Richard Lehman’s journal review – 29 December 2010

Richard LehmanJAMA  22-29 Dec 2010 Vol 304
2732   “Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the care system, but without it, the health care enterprise is lost.” Britons, take heed! This “special communication” was written by a social scientist and five doctors to inform the debate about American health care, but I think the lessons apply even more strongly to the UK health system in its present crisis. The main value of the piece – “A behavioural and systems view of professionalism” – lies in its stress on professionalism as a learned behaviour, which would be enhanced if it were part of a stable contract between society and medicine. Such a contract would observe doctors closely but trust them to act from good motives which become innate with repeated action. This is the very opposite of imposed change with financial incentives for random elements of behaviour, or the creation of a free-for-all between budget-holding doctors and distrustful patients. I foresee difficult days ahead for British medical professionalism.
NEJM  23 Dec 2010  Vol 363
While JAMA ends the year with a few uninteresting papers, the BMJ goes self-consciously festive and The Lancet goes into sulky hibernation, the Puritans and Brahmins of New England maintain the loftiest standards of research dissemination. There is, however, just a hint of seasonal levity in the title of perspective piece newly posted on their website: Can Congress make you buy broccoli? And why that’s a hard question.

2487   The end of warfarin has been a long time coming, and I’ve announced a number of false dawns over the years, but the oral factor Xa inhibitors do seem to be the real business. In the double-dummy, double blind ADVANCE-3 trial, the manufacturers of apixaban tested their new baby against a standard regime of low molecular weight heparin (enoxaparin) for 35 days after total hip replacement. All the nearly 4,000 trial subjects had bilateral lower limb venography at discontinuation of treatment, and the result was a clear win for the oral treatment, with no increase in bleeding. Three wise men (Bristol, Myers, and Squibb) gather in wonder around the crib of apibaxan, and of the increase in their profits there shall be no end.

2499   Meanwhile, over at Bayer Schering and Ortho-McNeil, all hopes were pinned on rivaroxaban in the EINSTEIN trial, where it was compared with enoxaparin followed by warfarin as standard treatment for acute deep vein thrombosis. Again, the new drug won, though in this case not by a statistically significant amount. So goodbye soon to INR testing and hello to the xaban family (why so named? because they ban Xa, of course). The editorial warns us of many trials and a few new family members to come (edoxaban is already with us) and makes a plea for “conscientious pricing” by the competing companies, so that these drugs will reach the tens of millions of people who might benefit. A nice thought: you read it here first.

2522   A registry of children with epilepsy was set up in Finland in 1964, and this study reports on long-term mortality in a cohort followed up for 40 years. The news is not good: the overall risk of death is trebled in these individuals, with an even higher risk in those with poor control.

2530   You can argue endlessly about which hospital outcome measures are important, but surely hospital-wide mortality isn’t a matter of debate. Oh, but it is, says this study: so much so that four common methods of calculating it produce substantially different results. Judging quality in hospitals is much more difficult than NHS websites would suggest: even the corpse count can easily go wrong.

Ann Intern Med  21 Dec 2010  Vol 153
769   If you have a big garden, it’s possible that you may want to grow Echinacea angustifolia and Echinacea purpurea for their modest late-season charms. The roots of the two species contain a variety of chemicals, all seemingly harmless to man, as shown in this trial where they were mixed together and fed to people who believed that they were coming down with symptoms of the common cold. The cold symptoms progressed equally in those given echinacea root and those given placebo, as you would expect. People coming down with colds will no doubt continue to take echinacea, but doctors should not continue to carry out trials of it: there have been enough already.

790   Evidence that dairy fat prevents type 2 diabetes has been around for some time, and this impressive study shows that it is probably mediated by trans-palmitoleic acid. The measurement of this fatty acid is difficult and the investigators went to great lengths to validate their assay and then to compare levels with incident type 2 diabetes in 3736 adults in the Cardiovascular Health Study, carrying out adjustments for a wide range of possible confounders. In the top two quintiles of  circulating trans-palmitoleate, the risk of type 2 diabetes falls by a factor of two and three – no marginal effect, this. Du beurre, du beurre, et encore du beurre: Brillat-Savarin’s three secrets of cookery may also be the secret of avoiding diabetes (and don’t forget to have some coffee afterwards – but that is another story).

Aristotle for the Week:

Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence but rather we have those because we have acted rightly. We are what we repeatedly do. Excellence then is not an act but a habit.—Aristotle1

This quotation from “Aristotle” heads up the JAMA article on professionalism which I mention at the start. I love its message; but it doesn’t really sound like Aristotle, and the citation is:

1. Durant W. The Story of Philosophy: The Lives and Opinions of the World’s Greatest Philosophers. New York, NY: Pocket Books; 1991.

In fact it is Durant rather than Aristotle who wrote these sentences, when trying to explain what Aristotle meant in his Nicomachean Ethics. He inserts a couple of (amended) quotes from the Ethics:

  • “With regard to excellence, it is not enough to know, but we must try to have and use it.”
  • “these virtues are formed in man by his doing the actions”

Now we don’t, of course, know how much of the text now called Nicomachean Ethics was written by Aristotle himself. It seems to me that these Zoroastrian precepts show how deeply the enlightened Persians had influenced the pagan barbarians of Greece. Sadly Aristotle’s thuggish pupil Alexander of Macedon then went on to destroy the civilization of Persia, probably with the encouragement of his teacher.