JAMA  16 May 2012  Vol 307
Do we all live on the same planet? I’m nearing the end of an amazing year at Yale, surrounded by superlatively intelligent people working on the outcomes of US healthcare. I myself occupy a space with brilliant newly qualified young doctors from India, Iran, and Brazil, putting together a book on patient-centred medicine. Most of the ideas we discuss about patient autonomy and shared decision making are quite new to them. All day long we work in cyberspace with people all over the world. When we leave the confines of our artificially lit space with temperamental air-conditioning, we blink in the sunshine and walk past black garbage-sifters begging for money, sallow drug addicts, and drunk disabled people shouting at each other. We share a street with these people, a town, a country, a world. But I cannot say that we really share anything with them, except perhaps for some coins we have in our pockets. more…

JAMA  9 May 2012  Vol 307
1925    In a wonderful letter to Humphry Davy in 1800, Coleridge declared that science, as a human activity, “being necessarily performed with the Passion of hope, is poetical.”

All good science is inspired with the poetry of hope; but, alas, so also is a lot of bad science. If results are negative, then it is a lot easier to hope vainly that they contain hints of great things to come than to admit that years of effort have simply proved nullity. more…

JAMA 25 Apr 2012 Vol 307
1809    Among the many virtues of JAMA, one cannot number a strong sense of the ridiculous. The poetry and medicine section is the world’s most reliable source of po-faced bad verse, this week’s example being an invective against Decadron; and the first research paper this week is a study called FISH.

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JAMA  25 Apr 2012  Vol 307
1717   Any budding young cardiology academic wishing to set up a publication of her own could do worse than start a Journal of Negative Stem Cell Trials in Heart Failure. There are enough of these to fill a volume every quarter-year or so, and editorials could reflect on all sorts of fascinating issues to do with how to wash bone-marrow cells, whether to pre-treat them with this or that, which bit of myocardium to put them in, whether tiny differences in this or that functional measure in various aggregated subgroups indicated that this treatment might actually work one day, etc, etc. This would save the rest of us from having the disappointment of bumping into these papers on a regular basis in the main medical journals. Ten years ago, they were really exciting, and we all took heart, so to speak; but the FOCUS-CCTRN published here is just another failure like the rest. The cells were autologous bone marrow mononuclear cells; they were introduced by transendocardial injection, mostly into male hearts damaged by ischaemia, and at six months there was no evidence that they were doing anything to any of 8 outcome measures. more…

JAMA  18 Apr 2012  Vol 307
1583   George Orwell predicted a nightmare world where soothing words would mean their opposites, and gave his dystopia the date of 1984. It was about that year that the term patient centred first appeared in the medical literature, coinciding with the time when the medical-industrial complex went totally out of control in the USA and patients were thrown entirely to the mercy of the market. Books and papers about patient-centeredness (sic) proliferated in America during the 1990s, but the momentum of medicine there has continued to career in the opposite direction. Now that total chaos and unaffordability loom, the US government has set up the Patient Centered Outcomes Research Institute with a hefty budget to find out how to put things right by finding out what systems of care work best for patients. A laudable aim and a fine-sounding name, certain to arouse suspicion among cynics everywhere; but this particular cynic is amazed and optimistic. To find out why, listen to the visionary speech which Harlan Krumholz gave to the PCORI Patient and Stakeholder group a few weeks ago. This goes way beyond the usual rhetoric of being nice and involving patients, and commits PCORI to a radical agenda of patient empowerment – the only way that health systems the world over can reclaim the true purpose of medicine. This article shows how Harlan’s vision is shared by others in the developing organization.
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JAMA  11 April 2012  Vol 307
1489   The new editor of JAMA feels that his worthy journal needs a bit of livening up, and who can disagree? He has borrowed an old idea from the BMJ, in the form of head-on for and against articles. “Should a 55-year-old man who is otherwise well, with systolic blood pressure of 110 mm Hg, total cholesterol of 250 mg/dL, and no family history of premature CHD be treated with a statin?” This is an awful question for several reasons. It implies that the doctor is the one who should decide, and the “patient” is the object who should, or should not, “be treated”. But in what way is this man a patient?  Why is he “otherwise” well? Is his illness being 55, having low blood pressure, or having a total cholesterol of 250 mg/dL? In this exchange of views, three doctors think he should “be treated”, and two doctors (one the editor of Arch Intern Med) think he shouldn’t. I would argue that it is none of their business: give him the evidence and let him decide. more…

JAMA  4 Apr 2012  Vol 307
1394    A special dread settles on me this week as I know I am going to have to write about breast cancer screening. But let’s leave the dread question of whole-population mammography for later, and consider the add-on benefit of annual ultrasound or single-screening MRI in selected high-risk women. While the war over breast screening rages unchecked in the letters and a book review in this week’s Lancet, let’s take refuge in this little corner of the battlefield, where at least the fog of war is not too thick and we can count a few weapons and estimate a few casualties. The volunteer combatants are women with dense breasts and at least one factor that increases their risk of breast cancer. The ultimate proof of victory, as in all screening studies, will be a reduction in total mortality. The casualty list should include every woman undergoing biopsy or surgery, because nobody comes away from these things altogether unscathed, be it mentally or physically. This study gives us a casualty list, including the number of enemy killed (breast cancers detected and operated on), but cannot give us any idea of the extent or the cost of victory, because it was run over a three-year period only. Our brave lasses certainly saw their share of action: 2725 over the age of 25 (!) went through annual mammography and ultrasound, and 612 ended up having MRI. During that time 110 had 111 breast cancer events: 33 detected by mammography only, 32 by ultrasound only, 26 by both, and 9 by MRI after mammography plus ultrasound; 11 were not detected by any imaging screen. Enough. We can tell from these figures that the three imaging modalities will pick up most cancers; but the true cost—mentally, physically, and financially—can only be hinted at in a study like this. Only very long-term follow-up will give us a true estimate of overdiagnosis and the degree to which such screening detects cancers which would never progress. But in just these three years, a total of 1272 biopsies were performed—more than ten for each cancer detected. So this high risk group may well see a small reduction in all-cause mortality over the course of their “screening lives,” but it will be purchased at a high cost in medical procedures and anxiety. In fact any woman undergoing this cycle of procedures would be extremely lucky to get away with a single fine-needle biopsy during her life—two or three would be more likely. more…

JAMA  28 Mar 2012  Vol 307
1257    Medical conferences exist to affirm everything that hinders the progress of medicine as a compassionate and honest enterprise. They are a showcase for authority figures, pharma-funded research, half-completed work in the form of abstracts and late-breaking sessions; they use up prodigious amounts of money and carbon fuels; they reward high-tech flashiness and set no value on basic care and joined-up thinking: they reinforce a career structure and a social hierarchy in medicine which undermines the whole concept of patient-centredness. I’m glad to see all these feelings shared by John Ioannidis in this Viewpoint piece. John is a famous iconoclast who wrote the classic 2005 PLoS Medicine paper, Why Most Published Research Findings Are False. Here he proposes that nobody with any ties to industry over the preceding 3 years should be allowed to organize a conference. Also, that in order to ascertain the educational benefit of conferences, the next one should be randomized. more…

JAMA  21 Mar 2012  Vol 307
1161    When in Japan, do not attempt to drop down dead. In 800 fire stations around the Islands of the Sun, teams of emergency medical service personnel stand ready to rush out and perform resuscitation for out-of-hospital cardiac arrest, which cannot be discontinued until an ambulance arrives and you are taken to hospital, barely alive or truly dead. This non-randomized study of Japanese CPR shows that if the emergency team used epinephrine (adrenalin), your chance of having spontaneous circulation when you arrived in hospital would be 18.5%, and if they did not, it would be 5.7%. On the other hand, your chance of being alive at one month without major neurological impairment would be 1.4% if you had been given epinephrine, and 2.2% if you had not. So I think we can conclude that epinephrine should not be given during CPR. Next we need to find out whether out-of-hospital CPR should be given at all, since there is no firm evidence one way or the other. more…

JAMA  14 Mar 2012  Vol 307
1029   The Viewpoint pieces in JAMA this week are a strange mix of fact and fantasy. The first is a piece about industry payments to physicians and teaching hospitals in the USA. I am currently at Yale University alongside the authors of this piece, one of whom is a good friend. I am observing the US health system at first hand, so I can tell you what is coming to the NHS. You think it’s bad enough that private firms are already buying up NHS hospitals and child health services? You ain’t seen nothing yet. The whole of the American health system is saturated with the influence of the pharmaceutical and medical devices industry: huge payments are made directly to individuals or institutions to influence purchasing decisions. In the UK, we call this corruption, but only for the time being: look at those lists of payments to our MPs from private health providers published in the Daily Mail, of all places. No wonder our legislators are baffled by all the opposition they are facing from British doctors as they try to open up our antiquated socialist NHS to the healing influences of unbridled capitalism. Come on all you GPs who will be running NHS plc—there is money to be made by everybody! In America there is due to be public listing of all such payments in 2013. I wonder if it will make any difference. It is wonderful how much public disquiet people can handle when they have a few million in the bank. more…