EBM Assesment in the Real World; or Critical Assessment on the Internet

A little discussion on Twitter led me to elaborate on red flags. Back in the days when I taught at a residency program, the Internet was exploding and it was important to apply the principles of critical assessment in order to evaluate the credibility of such vast access to new information. These are the same skills and principles we use in evidence-based medicine (EBM). The whole thing begins by not believing what you hear or read and being systematic and rigorously in analyzing the reasons not.

This Twitter interchange pretty much followed the same pattern. Shelley Petersen is a London based journalist and social networking marketer who focuses on innovative medical technologies and maintains an active twitter feed chock full of medical science articles. One of her articles raised a lot of red flags for me and when she asked me what those flags were I thought it was too much for 140 characters. It was time to tramp back over the article and provide a detailed analysis of what struck me as improbable and unreliable about the information.
The article was from a Pittsburgh paper and was fairly balanced, presenting some contrary perspectives, so the red flags were about what the principal was saying. In brief, the CEO of a private company was discussing how a long recognized function of telomere shortening and how it explained aging and all the diseases associated with aging.
1. Everyone has an inherent bias, mine is to be skeptical. The CEO of a company is to sell something. In this case, I suspect it is to sell a narrative to investors. I am dubious at the get-go, so red flag number 1.
2. Most research happens at universities. Scientists know that some of the best research happens at smaller universities, but when the only experts cited in any article are from Harvard and MD Anderson, I begin to suspect spin. Certainly I would expect some degree of balance between “name” institutions and other excellent university departments which are less of household names. Over-citing can raise flags.
3. Telomeres are not new. Telomere shortening is not new. When one individual claims he has insights that nobody else has been smart enough to figure out over decades, it is wise to be suspicious. Moreover telomere shortening is an epigenetic phenomenon. Nobody believes that epigenetic phenomena occur at the same pace everywhere in all tissues at the same time. Telomere shortening in fibroblasts does not predict telomere shortening in ovaries, or any other tissue. So wildly expansive claims should leave the reader incredulous that decoding this one phenomenon will end aging, cure all cancer (where telomere shortening may eventually pan out to a mechanism in one or another subtype of cancer), get rid of heart disease, cure wrinkles and fix your stiff knees..
4. Activating the immune system is a phrase that is a throw-away for naturopaths and quacks. Ask anyone with allergies or rheumatoid arthritis. An active immune system is not a good thing and depending on your definition, may well lead to a cancer, like say… lymphoma, a cancer of the immune system. Let’s face it, we all need a well-regulated immune system, but “activation” is meaningless in any scientific context.
5. Anyone who tries to market an innovative pharmaceutical product as a supplement is selling snake oil, plain and simple. The FDA evaluates specific therapeutic claims for specific pathological entities. They do not even evaluate absolute efficacy, drugs only need to demonstrate superiority over placebo. No such regulation exists for supplements, so many companies that do not have the ability to go through a rigorous review and demonstrate scientific merit will circumvent the process and come to market as a supplement. With the notable exception of nutritional deficiencies, there is usually no merit to claims that vitamins, supplements or minerals cure cancer, heart disease or any other disease. The idea that taking something as simple as a supplement may be appealing but has no basis in fact, since it is still an exogenous product, natural or otherwise. 
The principles of critical assessment are to assess date, author, quality of the publication and citations. Biological plausibility is important in assessing a scientific article, along with the link between the data and the claims made. This can be applied to journalistic information as well and when claims are expansive or vague, skepticism should take over. Any attempt to circumvent well-established processes to verify and certify scientific findings completely invalidates the speaker’s credibility in my mind. Being skeptical means you will believe only a small fraction of what you read, but this is not necessarily a bad thing. There is very little truth in much of what you come across on a daily basis, but there is plenty of hype and plenty of reasons for people to try and attract your attention.
Shelley’s work exposes me to a wide variety of information, which I find useful. The article itself was well-balanced and prudently presented, but the company and the spokesman were presenting snake oil under the guise of science.

Family Medicine in the New Healthcare Landscape

A couple of weeks ago, I was invited to our local residency graduation party to give a few words on behalf of the Clark County Medical Society. It was more of a party than anything else, but there was so much I wanted to say. It was supposed to be about the residents, they had a keynote speaker, and I had five minutes to promote the society. I also kept getting ideas right up to the time of the speech. I cannot tell you how many rules of public speaking I broke. I read most of the speech, way too fast, couldn’t keep eye contact with the audience and improvised on the fly… not really sure if the main points came through. It was probably more of an essay, probably more multi-layered than it should be for a simple five minute talk.
So here it is in blog format.

You are graduating into the single most exciting period in the past century of medicine. Sweeping changes to how healthcare is delivered is being contemplated and actually being enacted.
The last time this much change was going on at the same time was.. well, it was when I was graduating. They told me the same thing. From my  In the late 1980’s and early 90’s, a pharmaceutical revolution had reduced hospital stays and the technological revolution of minimally invasive surgery was about to threaten the need for beds across the country. HIV had been isolated and drugs were emerging that could potentially provide hope for a treatment. The practice of medicine was coming to be viewed more and more as a business and restrictions on physician advertising were being rolled back, along with the introduction of pharmaceutical direct-to-consumer advertising that was just starting at the time. Managed care was growing, HMO’s were felt to be the inevitable wave of the future and the first wave of integrated health systems was about to begin, with physicians selling their practices to hospitals that were reaching out blindly to won as many practices as they could.
Since then, we saw the boom of primary care in the HMO era, the consumer backlash that followed, and the unwinding of integrated health systems. It was painfully apparent by then that FP’s did not always have a good business sense and many lost money taking on capitated patients with exposure to too much risk. The hospitals realized they needed to pay attention to what they were buying when they bought a practice and for more than a decade, they were very cautious in such enterprises. The pharmaceutical industry seems to have split in two: the “me-too” drug manufacturers and the biotechs. The success of specialty drugs is perhaps nowhere felt more than in oncology where survival started increasing in the most stubborn of cancers like lung and pancreas. Indeed breast cancer is now more of a chronic disease than an acute illness and this may yet occur with other conditions. In fact, think of HIV/AIDs which is a persistent, annoying and important public health problem, now also best managed as a chronic disease. Some of our internal medicine colleagues, not known for being well remunerated have entered a golden age of their own, think of rheumatologists and the spread of biologicals in lupus and RA.
So maybe I’m wrong, maybe every age is the most exciting age in the history of medicine and the pace of change is merely accelerating. That means you will have to be accustomed to constant change throughout your careers. Such a thought can be a little sobering, because we all need some constants in our life. Living with constant change sometimes feels like living in the eye of a hurricane.
On the other hand, consider the following… no matter how much the content and context of medical care changes around you and your patients, some things do not change… a physician and a patient behind a closed door discussing their health. The generalist physician, in particular, is the one who does the troubleshooting. This never changes. Family medicine defined this way, is an integral part of the health care system. Worldwide, many experiments are under way in horizontal care with nurse practitioners, physician extenders, community health workers and the like… At the center of any program is a generalist physician who encourages, fosters and actively participates in caring professional relationships with people who may or may not know what kind of healthcare they need.
A mature specialty does not ask for the respect of its colleagues; it merely acts knowing that it is contributing to the well-being of everyone it touches by the individual acts of its practitioners.
A mature specialty does not criticize its colleagues for acting according to their immediate pecuniary interests. It recognizes its inherent power to guide and direct patients to where they will get the greatest value for their money. It also recognizes that much of its credibility in the eyes of the populace rests in the network of specialists to which they have access. People see value in getting to the right specialist quickly.
Primary care will be at the center of the future healthcare system and the fact that family physicians alone see all patients along the age spectrum provides a huge market advantage. I speak as an employer now. I have asked family physicians to step aside if they were uncomfortable with caring for certain age groups to step aside. I’d rather have an internist.
So how about some free advice to be valued as such from a doc who is now old enough to be looking downfield for a Hail Mary pass:
Family Medicine will be fine as long as you focus on certain things:
  1. Focus on the health of the population. In so doing, you will always be able to see the amount of value you are contributing to the communities where you work, no matter how little you actually get paid!
  2. Focus on the fact that without generalist physicians, the goal of a safe, efficient, effective health care system cannot be achieved.
  3. Focus on the fact that you need to work well with everyone in the allied health fields: PA’s, NP’s, pharmacists, home health aides, radiology technicians, lab porters… Medicine was never supposed to be a turf war and what you do depends on the contributions of so many, it is best to remember them in everything you do.
  4. Remember that nothing makes competition irrelevant than a change in the landscape. Your competition is not against PA’s, NP’s, specialists and the like… it is with them you must work to improve the health of populations.
  5. It is OK to say no to working more for less. There are settings where you can deliver better care with less effort and mean more to people. (And maybe make more money.)
  6. Stay involved.
    Medical and specialty societies are both important. In this county the WAFP is not as strong as the WSMA, but there are other counties where the opposite is true. Get involved in both. It’s not about how they represent you, but rather that when you get involved, you start driving how it represents you. There is nothing more important to understanding how a new relationship between family medicine and the rest of medicine will work until you see how family physicians are getting involved all the way up to the AMA.
I would like to leave you with this one final thought on how important your contribution is
“Family physicians are the guardians of the House of Medicine; the last credible proponents of sensible care.”

Egypt and Democracy

It was not my plan to start off a blog by a physician, medical director and policy “wonkabe” with a commentary on international geopolitics, but I have been recently obsessed with my father’s ancestral land and had some interesting online interactions.

When Mohamed Morsi was deposed by a military intervention following a popular uprising, the question became if the military’s action represented a coup. More to the point, the question was which party was behaving undemocratically.

First let me get some disrespect out of the way; it is easy to make fun of the USC graduate who worked for NASA and yet appears to be unable to speak English on a televised interview. He is wooden in front of the camera, tentative and sometimes speaks in confused and inarticulate manner. Even those for whom Arabic is a fluent and native tongue find him confusing. He spoke about inclusive and democratic dialogue but shut people out when they disagreed with him.

Nonetheless, were demonstrations, mobs and civil unrest an appropriate democratic response to an apparent political incompetence to govern? Usually a coup involves a small group of people installing themselves over a large majority of the population and enforcing their power through terror and a police state. This may not have fully occurred in Egypt this week, but even trivial human rights violations give a bad taste. Given the Muslim Brotherhood’s decades of persecution and professed patient non-violent path to power, the apparent failure of democracy has deep and profound implications about effecting change though political action rather than the point of a gun.

My  early experience in Canada was with governments that folded under popular opposition and pressure. Sometimes it occurred when it looked like political capital was tapped out. Frequently the popular dissatisfaction with a particular political figure played out along party lines. Pierre Trudeau was forced to resign in 1980, but when his successor was defeated in a general election, he managed to return and regain the post. Brian Mulroney was forced to resign as his popularity plummeted. Canada’s first prime minister John A McDonald was forced to resign due to a scandal. A crisis in 1896 involving numerous cabinet resignations and chaos in Ottawa forced the resignation of McKenzie Bowell two years after taking office and never having won an election.

In England, I doubt that Gordon Brown would have been able to usurp Tony Blair’s position had it not been for scathing criticism, popular disaffection with his leadership and plummeting poll numbers. The 1970’s brought a time of great unrest in strike-bound Britain, with at least one government collapsing and a snap election being called (Edward Heath 1974). Some would argue that Neville Chamberlain had to resign after losing face in a campaign of appeasement towards Hitler’s Germany.

In 1979, Indian PM Morarji Desai was forced to resign in the face of tumultuous internal party strife accompanied by numerous manifestations. More recently internal party strife has led to Australia’s Julia Gillard and Kevin Rudd flipping the post and they are even on the same side, belonging to the same party.

But all these are parliamentary democracies and things may not work the same in republican democracies. What happens in the US? We have the example of Richard Nixon leaving office for an unelected, quickly appointed vice president due to overwhelming public opposition and popular resistance to his rule. We also have a militia culture in some parts of the country that view themselves as the final arbiter of what the federal government can and cannot do. If recent attempts to pass gun control legislation had been judged too obtrusive by some segments of our society, civil disobedience would have been a real possibility. Even though I support this type of legislation, it is probably just as well we were unable to pass it because it was divisive. Much to the surprise and dismay of those in other democratic settings, the existence of a potentially violent resistance in the US is omnipresent but has not been a factor thanks to the structural and constitutional checks and balances that prevent any branch of government from accumulating too much power.

It has struck me in the past that the function of democracy is not to get things done, but to prevent any large group from doing something stupid. Democracy is the anti-accomplishment method of running a government.

But this has not been the purpose of the Muslim Brotherhood and the style of political Islam which appears to have only succeeded in Turkey. Islam in political terms is much like American “Fox News Conservatism” which seeks to remake society in ideological terms. The question posed by Deena Adel (@deena_adel) and Yamine El Rashidi (@yasminerashidi) in a recent twitter exchange is how a democratic system can be inclusive of a group bent on violence. The question I responded with is how can you integrate a group whose goal is the establishment of a totalitarian theocratic state.

The fundamental failure of Morsi, The Freedom and Justice Party and the Muslim Brotherhood was attempting to govern as though winning the election was a mandate for them to act as they wished. The fundamental platform, based on faith that their actions are always just as long as they further the interests of Islam, is that good people representing Islam are above the law and the constitution. This seems to me the assumption behind the constitutional slight of hand of late 2012. Understandably the Islamist statists do not see these actions as justification for military action or even having their candidate succumb to popular pressure to step down. “It is not fair, I was elected, ” Mr. Morsi said in one of his prolonged speeches. The manifestations of democracy begin and end with the election.

Of course the last sentence is not true. Democracy is a messy give and take between majority and minority power centers reflecting the balance of power in a society at any given point in time with the given understanding that it is a constantly shifting power base anyway. Civil society is based on the presence of stable institutions reflecting vested interests, whether the Cato Institute or the local chapter of the Soroptimists. Plural societies can organize around groups that even embody conflicting values within limits. Democracy requires constant cajoling, realingnment, arm twisting, threatening and rewarding. It requires the recognition that fundamental freedoms are never abrogated by the democratic process itself.

In an article by the Brookings, Hadi Shamid reflects on how 2013 will fall into the pantheon of Islamist betrayals like 1992 in Algeria, among others. But as I recall, the problem in 1992 was that the election was allowed to proceed in the first place with he Islamic Salvation front. It was a party that specifically and freely acknowledged a goal of introducing an Islamic totalitarianism. The failure of secular forces was to expect them to be defeated, so that when they won there was no choice but to forcibly shut them down like the anti-societal totalitarians they were.

The Islamists proper grievance is that the rules seem to change once they get in power. Attempts by liberals to demonstrate their openness to any and all opposition groups leads them to extend courtesies where consideration will bear no fruit. It is inadvisable and unwise not to be clear from the beginning: that any action which undermines a pluralistic, diverse and civil society will result in exclusion from the political process. This is what happened to Mr. Morsi and we are now left in the awkward position of trying to explain why the military in Egypt is the entity to forcibly enact principles of democracy.

The fact that David Brooks’ Defense of the Coup is so insulting in reference to “lacking the most basic mental ingredients” for a democratic transition reflects this basic dynamic. We explain democracy as we understand it, using Western terms with our education and a half millennium of enlightenment thinking. The messages are being received by a group whose intellectual heritage missed the enlightenment altogether and whose logic remains in a theocratic constraint where logic does not need to be rooted in any verifiable empirical evidence. Mr. Brooks makes the correct observations, but comes to the wrong conclusions. The problem is not DNA, it is intellectual heritage. The problem may be an elitist perspective bred by education and an inability to reach out to the less instructed.

I am cautious to point out that the US must play its cards right in order to secure the entire world’s future stability. The fault for the terrorist attacks on 9/11 rests only with the terrorists themselves, but the sequence of events that unleashed our current Islamist nightmare may well be traced back to Western goofs over the past century. They may also even include Nasser’s 1954 crackdown on the Brotherhood as Hadi Shamid suggests.

I am equally cautious to point out that the root of Islamist excess today rests in Christian excess of the past. I remember reading an account from Turkey a century and a half ago, where a Muslim trader expressed resentment that every time he wanted to develop a business, he had to go through Christian middle men. The Copts in Egypt were in the majority a little over a century ago, but their [our] concern for the poorer Egyptian and mostly Muslim brethren’s social and economic well-being was perhaps at times less than admirable. The milk of Christian love must first look at oneself, not for fault but for root cause.

Today Coptic communities are poorer than ever, escaping Egypt for economic and physical security, and struggling to help create a better Egypt for all. I am personally a half-century removed from basking in Egypt’s summer sun, but I have drunk from the Nile and my thoughts ever go back. We all need to find a better way to communicate the meaning of democracy and our intolerance to attitudes that will not support a civil society. Islamist disappointment is quite justified, but this is because Islamist ideology is simply not compatible with democratic institutions and processes.

I hope this article leads to a respectful discussion of the role of political Islam in democratic Arab states. I hope it is not offensive to any parties.