This Mans Simple System Could Transform American Medicine

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Katherine Carpenter couldnt sleep. For more than a week shed been coughing herself awake every night and then hacking until she retched. Finally, she decided to see a doctor.

The physician suspected bronchitis and wrote Carpenter a prescription for heavy-duty cough medicine. She also suggested antibiotics. Thats pretty standard: Up to 80 percent of people who go to a physician for acute bronchitis are prescribed antibiotics. But Carpenter, an import entry agent for UPS, didnt want antibiotics. She thought theyd stop working if you take them too often, and she suspected her symptoms were caused by a virus, which antibiotics dont affect anyway.

She didnt know it, but her hesitation had science on its side: A meta-analysis in the Cochrane Database of Systematic Reviews looked at 17 trials on antibiotics for people with acute bronchitis, and concluded that they only slightly shorten the duration of the illnessif they have any benefit at all. (And of course theres the issue of antibiotic resistance to consider.) In the end, Carpenter refused the prescription, and her bronchitis eventually cleared up. But the experience left her with the distinct impression that she was just one more patient on the medical assembly line. I felt like a number, she says.

Instead of being a number, Carpenter might have preferred to see a number, one that can help us weigh the benefits (or lack thereof) of a treatment. That number exists, and its called the number needed to treat. Developed by a trio of epidemiologists back in the 80s, the NNT describes how many people would need to take a drug for one person to benefit. (The NNT for antibiotics in a case of acute bronchitis is effectively infinity, because the medicine is no better at curing the illness than a placebo.)

Consider a couple other examples: If your kid is throwing up and you take her to the hospital, she might get a drug called Zofran. The NNT for that is 5, meaning that only five kids need to take Zofran for one of them to stop throwing up. And if you look at Zofrans number needed to harm (the number of people who would need to take a drug for one to have a bad side effect) the answer is well, there really isnt oneno one has a significant side effect.

Now, say youre pushing 50. Youre healthy, but your doctor suggests you start taking a baby aspirin. Just in case, you know? That NNT is 2,000. Thats how many people have to take a daily aspirin for one (nonfatal) heart attack to be prevented. Statistically speaking: Not especially helpful.

Its unfortunate, then, that the NNT is not a statistic thats routinely conveyed to either doctors or patients. But you can look it up on a site that youve probably never heard of: TheNNT.com. Started by David Newman, a director of clinical research at Icahn School of Medicine at Mount Sinai hospital, the sites dozens of contributors analyze the available studies, crunch the numbers on benefits and harms, and then post the results. While a low NNT is generally good and a high NNT is bad, you also have to consider the severity of both the illness and the drugs side effects. Which is why the team added a color-coding system: Green for when a treatment makes sense, yellow for when more study is needed, red for when the harms and the benefits cancel each other out, and black when the harms outweigh the benefits.

Newmans goal for the site is nothing short of a revolution in medical practice. He wants doctors to base their treatments on good scientific evidence, not tradition, hunch, and the fear that patients will see them as doing nothing. And he wants patients to start demanding such care. Thats the big picture, anyway. For now, hed be happy if he could just get people looking at medicine in a different way. People tend to think that if its a medical intervention, theres science behind it, he says. Unfortunately, thats often not the case. It is a lie to tell patients to do something without telling them, You should know weve done lots of research on this and we cant find any benefit to it.

Its a bright, cold morning outside Mount Sinai Hospital in New York City. Central Park is across the street, and runners huff along the paths, baby joggers in front, dogs in tow. Newman has just arrived at work in the emergency department where hes an attending physician, and hes giving his residents the Three Networks spiel.

ABC, always be closing. You want to be moving patients back home or into the hospital for treatment. At the ER, the front door is always open, but if the back door is closed, and you have people mounting up, things get missed, heart attacks occur, sepsis gets worse, and people die. Always be closing. Then comes NBC, never be consultingdont call specialists if you can avoid it. Then CBS, close before signoff. Theres good evidence that medical errors are more likely to occur with handoffs. Discharge your cases before the end of your shift to avoid these errors, he tells his charges.

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This Mans Simple System Could Transform American Medicine

Policies on marketing gifts to medical students

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PUBLIC RELEASE DATE:

14-Oct-2014

Contact: Maya Sandler medicinepress@plos.org PLOS

Interactions between health care professionals and the prescription drug and medical device industries are common in the United States, especially in academic medical centers, and may include gifts to medical students such as textbooks and interactions of marketing representatives with students. Such practices have been criticized as potentially conveying biased information and reducing the students' skepticism about potentially misleading claims. Numerous expert professional groups and medical societies support development of policies by medical schools to limit such interactions, and some medical schools have implemented such policies. However, whether such policies are effective remains unclear. James Yeh and colleagues (Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA) compared the 2011 survey results of a nationwide random sample of first and fourth year US medical students (1610 responses; 49.3% response rate) regarding interactions with and gifts from pharmaceutical marketing representatives with policy dimensions reported for 121 allopathic medical schools on the American Medical Student Association (AMSA) PharmFree Scorecard and the Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database for 2010. The policy dimensions included individualindustry interactions, institutionalindustry interactions, and industry involvement in educational activities.

The authors found that students from schools with the most stringent industry interaction policies were less likely to report receiving gifts (AMSA score, odds ratio [OR]: 0.37, 95% CI 0.190.72; IMAP score, OR 0.45, 95% CI 0.191.04) and less likely to interact with marketing representatives (AMSA score, OR 0.33, 95% CI 0.150.69; IMAP score, OR 0.37, 95% CI 0.140.95) than students from schools with the lowest ranked policy scores. Adjusting for year in training and medical school size did not change the relationship substantially, but when they adjusted for funding from the National Institutes of Health, the association was no longer found. The authors suggest this may have been because schools with NIH funding have more experience implementing policies to address institution-industry interactions and more funding for compliance officers, or because schools with less NIH funding may be more dependent on pharmaceutical company gifts to help fund educational activities. The study's limitations included that it was cross-sectional in nature and the survey was conducted a year after the policy dimensions were rated.

The authors state, "Policies banning gifts were associated not only with reduced reports of receipt of industry gifts by students, but also with fewer interactions with pharmaceutical marketing representatives overall and greater perception of adequate separation between the faculty and industry. These results suggest that as US academic medical centers look to create or reform regulations on industry interactions for medical students, limiting receipt of gifts should be a central feature of the policies. Medical trainees who receive even small-value gifts from marketing representatives have been found to have more favorable attitudes towards pharmaceutical products and marketing representatives and tend to believe they are immune to the biases that can arise from such interactions." They conclude, "As medical schools review policies regulating medical students' industry interactions, limitations on receipt of gifts and meals and participation of faculty in speaking bureaus should be emphasized, and policy makers should pay greater attention to less research-intensive institutions."

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Research Article

Funding: Survey funded by a grant from the Edmond J. Safra Center for Ethics at Harvard University. Institute of Medicine as Profession's data were made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin. ASK is supported by a Greenwall Faculty Scholarship in Bioethics, a Robert Wood Johnson Foundation Investigator Award in Health Policy Research, and a career development award from the Agency for Healthcare Research & Quality (K08HS18465). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: KEA was a member of the American Medical Student Association (AMSA) at the time this study was carried out and received funding to attend conferences from AMSA. ASK is a member of the Editorial Board of PLOS Medicine. Preliminary results of this study were presented in a poster at the Eight Annual Massachusetts Medical Society Research Poster Symposium in the health policy/medical education category in December 2013 and received a second-place prize. An abstract of the study was presented orally and selected as a finalist for the Mack Lipkin Sr. Research Award at the Society of General Internal Medicine Annual Meeting in April 2014.

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Policies on marketing gifts to medical students

Medical school makes funding cuts manageable

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Despite the John A. Burns School of Medicines (JABSOM) top funder receiving budget cuts, the school continues to maintain its forward momentum in the field of biogenetics research with help from its team of researchers and by using the money it is currently receving to build a self-sustaining research facility.

According to a National Insititutes of Health (NIH) fact sheet, in March 2013, President Barack Obama signed an order that initiated a process known as sequestration for the institutes fiscal year 2013 budget. This required the organization to cut its budget by five percent or $1.55 billion.

This cut affected research in universities nationwide, and according to Talia Ogliore, public information officer for the Office of the Vice Chancellor of Research at UH Mnoa, dropped the amount received by University of Hawaii at Mnoa during the federal stimulus years from $68 million to between $40-$44 million a year since 2012.

In recent years, UH Mnoa has increasingly sought to diversify our funding sources for health-related research, looking for additional opportunities with state, local and private health organizations and Hawaii non-profits, many of which have medical missions, Ogliore said in an email interview.

According to Ogliore, this research funding has come from various medical facilities such as the Queens Medical Center, Kapiolani Medical Center for Women and Children and Kuakini Medical Center.

Making cuts manageable

Tina Shelton, communications and government affairs director at JABSOM, explained that small changes, such as trips to academic meetings being replaced with conference calls, have made the cuts manageable.

The faculty itself has upped its pursuit of lesser-known funding with energetic and aggressive grants proposals that rely on the success of previous research such as the worlds first cloning of a mouse, Shelton said.

She added that these efforts to bring in the extra funding not only help with the discovery of new scientific breakthroughs but also help JABSOM as the medical campus is required to be completely self-sustaining. All maintenance of the buildings, salaries of the faculty and other expenses must be paid for by JABSOM. UH Mnoa and the UH system also benefit as 50 percent of outside funding acquired goes to help fund the other campuses.

Receiving grants

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Medical school makes funding cuts manageable

Jeff Vinik hires Tallahassee lobbyists amid talk of USF med school move

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TAMPA Tampa Bay Lightning owner Jeff Vinik has hired heavy-hitting lobbyist Brian Ballard and two others to represent his interests in Tallahassee.

A Lightning spokesman would not comment Tuesday on the goals to be given the lobbyists, who weren't talking much, either.

But it would come as no surprise for them to lobby the Legislature for millions of dollars for a new downtown medical school for the University of South Florida a project USF is considering putting on Vinik's land near Amalie Arena.

Tampa Mayor Bob Buckhorn assumes Vinik hired the lobbyists for that purpose.

"I don't know that for a fact, but I've got to believe that he may try and help the process as best he can, as will I," he said.

On Monday, Buckhorn met with one of City Hall's lobbyists, William Peebles, telling him that funding for a downtown medical school is "the city's top priority" for next spring's legislative session.

USF assistant vice president for government relations Mark Walsh said he hadn't heard that Vinik had expanded his lobbying team, but "if they want to work with us,'' he said, "we always welcome the help."

Along with Ballard, Vinik's companies hired Ballard's associate Greg Turbeville and attorney-lobbyist Mark Logan, who has worked with Ballard in the past. Brandon-based lobbyist Ronald Pierce, who already had worked with the Lightning and the arena, also is part of the expanded team.

A state lobbying registry indicates Ballard, Turbeville and Logan will represent the Lightning, Strategic Property Partners, Vinik's real estate holding company, and Tampa Bay Sports & Entertainment LLC, the parent company of the Lightning, the Tampa Bay Storm and Amalie Arena.

Ballard said it's too early to start talking about the work, but he's impressed with Vinik.

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Jeff Vinik hires Tallahassee lobbyists amid talk of USF med school move

Medical courses in Damascus taught on the wild side — Gazette.Net

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Dr. Ellen Smith, of Damascus, offers doctors and medical students the chance to take their knowledge and skills from inside the four walls of a hospital to the great outdoors.

For almost 10 years, Smith has been offering wilderness medicine courses to anyone interested whether they have a medical degree, are seeking a medical degree or just often find themselves outside.

There are a lot of educational gaps on how to handle stuff outside of the hospital, Smith said. You dont have the equipment that a paramedic has, but you have the knowledge of a doctor.

Smith estimates that she has taught her course, which she created utilizing her experience as an emergency medicine physician and sports medicine doctor, to more than 600 people ranging from doctors looking for continued medical education to Boy Scout leaders.

This is one of the most interesting and fun branches of medicine because it involves hands on movement and a less didactic [approach], Smith said.

On Saturday, Smith brought students from Virginia Commonwealth University School of Medicine and University of Maryland School of Medicine to a wooded area near Difference Makers Church in Damascus to take the course.

These students are in the first two or so years of medical school and are exploring all different types of medicine, Smith said, explaining that experiencing it is the best way to decide what path to take.

Smiths curriculum has been approved by the American College of Emergency Physicians as well as the American Medical Association and although her regular course gives certifications of completion, the course she taught last weekend was geared toward introducing the students to the field rather than giving them any sort of credit.

When I started med school I was very interested in wilderness medicine and VCU didnt have an interest group or any sort of elective, Phillip Sasser, a Virginia Commonwealth University medical student said. Me and a few people started a wilderness medicine interest group this year.

Sasser reached out to Smith because he and the group were looking for someone with experience that would be with them physically during a camping trip or full day lesson, similar to what they did last weekend. Sasser felt as if he needed to learn and practice this type of medicine outside and in the environment it would be used. Smith responded to his request immediately and told him to gather no more than 60 students who wanted to participate.

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Medical courses in Damascus taught on the wild side -- Gazette.Net

Liberty Reserve Founder Faces Court Appearance

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A man accused of creating an online, underworld bank that helped launder $6 billion for drug dealers, child pornographers, identity thieves and other criminals was facing his first court appearance in Manhattan.

Arthur Budovsky, 40, the Costa Rican founder of currency transfer and payment processing company Liberty Reserve, was scheduled to appear in federal court in Manhattan on Tuesday afternoon. He was extradited from Spain to the U.S. on Friday.

Once an American, Budovsky renounced his citizenship after setting up the company in Costa Rica, where all online businesses are legal and there aren't laws regulating them.

Budovsky was arrested in Spain on May 23 and held to face a Manhattan indictment against him and others.

U.S. officials accuse Budovsky of using Liberty Reserve as a kind of underworld bank that handled about $6 billion worth of illicit transactions for 1 million users, including 200,000 in the U.S.

Budovsky has said he created a secure platform for online financial transactions, and Liberty Reserve cooperated with investigators. According to court documents, Budovsky moved his business to Costa Rica after he was convicted on state charges related to an unlicensed money transmitting business.

When he announced the charges in May 2013, U.S. Attorney Preet Bharara said Liberty Reserve "became the bank of choice for the criminal underworld."

He said the case might represent the largest international money laundering case ever brought by the United States.

During the Liberty Reserve investigation, authorities raided 14 locations in Panama, Switzerland, the U.S., Sweden and Costa Rica. In Costa Rica, investigators recovered five luxury cars, including three Rolls-Royces. Authorities also seized Liberty's computer servers in Costa Rica and Switzerland.

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Liberty Reserve Founder Faces Court Appearance

Robert Burke: As Libertarian, I'm headed forward in the other direction

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My name is Robert Burke. I am running for governor of Wisconsin, and I need your vote. Our current two-party system is broken, and as my counterpart in Minnesota says, this year we need to "Vote Differently." Who we send to Madison and Washington, D.C., is irrelevant because the machine of the two-party system is in control. Money, influence and corruption are the flavor of every day, and it needs to change. We do this one by one. It's slow and it's messy, but in the end it will be well worth the fight freedom is always worth the fight. Many have perished in America's quest for that freedom, and our blindness to the truth disrespects those sacrifices.

Libertarianism is different in that all candidates follow a set of principles laid out in our platform, which you can find at RobertBurkeforGovernor.org. Everyone running for office follows these principles and we have a committee whose job it is to review our voting record and hold our elected officials accountable to the voters who put them in office. Should our elected officials stray too far from these principles we will eject them from the party, because unlike the red and blue team, Libertarians arent afraid to hold our elected officials accountable just to hold a seat. These principles say you are free and that the proper role of government is in the protection of those freedoms and your personal property. These principles are not subject to special events or situations and they are not open for compromise. When you vote for a Libertarian you will get a Libertarian limited government, maximum freedom.

In 2012, I recognized there was a problem and left the red team. I started a political party in my local community, and held educational events, walked the parades, and visited people at our county fairs. I joined the state party and helped organize the workings and co-chaired the largest state convention in our history. Last fall, I wrote our campaign plan and recruited 11 people to join me on the ballot, and together we represent one of the largest third-party slates in recent history. I took responsibility and stepped to the head of the ticket.

This is leadership.

We live every two years from crisis election to crisis election, and thats how the two party system likes things. You have to vote for the red team or the blue team wins; you have to vote for the blue team or the red team wins. It's time to stop living in a manufactured fear created by this red/blue paradigm. Throughout the history of the world, freedom has always meant better lives for people. This year, don't waste your vote on the lesser of two evils: Peace and freedom are among your choices.

Vote Robert Burke-Libertarian this fall because nothing gets the attention of the powers that be than leaving their ranks. FORWARD IS IN THE OTHER DIRECTION. Im headed that way if youre interested.

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Robert Burke: As Libertarian, I'm headed forward in the other direction