this essay on wealth, wealth creation, the “rich,” and entrepreneurialism.  A similar theme is expressed more bluntly at The Volokh Conspiracy, discussing Ayn Rand. Coyote asks why government seems so hell-bent on putting more obstacles in front of entrepreneurs, in the context of tightened restrictions on “angel investments” in startups.

• Two recent guest posts at KevinMD point out that the concept of the patient-centered medical home is probably way overhyped, given the current evidence “for” it.

• Here are three articles on a lighter note to close out this week’s edition:  Foreign Policy seems to overreach in calling this next century “the Canadian Century;” The Economist takes on job-title inflation; finally, Hit & Run looks at San Francisco’s recent ban on soft drinks in municipal vending machines, and compares Coke to the alternatives.
  

The UCSF-Altria imbroglio

As the New York Times, its Prescriptions blog, and the San Francisco Chronicle have been reporting, there’s been a scandal of slightly more-than-minor size involving the UCSF Chancellor’s stock holdings.  Dr. Susan Desmond-Hellmann — the oncologist at the head of UCSF’ — disclosed shareholdings in the area of $100,000 in Altria, the company formerly known as Phillip Morris that makes most of its money from tobacco-related products.  Since that disclosure, followed promptly by divestment, Dr. Desmond-Hellmann’s holdings in health products/pharmaceutical companies and fast food companies — this time to the tune of millions of dollars — have come to light.  The investments were apparently made by a third-party financial advisor without her knowledge, and this advisor has since been instructed to purge her shareholdings in alcohol, tobacco, and firearms manufacturers.

Reading these articles prompted me to consider one of my earliest posts here, in which I argued that there is nothing unethical, unseemly, or untoward about life/health insurance companies holding shares in fast food companies.  Does the same argument apply to Dr. Desmond-Hellmann’s holdings?

Yes and no.

In my mind, the most problematic of her stocks are the pharmaceutical and health products companies.  These firms are probably vendors or research sponsors at UCSF, or have the potential to be.  The Chancellor’s shareholdings in these firms are substantial, and the potential for a conflict of interest is definitely present.  As one of the ethicists quoted by the Chronicle points out, recusal from decisions that would trigger this conflict may be all that is required, but continuing to hold the shares certainly creates the appearance of impropriety.  While some have pointed out that physician-industry relationships aren’t always eeevvvilll, as others would have us believe, there is a difference between productive collaboration of the sort Dr. Rich discusses and passive shareholding of the sort at question here.

I personally find her other shareholdings to be less objectionable.  Alcohol, firearms, soft drinks, and fast food are all legal products that can be used or abused, depending on who is doing the ab/using.  I see nothing intrinsically “evil” about them that should force medical leaders to steer clear.  Many of these firms (McDonalds, Pepsi, etc.) are also components of major equity indices, and as such may well have been chosen for that reason.  It’s highly unlikely that they will be directly involved with UCSF as vendors, donors, or sponsors, though I could be wrong about this.  Tobacco, however, doesn’t pass the smell test with me, especially not when we’re discussing an oncologist.  Arguably, it’s the only one of the products in question that is inescapably harmful regardless of how it’s used.  Of course, I would be remiss if I didn’t point out that there are lots of anti-smoking groups out there who have let their love for tax revenue outweigh their desire to reduce smoking.  This doesn’t make Dr. Desmond-Hellmann’s Altria holdings more palatable, in my view.  It just places them in the context of “how worse could it be/what company is she in.”

There is a growing obsession with rooting out conflicts of interest in healthcare, often under the rubric of reducing “waste and fraud.”  Much of this is a good thing, though as people like Dr. Rich point out, this obsession comes with a risk of harmful side effects.  More and more attention seems to be paid to “who owns which shares.”  Given that companies like McDonalds, Pepsi, and Altria are major blue-chip companies that are components of the DJIA/S&P 500 — thus likely to be held by many people and institutions — and targets for public health activists, it will be interesting to see how this plays out in the future, and where the line will be drawn for medical professionals who want to be perceived as “ethical investors.”

Around the Mediverse: June 28, 2010

The unusual delay since the last edition of “Around the Mediverse” means that this one features a higher-than-normal number of…

Fun tidbits, health-related and otherwise, from around the ‘tubes:

• SBM gives us a peek behind the curtain of how the FDA decides whether drugs should be available over-the-counter instead of by prescription only.

• Hit & Run, on the other hand, shows us what vendors have to do in order to have their brownies approved by the Pentagon.  I honestly thought it was a joke… I was wrong.  This is the sort of thing that the OSS recommended to those agents infiltrating enemy governments.  Seriously.

• David Williams at the Health Business Blog talks about the PPACA’s mental health parity requirement, and how it might end up driving evidence-based managed-care from insurers.  InsureBlog points out, though, that the regulations mean that mental health “parity” is actually anything but.  Insurers may well be forced to treat mental health care more generously than other covered services.

• On the subject of evidence, Hit & Run discusses scientific denialism of both left- and right-wing political flavours.

• Edwin Leap tells a tale of government/regulatory burdens to hiring by a small business… specifically, his medical practice.

• Richard Posner discusses whether asset-price bubbles, like the housing bubble of the mid-2000s, can be explained by rational behaviour on the part of market participants.

• The Placebo Journal Blog points out that government programs that enlist others to root out physician wrongdoing promise monetary rewards and bounties, whereas a new program that enlists physicians to root out drug company wrongdoing promises to pay whistleblowers… well, you’ll see.

• With so much of California’s fiscal situation being driven by out-of-control public sector pensions, you’d think that they would be focused on getting the best money managers to get them the best possible return on the pension fund instead of worrying about how many CalPERS money managers are women or minorities.

• Can anti-market regulation be harnessed for a pro-market climate change response?  A modest proposal in that vein.

• Greg Mankiw reports that some Japanese men are too sexy for their equities, too sexy for commodities, too sexy for corporates… oh yeah…

• Buy your own journalist!  Well, not really.  More like targeted micro-charity for investigative reporting.  I like this model better than the FTC’s.

• A series of side-splitting Marxist-Socialist jokes.

• What would “Around the Mediverse” be without a tale of ridiculous litigation?  The propofol litigation, however, could have real adverse consequences for those patients needing anesthesia now that one of its manufacturers has withdrawn from the US market.  See Great Zs, Overlawyered, and Skeptical OB for details.

• Dr. Wes discusses some of the often-overlooked biases inherent to the way medical research is conducted, and what it might mean for the wide applicability of results.

• What do patients think of evidence-based medicine?  More importantly, what does government think about it… forget “Mammogate,” let’s talk pseudo-science and quackery in the health reform bill!

• Jason Shafrin points out that when measures of income inequality are adjusted to include health insurance benefits, the standard narrative about widening inequality changes.

• MLRs, what are they good for?  David Williams and Reason have interesting, unorthodox takes on the question.

• Rounding out this week’s selection, Dr. Rich has an unorthodox take on a hot-button issue… this one being the appropriate nature of the relationship between physicians and pharmaceutical companies.  It’s a perspective that I haven’t seen well-elucidated elsewhere, so it’s well worth reading the full thing.

NEJM steps into minefield, suffers consequences as expected

My first substantive post on this blog dissected an article in the American Journal of Public Health in which a group of Harvard-affiliated medical researchers strayed far from what one would imagine is their usual area of expertise.  Their claim was that various health and life insurers hold outsized stakes in fast-food companies, and thus are unethically profiting from their policyholders’ unhealthy behaviour.  A rudimentary look at their numbers and some basic familiarity with how insurance works are all that is needed to realize that this claim doesn’t hold water.

Now the NEJM has done something similar.  The Drug and Device Law blog looks at a recent NEJM Special Report on the experiences of qui tam whistleblowers in lawsuits against drug companies, and rips the authors to shreds.  The full post is well worth a read.

I’m not the most avid reader of medical journal articles (I see some of them when they’re recommended to me), but I suspect that this sort of thing has been going on for a while, and is likely to continue apace.  More and more spheres of life, especially law, policy, “social issues,” etc., are being recognized for their effects on people’s health, and interest in these areas from medical academia seems to be growing.  One could argue whether this is part of a larger trend of overmedicalization of society, but that’s a question for another time.  What is clear from these two specific examples is that in order for observers to take seriously medicine’s contribution to scholarship and policy in these areas, medicine’s contribution has to reflect a reasonably sophisticated understanding of how the law/political process/various environmental determinants of health actually work.

When, as in these two cases, medical researchers don’t even get the basics straight, it’s just embarrassing.

(DDL post found via Overlawyered)

Around the Mediverse: May 7, 2010

Fun tidbits, health-related and otherwise, from around the ‘tubes:

• This past week saw lots of discussion of primary care, its role, and its future.  Dinosaur talks about the different skills needed for diagnosis vs. treatment, and ill-care vs. well-care in the context of NPs and PAs filling the primary care void that medical students are shying away from.  A guest post at KevinMD talks about how concierge care can be a boon for internists and their patients alike.  Dr. Rob discusses the long-term relationships that primary care physicians can forge with their patients, and how that affects both the physician and patient.  The Placebo Journal Blog explains why it doesn’t buy into the idea of e-mail communication between physician and patient… at least not in this legal environment. Dr. Bob Centor posted 4 pieces touching on the theme of primary care revitalization in the context of internal medicine.  He argues that policy wonks misunderstand the causes of practice variation, and even the nature of primary care itself.  He explains how being “out of flow” can be damaging to physician morale, and implicitly to physician supply.  Finally, he proposes a change in the nature of internal medicine practice to one more closely resembling that found here in Canada:  that of a consultant.

• I like the idea of “concierge” medicine, even though there are many vocal opponents of the concept.  I reject their argument that it is necessarily something that will limit itself to the richest and best-off in society.  I present to you PartnerMD and Qliance.  Much more has been written on Qliance here, here, and here.

• I used to be a fan of “more regulation” until I realized that the costs of compliance are very real, especially for small businesses (say, small independent medical practices).  Coyote points out that the new healthcare bill imposes a whopper of a new tax filing requirement on all businesses… one whose passage is a scary commentary on the state of the legislative process.  Relatedly, the Volokh Conspiracy tells us that provisions in the new financial reform bill could screw up medical practices that allow their patients to pay on installment.  All of a sudden, Dr. Rich’s conspiratorial rhetoric becomes the tiniest bit more believable.  Payment plans are a great way to make out-of-pocket payments accessible.  Get rid of those…

• The Volokh Conspiracy had a series of eloquent posts on Harvard Law School’s Emailgate, all to be found here.

• Also in the Harvard Square area, two of my favourite economists take on the question of “price gouging” in the context of the recent water main break in Boston.  Relatedly, two bloggers at Volokh Conspiracy address recent research that suggests that people who lean left are more likely to be uninformed about economics.

• Economists like to say that their field is a science.  There’s some legitimate disagreement on that point.  There really shouldn’t be any such debate about the nature of such things as homeopathy and the anti-vaccine movement.  It’s unfortunate that there still is.  Megan McArdle discusses homeopathic WMDs in the first link, and Science-Based Medicine answers all of your anti-vaccine loaded questions in the second.

• There’s been a lot of anger directed at Wall Street recently.  Someone there decided to direct a little bit back to the rest of us.  Enjoy!

• Maggie Mahar at Health Beat Blog argues that our society is suffering from “cancerphobia” and an accompanying “epidemic of diagnosis.”  If I weren’t already persuaded of these points, this would have convinced me.

• There’s always a lot of talk about Medicare and Medicaid, but this past week brought us talk from CMS.  Health Affairs conducted a roundtable discussion with past heads of CMS.  The transcript is fascinating; the conversation touches on political and funding dynamics within the agency and department, the mechanics of anti-fraud activities, the implementation of reform, how physicians were ignored, and how Don Berwick will fit within the agency.  From the CMS of the present, we get the Chief Actuary’s report on the PPACA, summarized by John Goodman.  It really does not look pretty.

• Science-Based Medicine discusses “Big Pharma,” and explains the FDA regulations that require drugs to “belong” to a disease… something that I didn’t previously know.

• InsureBlog discusses the travails of a health insurer offering a so-called 100% HSA/HDHP.  I have to wonder, from an economics point of view, whether people will be more judicious in their spending even though the money originally came from someone else (i.e. their HSA was topped up for them).  Endowment effects and whatnot.  If that is the case, and if the insurer can get the premium right to reflect the relative injudiciousness relative to “true” out-of-pocket spending, then this model could be a very real alternative to the current mainstream of first-dollar medical coverage.

• What are economics bloggers worried about?  Mark Perry lets us know.

• Hospitals tend to be big fans of pain charts, and making sure that pain is not overtreated.  Not everyone feels the same way about childbirth.  Amy Tuteur argues that the latter group are in fact demeaning the women they purport to want to empower.

• Finally, a tale of a near-mugging in Warsaw, and the compassionate and hilariously profanity-laced response of the local police.  Language most definitely not work-safe, and not family-friendly.