If It’s Broke Make It Worse – More Healthcare Reform Incoherence

November 25, 2009

I’ll just put up a few items which speak for themselves which won’t stop me from a few comments. Paul B Ginsburg has an article in tomorrow’s NEJM – Getting to the Real issues in Health Care Reform. He describes the bills emerging from the House and Senate which would “reform” the country’s healthcare “system”. His tone is dispassionate and analytical. It’s like a matter of fact description of someone walking down the middle of an interstate highway at a peak traffic hour naked save for a canvas sack over his head. Ginsburg’s concluding paragraph is a gem of nonchalant inadvertence:

If combined House-Senate reform legislation makes it to the President’s desk for signature, enactment would be only a start to the reform process. regulations will need to be written, organizations (such as exchanges) will need to be built, and midcourse corrections will need to be legislated to deal with the unforeseen consequences. And since only tentative steps will have been taken to reform care delivery, policymakers will inevitably have to return to battle on that front.

Doubtless Ginsburg is right. If you are not horrified by the above you don’t understand where we’re headed. Dr Ginsburg (he’s a PhD) works for the center for Studying Health System Change in Washington, DC. The legislation about to emerge from congress is his retirement plan, his children’s education, the educations of his grandchildren and that of his descendants down to the end of recorded time.

MSNBC, which is more left than Warren Spahn, quotes a piece from the NY Times about the ever increasing incidence of medical bankruptcy. If you actually read the article you’ll find this in the 11th paragraph: How many personal bankruptcies might be avoided is unpredictable, as it is not clear how often medical debt plays a back-breaking role. There were 1.1 million personal bankruptcy filings in 2008. In essence the argument is made that we should reform healthcare because it will relive bankruptcy due to overwhelming medical bills though we don’t know whether or not this is a common event.

MSNBC also reports that one in four American mortgage holders are under water – ie, they owe more than their homes are worth. This would seem to be at least as big a problem as medical bankruptcy, probably worse. Why not have mortgage reform which would have the government compete with banks in offering low cost mortgages which would never be allowed to sink beneath the surface of our turbulent economic sea? Come to think of it we already did. Do you remember how that worked out?

Once you realize how much fun it is to reform things there’s no reason to stop spreading the enjoyment to every state, county, precinct, ward, and boulevard of our benighted and largely unreformed land, especially when it really doesn’t cost anything as the Chinese seem willing to pay for it all.

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More on Screening for Breast Cancer

November 18, 2009

The United States Preventive Services Task Force last Monday released new guidelines for breast cancer screening. Predictably, the Task Force’s recommendations for less vigorous screening has resulted in a chorus of dissent verging on outrage from a variety of special interest groups. The American Cancer Society says it’s not going to change its recommendations for annual breast cancer screening beginning at age 40. The society reacted so quickly that it’s hard to believe they had time to read and analyze the offending report.

The ACS’s position is not a surprise to anyone who has followed their stand on screening. They’re always for as much of it as they can find. They are prisoner’s of their component groups which often prevents them from acting dispassionately and with careful analysis. Patient advocate groups, urologists, and radiologists – just to name few – often influence the policy making of the ACS.

In assessing the advice given by a society that represents a disease constituency you must remember that it often has an axe to grind even when it’s not for profit and purportedly acts in the public interest. Furthermore, medicine is not a science, though many of its components are, and even if it were scientists are as forgetful of scientific method as anyone else when a passion grips them.

I wrote a short while ago about the paper in the JAMA which detailed the problems inherent in screening for both prostate and breast cancer. The current Task Force report is just another reminder that screening is not as simple nor innocuous as it’s often said to be.

The Task Force recommends that women who are not at increased risk for breast cancer not get screening mammograms until age 50 and that they get them every other year rather than annually. They further state that they can’t tell if screening mammography conveys a benefit at age 75 or above.

A number of commentators have construed a political message from this report. It’s release in proximity to congress’s efforts to pass a bloated healthcare “reform” bill is largely responsible for observers hostile to “reform” seeing this as the start of government mandated rationing of medical care. It really is just a risk-benefit analysis of the value of breast cancer screening. It’s very hard to get the public, and many physicians, to understand that screening has a downside as well as a benefit and that most screening tests are of unproven value or have been proven to be of no benefit.

The reports of the Task Force is below. Also below is the Canadian study on breast cancer screening published in 2002. It failed to show any benefit at all of breast cancer screening. Radiologists went mad when it appeared and has rarely been discussed since. Read both and and make up your own mind.

Screening for Breast Cancer – U.S. Preventive Services Task Force

The Canadian National Breast Screening Study


Glitches Mar Turandot in HD

November 8, 2009

Turandot

Franco Zeffirelli’s sumptuous, gaudy, excessive, over-the-top, or whatever suits your taste production of Puccini’s Turandot was broadcast in HD November 7, 2009. Unfortunately, the transmission was repeatedly interrupted by dropped audio, and occasionally video, signals. An announcement in our theater was made that the problem was global and that the Met was trying to fix it. Perhaps it would have been better to have referred the matter to Congress as they seem to have the time and inclination to fix anything. Not an enjoyable experience. Technical problems have been an ongoing feature of these broadcasts. I don’t have enough knowledge to know how fixable these difficulties are.

Puccini’s final incomplete opera is clearly his most technically advanced, but it suffers from the burden created by its two protagonists. They are, simply put, repellent. The tenor, Calaf, is a self centered narcissist (forgive the redundancy, but he deserves it) who doesn’t give a gnat’s ass about anything other than what he wants. The soprano is worse. She seems to have drawn from “Venus in Furs”, “Psychopathia Sexualis”, and “Three Essays on the Theory of Sexuality”. Her only pleasure is decapitating as many men as she can lay her sword on. Her head-hunting career is in its third year as the opera starts. She’s got 22 heads on her belt. She’s out to revenge an assault by the King of the Tartars on her ancestor Lo-u-Ling “Many thousands of years ago.” This is not your typical Puccini heroine. She inflicts torture instead of receiving it like Butterfly or Suor Angelica. Thus the necessity of Liu, the short-suffering slave girl who gets the really good Puccini soprano tunes.

Had Puccini lived he doubtless would have made many changes to what is an incomplete first draft. But if spinach were chicken soup Popeye would never get a cold. So Turandot is what it is. An unfinished opera that still is a masterpiece and is the last of the great Italian operas. After this the rest is noise. It works if you have a two great sopranos, a great tenor, a great chorus, and a great orchestra.

Maria Guleghina is new to the title role. She did about as much with the role as anyone not named Birgit Nilsson can do. She was able to manage the demand for Wagnerian volume though her high notes sometimes wobbled and her soft ones occasionally strayed from the correct pitch. But considering the difficulty inherent in Turandot, an honorable essay.

Marcello Giordani recently has been singing lyric roles like they were written for a spinto, so it was edifying to hear him in a real spinto role. His tone was bright and his high notes ringing. Having heard him in the house numerous times I’m sure he had the necessary volume. My only quibble is that he has made the decision to eschew deep chest resonance for his low notes making them almost inaudible.

When Nilsson and Corelli sang Turandot together they held their high notes so long that EMS had to be called to prevent their deaths from asphyxiation. No need for emergency services here. Guleghina’s and Giordano’s  high notes were there, but they didn’t stay for dinner.  The tenor did very well with “Nessun Dorma”. The great tune was well sung and capped with a ringing “Vincerò”. Interestingly, while this aria is indelibly associated with Luciano Pavarotti, the late tenor only gave six performances of the complete opera at the Met – all in 1997 when he was about 20 years past his peak.

The best singing of the afternoon came from newcomer Marina Poplavskaya as Liu. This was only her eighth performance at the New York house. She debuted there in 2007 as Natasha in Prokofiev’s War and Peace. She has a lovely lyric voice that handled the role’s pianissimos with ease and grace. She says she prefers Italian roles to Russian. I think she said she’s going to sing Violetta at the Met next season. Also, she looks as good as she sounds. Another operatic beauty from the land of the Czars – Russia not Washington.

Samuel Ramey’s voice has become a sine curve. Timur is not a stressful role so his wobble was tolerable. The great bass should hang it up and not stain the memory of his glorious, though undeniably past, performances.

Thirty year old Andris Nelsons  is a Latvian conductor (I know the name doesn’t sound Latvian – as if I know what Latvian sounds like); he is the principal conductor of the City of Birmingham Symphony Orchestra. He lead an energetic and well paced performance allowing that it’s hard to judge the sound of an orchestra from a telecast that’s pulsing in and out.

Puccini’s choruses in Turandot rival those of Mussorgsky. As expected the Met’s chorus was brilliant.

Gary Halvorson was the video director. As is typical for these telecasts there were too many close ups. This was even more a problem for this production which sprawls across the Met’s vast stage and which is almost as busy as a second of one of James Joyce’s daydreams.

The broadcast had an intermission feature about severed heads – really. They pop up from time to time in opera. The designer in charge of severed heads was interviewed by hostess Patricia Racette. The ensuing discussion though specialized was edifying. Someone should tell the designer in charge of severed heads that a head once disconnected from the rest of the body has no neck. Immediately after the fatal blow the disconnected neck muscles retract leaving no neck behind. All the severed heads displayed by the designer in charge of severed heads had very prominent necks.  But after all, what’s in a neck?

Just for fun cogitate about Turandot’s riddles. She’s been posing them, see above, for three seasons. She is, I suppose, just a silly teenager. Further suppose that no one gets her riddles right. Years go by. Her youth fades. Instead of princes she starts getting butchers,  then lawyers, then deans, then nobody. There she sits alone with her riddles and her wrinkles. Lucky for her Calaf got the right answers. Can you imagine what kind of a couple they make? And they lived dysfunctionally ever after.

Zeffirelli’s opulent Puccini contrasted sharply with Luc Bondy’s barbershop mounting of Tosca which opened the broadcast season and which replaced Zeffirelli’s super spectacular staging of the Puccini thriller. No question which I prefer. Decide for yourself.

Finally, I can’t resist revisiting the pronunciation wars. Racette was dotting the final t in Turandot like a gatling gun – dot.com, dot.org, dot.dead. They were so forceful that they may have been the cause of the transmission difficulties that affected the telecast. Marcello Giordani, on the other hand, was having none of it – Turandooooooooooooooo. His tongue wasn’t within a mile of the roof of his mouth. The Mandarin also ignored the final t. I couldn’t hear it articulated by Ping, Pang, or Pong either. Turandot only says her name once. I thought I heard a hint of a t from Guleghina. But it was just a whiff, a shadow, a whisper, a soupçon, a dribble, a suggestion, a trace, a touch, a tad,  a teensie-weensie tiny tiny t.

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Ford, the UAW, and the Public Option

November 3, 2009

If you want any further proof that government run health insurance will run private health insurance into the ground look at Ford and the United Auto Workers. The union which along with the federal government owns GM and Chrysler has refused to adjust its contract with Ford to match that which it has with the government owned auto makers. “The deal would have brought the automaker’s labor costs in line with General Motors Co GM.UL and Chrysler Group LLC, both of which won additional concessions as part of their government-financed bankruptcies.” [Quotation from the above link.] The union’s rationale for rejecting contractual readjustments is that Ford is in better economic shape than its American rivals. Not for long if Ford’s labor costs are much greater than its competitors.

The UAW made concessions to GM and Chrysler because the government forced them to. When the government runs a health insurance scheme it will do the same thing. It will adjust its contracts any way it wishes. If these readjustments lose money the tax payers will cover the difference. Private health insurance companies will suffer the Ford Effect. They can only lose.

Ford took no federal money and ran its business better than its bankrupt but bailed out competitors. It’s now going to suffer for doing a better job than its profligate and mendicant competition.   This is the new American way.

And while we’re at it, how does Ford negotiate with the UAW which owns a piece of GM and Chrysler. Is there not some conflict of interest here? It’s not just the camel’s  nose that’s getting into the tent.

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The Limitations of Cancer Screening

November 1, 2009

A recent article in the JAMA has received a lot of coverage in the lay press. It analyzes screening for breast and prostate cancer. Critics of both screening tests (including me) have, over many years, pointed out the problems inherent in screening for any disease, but most specifically these two. We mostly have been ignored.

The rationale driving screening for these two cancers (or indeed any cancer) is that the earlier the tumor is diagnosed the better the likelihood for cure. Screening for these two cancers has had limited or no effect on treatment outcomes. First we need to distinguish survival time from mortality. Assume a patient has a cancer which will kill him in 10 years irrespective of treatment. If the diagnosis is made nine years after the onset of the cancer survival time is one year. If the diagnosis is made one year after onset survival is nine years. But the patient dies at exactly the same time. Survival has increased without affecting mortality. It took decades to make surgeons and oncologists admit to this bias of the early diagnosis of a tumor that lacked effective treatment. They have, in the main, refocused on age adjusted mortality which gives a better picture of where we are regarding diagnosis and treatment of cancer. But an improvement in age adjusted mortality cannot distinguish a salutary effect secondary to early diagnosis from that due to new and effective treatment.

Next assume another scenario. The patient has a tumor of such low grade malignancy that he will die of something else before the “cancer” kills him. Here early diagnosis and treatment seem to have cured the patient. He’s diagnosed, treated, and seemingly “cured”. But there’s no other possible scenario. He was never going to die from his tumor no matter how much or how little was done to or for him.

Both these scenarios offer the patient nothing but side effects without any therapeutic benefit. In both of them the patient would have been better off never to have been screened. The figure below from the JAMA paper shows four different screening outcomes.  Cancer progression is plotted against time.

cancer screening

Four cancer screening outcomes

Tumor A never gets large enough to cause any problem. If it were not detected by a very sensitive screening technique the patient would live his life in blissful ignorance of its presence. Tumor B gets big enough to be detected by imaging or by a biopsy, but it too never causes a threat to life or health. Tumor C will eventually metastasize and kill the patient if not detected early and treated. Tumor D is so malignant that it likely has spread before it can be detected and treated. Note that screening is of no benefit in three of these four tumors.

There is another possible scenario that is typically overlooked by physicians in this field. In this one the tumor spreads as soon as it appears. It doesn’t have to go through the stages on the figure. Here again screening will be useless.

Perhaps as high as 90% of prostate cancers will cause no harm. treating them, however, causes significant morbidity. “Even in breast cancer, for which there is evidence and agreement that screening saves lives, …for every breast cancer averted, even in the age group for which screening is least controversial (age 50-70 years), 838 women must undergo screening for 6 years, generating thousands of screens, hundreds of biopsies, and many cancers treated as if they were life threatening when they are not.” [The quotation is from the JAMA paper linked above.]

Managing these diseases would be vastly improved if they were like colon cancer. Here we can identify benign polyps that if not removed would become malignant. Thus we can prevent colon cancer rather than having to treat it. Screening in this instance makes a lot of sense.

Our problem is that we have difficulty telling the tumors that will benefit from screening and early diagnosis from those that won’t, though we are getting better at differentiating them. The authors of this study make several recommendations, all of which are reasonable.

1. Develop and validate biomarkers to differentiate significant and minimal risk cancers.
2. Reduce treatment burden for minimal risk disease. Rightly believing that a lot is in a name, they advise not calling minimal risk disease cancer. The word is too loaded to use casually.
3. Develop tools to support informed decisions. Yet another plea for doctors to talk to their patients about the implications of screening before they do it.
4. Focus on prevention for the highest risk patients. This is easier said than done, but we are making progress here and should do better in the near future.

We’ve been trying to get both physicians and patients to face up to the complexity of screening for years. This holds true for screening for any disease. This paper should help a bit.

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