Archive for July, 2014

The Medical Student Who Wants to Bring Down Dr. Oz

Wednesday, July 23, 2014 // Uncategorized

Dr. Oz is a TV personality who I described as an alchemist.  He spins
BS into gold.  He is dangerous because he seamlessly mixes fact and fantasy.  The uninformed viewer can’t discern which is which.

Meet the medical student who wants to bring down Dr. Oz

Updated by on July 12, 2014, 8:50 a.m. ET @juliaoftoronto [email protected]

<img src=”http://cdn1.vox-cdn.com/uploads/chorus_image/image/35603312/151703553.0_standard_234.0.jpg” alt=””/>
NBC NewsWire

Benjamin Mazer is a third-year medical student at the University of Rochester. Last year, after becoming increasingly concerned with the public-health impact of Dr. Mehmet Oz’s sometimes pseudoscience health advice, he decided to ask state and national medical associations to do something about it.

“Dr. Oz has something like 4-million viewers a day,” Mazer told Vox. “The average physician doesn’t see a million patients in their lifetime. That’s why organized medicine should be taking action.”

Last year, Mazer brought a policy before the Medical Society of the State of New York—where Dr. Oz is licensed—requesting that they consider regulating the advice of famous physicians in the media. His idea: Treat health advice on TV in the same vein as expert testimony, which already has established guidelines for truthfulness. I asked Mazer about what inspired the policy, and what became of his efforts.

 

“Dr. Oz has something like 4-million viewers a day. the average physician doesn’t see a million patients in their lifetime.”

Julia Belluz: So you’re the medical student who wants to bring down Dr. Oz?

Benjamin Mazer: I’m definitely not the only one. This issue was brought up by a number of physicians I worked with during my family medicine clerkship. We had all of this first-hand experience with patients who really liked his show and trusted him quite a bit. [Dr. Oz] would give advice that was really not great or it had no medical basis. It might sound harmless when you talk about things like herbal pills or supplements. But when the physicians’ advice conflicted with Oz, the patients would believe Oz.

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JB: Tell me about the policy you proposed. How did doctors react?

BM: I wrote policy for the Medical Society of the State of New York [where Dr. Oz is licensed] and the American Medical Association asking them to more actively address medical quackery on TV and in the media—specifically Dr. Oz.

The New York policy was passed in modified form. Organized medicine in New York is aware of what Dr. Oz is saying and how he is able to fall through the gaps of regulation. Many New York physicians testified at their annual meeting about the harm they are seeing happen day-to-day with their own patients. Patients stop taking proven medications in favor of “natural” medications that Dr. Oz promotes. Many patients trusted Dr. Oz more than their own family doctors and this conflict hurt the doctor-patient relationship.

When we brought the policy to the American Medical Association, they reaffirmed existing policy instead of our resolution asking them to take action against inappropriate medical testimonials on TV. The AMA basically thought they were doing enough with existing policy.

JB: Why don’t you think the policy was picked up at the national level?

BM: Organized medicine is a slow beast. Also, some people might be underestimating the harms he’s doing. Many physicians and certainly much of the public often ask, “What’s the harm in an herbal pill or new diet?” The indirect harms can be great.

Organized medicine has an interest in protecting physicians as a profession. They want to maintain the prestige, trust, and income that physicians have historically received in the US. In order to protect the profession as a whole, organized medicine sometimes has to protect individual doctors, even if they are not acting in the best interest of patients. The AMA may fear that undermining Dr. Oz could undermine overall trust in doctors.

JB: Was there a particular patient who inspired this crusade against TV quackery?

BM: The patient who inspired the policy I wrote was an older woman in her 60s who had a lot of the classic, chronic health problems we deal with in America. She was overweight, she had diabetes, heart disease. And so the physician I was working with was recommending these oral diabetes medications that are pretty standard fare. She had watched the Dr. Oz Show featuring green coffee-bean supplements—and how it was great to lose weight—and she was convinced this was going to be a huge impact on her weight.

We tried to politely express concerns that this probably wasn’t going to be effective because there’s no evidence for it. She refused the diabetes medications. The hope she had placed in the green coffee-bean extract was part of that.

JB: What do you think is the impact of Dr. Oz’s sometimes dubious health advice?

BM: I think these things impede the doctor-patient relationship. These doctors are actually doing a great job. But the trust people are placing with Dr. Oz—when their family physicians even nicely try to contradict him—disrupts their relationship.

JB: As a soon-to-be physician, what are you thinking when you hear Dr. Oz say he believes in magic?

BM: The movement in medicine has been toward evidence-based medicine because physicians had done things by their gut and belief for hundreds of years. Most physicians would agree it’s only through the scientific process and evidence that we were able to make huge differences in medical care. It’s insulting to talk about important medical issues and drugs as if it they were a matter of belief. It degrades all that work that has been done.

JB: If you could talk to Dr. Oz, what would you say to him?

BM: I would probably say that he does have the health interest of his viewers in mind. But in the long term, undermining good science and the relationship patients have with their current physicians is probably doing much more harm than good. If they’re not going to listen to advice from physicians—who are providing good, evidence-based advice—if they’re going to listen to other doctors on the show, it’s going to do more harm than good.

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New Battle on Physician Certification

Tuesday, July 22, 2014 // Uncategorized

The following is an article from the Wall Street Journal which covers the power and money play by the American Board of Medical Specialties to require their continuing medical education for physicians. These actions potentially affect hospital privileges and coverage by insurance companies.

Doctors Upset Over Skill Reviews

New Learning Requirement to Maintain Certifications Called Costly, Irrelevant

 By
Melinda Beck
  • July 21, 2014 7:27 p.m. ET

    A new program mandates that physicians take more courses to maintain their board standing. Anesthesiologists practice on a simulator. American Society of Anesthesiologists

    The medical community is embroiled in a bitter debate about what board-certified physicians should be required to do to prove that their knowledge and skills are up-to-date.

    Besides holding a state medical license, about 75% of U.S. doctors are certified by 24 privately run boards, signifying that they have mastered their area of specialty, in fields ranging from internal medicine to orthopedics. The specialty boards require their physicians to pass rigorous exams, generally every 10 years, to stay certified.

    In recent years, those boards also have begun requiring doctors to enroll in official Maintenance of Certification programs in between exams to show they are committed to lifelong learning and quality improvement.

    The American Board of Internal Medicine, the largest specialty board with more than 250,000 members, put its new MOC requirements into effect in January. Internists must earn points every two, five and 10 years by completing so-called modules on medical knowledge and practice assessment, with activities such as surveying patients on their communication skills and reviewing charts to identify ways to improve care. Board officials say the program takes five to 20 hours a year and costs $1,940 over 10 years, including the exam; or $2,260, including recertification in sub-specialties such as cardiology or pulmonology.

    Lois Nora, president of the American Board of Medical Specialties, which oversees the 24 boards, says the public trusts board certification to be the gold standard for physicians, and taking a test every 10 years is no longer sufficient to keep up—especially given the increasing focus on quality measures in health care.

    “Most practicing physicians have not had formal courses in patient safety or quality improvement. MOC is a structured way to make sure that is happening,” she said.

    But in a flurry of angry editorials and letters to newspapers and medical journals, websites and blog posts, many doctors are deriding the MOC requirements as costly, irrelevant and time-consuming, and largely a moneymaking venture for the specialty boards.

    Many contend there is no research showing that the MOC activities improve patient care and complain that they already are overburdened with paperwork, including logging many hours in continuing-education courses required to maintain their medical licenses. Those requirements are set by state medical boards and are separate from specialty-board certification.

    “No one wants to come out and say they’re against quality, but most physicians find these modules to be cumbersome and, frankly, a joke,” said Richard Armstrong, a board-certified surgeon and CEO of Docs4PatientCare, one of several doctors groups opposing MOC.

    Last month, the American Medical Association’s House of Delegates called for an independent evaluation of MOCs’ impact on physicians and patients.

    The American Board of Internal Medicine’s program has come in for particular criticism. Since April, more than 17,000 physicians have signed an online petition calling for the board to waive all its MOC requirements except the exam every 10 years.

    A recent survey by the American College of Cardiology, whose members are almost all board-certified internists, found that 87% opposed the MOC requirements. The American Association of Clinical Endocrinologists, whose members are also internists, expressed “strong concern” that MOC programs are creating a barrier to patient care by monopolizing physician time and driving some to stop practicing rather than comply.

    Richard Baron, CEO of the American Board of Internal Medicine, says some doctors are not as up-to-date as they think they are. The pass rate for internists on the 10-year exam has dropped from 90% five years ago to 65% this year. When they don’t pass the exam, “it’s a wake-up call. And then they study and the ultimate pass rate goes up to 95%,” he notes.

    Many of the MOC activities, he says, are in keeping with new demands on doctors to show quality improvements. “In the past, doctors might be tested on what good glucose numbers are, and what medications to use. Now there is increasing emphasis on knowing, of the patients I saw last year, what percent did I achieve good glucose control in?”

    The Association of American Physicians and Surgeons, a conservative group, has filed suit in federal court charging the American Board of Medical Specialties with restraint of trade. Even though the ABMS notes that maintaining board certification is “voluntary,” many physicians say they have no choice because board certification is often required to have hospital privileges or join insurance networks. Those who decline are listed as “Not Meeting MOC Requirements” on the ABMS website where patients can check doctors’ credentials.

    In a statement, the ABMS said the lawsuit’s claims “are without merit.” The group says over 500,000 of the more than 800,000 board-certified physicians have enrolled in MOC programs to date. Many of the rest are exempt because they were certified before 1990, when the designation was good for life.

    The ABMS also says it has arranged with some 32 major health systems, including the Mayo Clinic and M.D. Anderson Cancer Center, for their own in-house quality-improvement projects to satisfy some MOC requirements for their doctors.

    But physicians in private practices say that leaves them at a disadvantage in complying, without the support of that larger infrastructure. Studying, traveling to distant test sites and review programs and paying other doctors to care for their patients while they are away all add to the cost, they say.

    Some critics fear MOC programs eventually may be required to maintain state medical licenses. But Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, says that fear is unfounded. The federation is devising its own program to stress professional development, called Maintenance of Licensure, and says that MOC could be one way for doctors to meet those goals, depending on what each state board decides. “We are not trying to devise more hoops for physicians to jump through,” Dr. Chaudhry insists.

    State boards also can reject the federation’s Maintenance of Licensure program entirely—and several, including New York, Ohio, Texas and Florida, already have passed resolutions against making it or MOC a condition of licensure

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    Niacin Fails Again

    Wednesday, July 16, 2014 // Uncategorized

    Raising HDL (high density lipoprotein) AKA “good cholesterol” has been the holy grail of treating heart disease for years.  The problem is that there is no proof that making the number higher translates to fewer heart attacks.  There is ample proof that lowering LDL (low density lipoprotein) AKA “bad cholesterol” with statin medication does.  Here is an editorial from today’s New England Journal of Medicine which summarizes the findings of an article which should put the nail in the coffin of routine niacin use.

    Niacin and HDL Cholesterol — Time to Face Facts

    Donald M. Lloyd-Jones, M.D.

    N Engl J Med 2014; 371:271-273July 17, 2014DOI: 10.1056/NEJMe1406410

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    Article

    For the past four decades, the concentration of cholesterol contained in high-density lipoprotein (HDL) particles has been a major focus of research and a target for potential prevention opportunities. Data from observational epidemiologic studies have consistently shown a strong inverse association between HDL cholesterol concentration and the risk of coronary heart disease that is linear and graded, at least through the majority of the HDL cholesterol distribution encountered in the general population.1 But clinical trials have yet to show a causal role for HDL cholesterol or to deliver the longed-for outcome of reducing the risk of coronary heart disease and the broader cardiovascular risk by raising HDL cholesterol levels specifically.

    Niacin, or nicotinic acid (also known as vitamin B3), is an essential human nutrient that increases HDL cholesterol concentrations by means of a variety of mechanisms affecting apolipoprotein A1, cholesterol ester transfer protein, and ATP-binding cassette transporter A1, all of which appear to enhance reverse cholesterol transport. Other effects of niacin also lead to modest reductions in low-density lipoprotein (LDL) cholesterol concentrations and more substantial reductions in triglyceride levels, all of which might be expected to have salutary effects on the risk of coronary heart disease. The earliest trial to test immediate-release niacin, the Coronary Drug Project, suggested that this might be the case among middle-aged men with coronary heart disease and marked hypercholesterolemia.2

    In this issue of the Journal, the Heart Protection Study 2–Treatment of HDL to Reduce the Incidence of Vascular Events (HPS2-THRIVE) investigators present data from the latest and largest trial to examine a strategy of raising the HDL cholesterol level to reduce cardiovascular risk.3 This rigorously performed randomized, controlled trial enrolled 25,673 adults, 50 to 80 years of age, with clinically manifest cardiovascular disease and addressed the clinically relevant question of whether extended-release niacin combined with laropiprant, a new agent that helps prevent flushing, could reduce major vascular events, as compared with placebo. Background statin-based therapy was standardized before randomization, resulting in a mean LDL cholesterol level of 63 mg per deciliter (1.63 mmol per liter) before study-drug treatment. During the trial, participants receiving niacin–laropiprant on average had an HDL cholesterol level that was 6 mg per deciliter (0.16 mmol per liter) higher, an LDL cholesterol level that was 10 mg per deciliter (0.26 mmol per liter) lower, and a triglyceride level that was 33 mg per deciliter (0.37 mmol per liter) lower than levels in those receiving placebo. Despite these favorable responses, over a median follow-up of nearly 4 years there was no significant reduction in the primary end point of major vascular events associated with niacin–laropiprant, with a rate ratio of 0.96 (95% confidence interval, 0.90 to 1.03). The lack of efficacy was uniform, with no substantive differences in response to therapy noted across the major prespecified subgroups.

    Given this lack of efficacy, the most important and worrisome findings of HPS2-THRIVE were the adverse events associated with niacin–laropiprant. In addition to the expected skin-related adverse effects, there were significant and excess adverse events related to gastrointestinal, musculoskeletal, infectious, and bleeding complications, as well as substantial excess adverse events related to loss of glycemic control among persons with diabetes and new-onset diabetes among persons without diabetes at baseline. Of great concern was a 9% increase in the risk of death (number needed to harm, 200) associated with niacin–laropiprant that was of borderline statistical significance (P=0.08).

    Also in this issue of the Journal, further data are provided by Anderson et al.4 regarding adverse events in the Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes (AIM-HIGH) trial,5 which had examined the addition of extended-release niacin versus placebo to statin therapy in 3414 patients with stable atherosclerotic disease and a low HDL cholesterol level. The AIM-HIGH investigators had found no benefit in terms of a reduction in cardiovascular risk with niacin, but they also had observed excess adverse events including skin-related, gastrointestinal, glycemic, and other complications typically associated with niacin use.5 The new data from the study by Anderson et al. suggest a significantly higher rate of infections and infestations among patients receiving niacin than among those receiving placebo, as well as a nonsignificantly higher rate of serious bleeding, in the AIM-HIGH trial, which was much smaller than HPS2-THRIVE.

    It should be noted that the exhaustive systematic review of the literature performed by the recent American College of Cardiology–American Heart Association (ACC–AHA) cholesterol guideline panel identified many of these same niacin-related adverse events (in addition to excess atrial fibrillation). This assessment led to very limited and cautious recommendations regarding the use of niacin and extensive discussion of safety concerns in those guidelines.6 Whereas some debate about the role of laropiprant in the excess adverse events observed in HPS2-THRIVE is warranted, the larger size of HPS2-THRIVE and the consistency of the overall findings with earlier trials of niacin alone suggest that niacin is the major problem.

    What now should we make of niacin and the HDL cholesterol causation hypothesis? On the basis of the weight of available evidence showing net clinical harm, niacin must be considered to have an unacceptable toxicity profile for the majority of patients, and it should not be used routinely. As suggested in the recent ACC–AHA guidelines,6 niacin may still have a role in patients at very high risk for cardiovascular events who truly have contraindications for taking statins (and other less-toxic drugs, such as bile-acid sequestrants) and who have a high LDL cholesterol level. Likewise, it might be considered as a fourth-line agent (after intensive lifestyle modification and use of fibric-acid derivatives and pharmaceutical-grade fish-oil preparations) for patients with severe hypertriglyceridemia, in whom we are trying to prevent pancreatitis.

    The consistent findings of a lack of benefit of raising the HDL cholesterol level with the use of niacin when added to effective LDL cholesterol–lowering therapy with statins seriously undermine the hypothesis that HDL cholesterol is a causal risk factor. The failure (to date) of cholesteryl ester transfer protein inhibitors, such as torcetrapib and dalcetrapib, to show any reduction in cardiovascular risk despite the marked increases in the HDL cholesterol level associated with these drugs7,8 lends further credence to the notion that HDL cholesterol is unlikely to be causal. Finally, compelling data from a large mendelian randomization study9 also argue that the HDL cholesterol level has a role solely as a risk marker and not a risk factor that merits intervention to reduce cardiovascular events. Although higher HDL cholesterol levels are associated with better outcomes, it is time to face the fact that increasing the HDL cholesterol level in isolation seems unlikely to offer the same benefit.

    Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

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