When More Medicine Is Less
A Dartmouth study finds a greater risk of death among patients treated in high-cost hospitals and clinics -- and highlights conflicts of interest
COVER STORY
By John Carey
BusinessWeek, MAY 29, 2006
Getting more medical care, and paying more for it, can actually make your health worse. That's the paradoxical conclusion of Dartmouth Medical School's Dr. Elliot S. Fisher. He found that the amount spent per person on health care varies dramatically in different parts of the country. Southern California is high cost, for instance, while Northern California is low cost. Spending is high in the Boston area, and low in Western Massachusetts and Minnesota.
Fisher originally expected to find that people in areas with more healthcare would be healthier and longer-lived. The opposite was true. "If anything, it looks like there is a substantially increased risk of death if cared for in high-cost systems," he says. The reason: The additional tests and procedures in the high-cost areas bring more risks than benefits. "A large portion of those extra costs are due just to proximity to health care," says George Bennett, CEO of Health Dialog Analytic Solutions, which tries to get unbiased information to patients. "Not all those expenditures are optimal or even appropriate."
Why does this happen? Clearly, one huge underlying cause is money. The way the U.S. health-care system is structured offers doctors, hospitals, and companies enormous financial incentives to provide more and more care. Surgeons will get paid if they do a bypass operations, insert ear tubes in children, or take out a prostate. If they recommend waiting or doing drug therapy instead, there's no payday.
"You get paid for operating and not paid for not operating," says Dr. Jack Paradise, a professor of pediatrics and otolaryngology at the Pittsburgh School of Medicine and Children's Hospital of Pittsburgh. "Conflict of interest is hard to rule out."
POTENTIAL CONFLICTS. Similarly, hospitals get higher revenues if they put more patients in their new catheter labs or operating rooms. This isn't to say financial considerations outweigh medical choices. But studies have shown wide variations in the amount of care among hospitals -- and again, more care doesn't bring better results.
Researchers at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School have looked in detail at what happens in the last six months of life at 77 top hospitals in the U.S. The results were startling: The average number of days spent in the hospital during the last six months of life was 10.1 days at Stanford University hospital compared to 27.1 days at New York University Medical Center. The average number of doctors visits ranged from 17.6 to 76.2, with NYU at the top.
Yet there's no evidence that the more intensive care brings better outcomes or quality of life. In fact, the researchers suggest, the opposite is true. "The problem is not underuse in low-rate regions and hospitals, but overuse and inefficiency in high-rate regions," concludes Dr. John E. Wennberg, professor of medicine and director of Dartmouth's Center for the Evaluative Clinical Sciences.
The potential conflicts of interest are even starker with drug and medical device makers. The pharmaceutical and device industries are, after all, businesses. Like any businesses, they would be remiss in their duty to shareholders if they didn't try to sell as many of their products as possible.
GOVERNMENT CONCERN. Health care is different from, say, selling cars. No one is hurt if people buy one car over another, or more cars than they need. But for all their benefits, drugs have dangers. Taking the wrong one, or the wrong combination, or too high a dose, or one that's not needed, does hurt people -- and raises health care costs unnecessarily.
That's why the Food & Drug Administration puts curbs on the marketing practices of companies. But because of the huge amounts of money that come with increased sales, they have every incentive to push the envelope when it comes to marketing. As a result, they often work to turn ordinary conditions, like jittery legs, into "diseases" that need treatment (see BW Online, 05/08/06, "Hey, You Don't Look So Good").
They woo doctors with free samples, gifts, trips, and other enticements to prescribe more drugs and use additional devices. A recent lawsuit, for instance, accuses Medtronic (MDT ) of handing hundreds of thousands of dollars for minimal work to prominent back surgeons who are in a position to boost use of the company's spinal-implants. Medtronic spokesman Rob Clark notes that these are allegations. "We do not tolerate any kind of conduct that is unethical...or violate the law," he says.
BOTTOM-LINE BIAS. In another case, Warner-Lambert, a part of Pfizer, (PFE ) was ordered to pay $430 million after pleading guilty to charges of illegally marketing its epilepsy drug, Neurontin, for unapproved uses. The company aggressively pushed the drug for conditions like bipolar disorder, back pain, and headache -- for which there was little or no evidence of effectiveness.
The marketing campaigns, which included trips and big "speaker" fees to doctors, turned the drug into a blockbuster, with billions of dollars in sales per year. But while the practices fattened the company's bottom line, many patients may have been hurt by unnecessary use of the drug, which lawsuits allege can cause suicidal thoughts, tumors, and convulsions.
These powerful financial incentives make it that much harder to get the right treatments and the right amount of care to Americans.
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Thursday, October 19, 2006
Medicine's Industrial Revolution
Medicine's Industrial Revolution
COVER STORY
By Howard Gleckman, with John Carey
BusinessWeek, MAY 29, 2006
Sometimes medicine performs just as it should. Vaccines have banished smallpox. Surgery can cure early-stage colon cancer. But the disturbing truth is treatments that are proven to work reach only about half of the Americans who need them, according to a series of studies by RAND Corp. And in hospitals, simple measures that protect patients' lives are often hard to implement.
Hygiene is a good example. For 150 years we have known that doctors with unwashed hands pass infections from patient to patient. The Centers for Disease Control & Prevention figures that 80% of hospital-acquired infections are transmitted this way, costing billions of dollars annually to treat and killing thousands of people.
With this in mind, the University of Pittsburgh Medical Center's Presbyterian Hospital installed alcohol-wash dispensers in every room and allowed nurses to ban doctors who don't wash up from entering patients' rooms. Yet more than one-quarter of UPMC's doctors still haven't gotten the message, says Chief Medical Officer Loren H. Roth. Things have improved in recent years, "but a lot of physicians and residents are still not complying," he says.
One major cause for such huge gaps in care is that financial incentives can be skewed. Insurance companies, which have learned that high infection rates cost them money, are beginning to provide bonuses to encourage hospitals to make big improvements. Highmark Inc., which operates the Blue Cross/Blue Shield plans in Pittsburgh, will give UPMC $10 million this year for lowering infections.
But doctors don't have the same incentives. They are usually not hospital employees and are paid based on the number of patients they see and procedures they do. Repeatedly stopping to wash up may slow them down and cost them money. That has hospitals such as UPMC as well as private insurance companies and Medicare scrambling for new ideas. "How do we align incentives so we pay more for prevention than for solving the disaster after it happens?" asks Donald R. Fischer, chief medical officer at Highmark.
UPMC's Roth says that improving the quality of care may also mean challenging a bedrock belief: that each patient is unique and that doctors must bring individualized judgment to each case. This view "has a kind of appeal to it for both the profession and patients," says Roth, "but it is not so." Most illnesses and injuries can best be treated by standardizing care, he argues. The goal is to "industrialize every process we can."
This idea horrifies some doctors, but businesses and insurance companies, who pay many of the bills, are cheering Roth on. "We know if you take beta blockers, you are much less likely to have a heart attack," explains Helen Darling, president of the Washington-based National Business Group on Health, which represents major employers. "We can reward you for meeting those standards."
Independence Blue Cross has gone a step further. It gives physicians lists of members with chronic conditions such as diabetes and asthma. The list includes the recommended treatments and tells who has received them. "Then when a patient shows up, the missing services can be provided," explains Dr. I. Steven Udvarhelyi, senior vice-president at the insurer. Doctors, who were leery at first, have embraced the plan.
Of course, you have to get people into physicians' offices. To do this, several health plans and companies have teamed up with Health Dialog Analytic Solutions, which identifies employees or plan members with the greatest needs and reaches out through phone calls and mailings. "The touch is very soft," says Joe Checkley, director of global benefits at American Standard Cos (ASD ). "It's saying: 'Here are some tools for you, and what can I do to help?"'
The early results are good. At Independence Blue Cross, with about 2 million members, "we know that the program overall reduces medical costs by about 2%," says Udvarhelyi. "That's for the entire population, not just the people that we touch. For them the reduction is orders of magnitude larger." With efforts like these, treatments that do work are now getting to more of the people who need them.
Read article at the original source
COVER STORY
By Howard Gleckman, with John Carey
BusinessWeek, MAY 29, 2006
Sometimes medicine performs just as it should. Vaccines have banished smallpox. Surgery can cure early-stage colon cancer. But the disturbing truth is treatments that are proven to work reach only about half of the Americans who need them, according to a series of studies by RAND Corp. And in hospitals, simple measures that protect patients' lives are often hard to implement.
Hygiene is a good example. For 150 years we have known that doctors with unwashed hands pass infections from patient to patient. The Centers for Disease Control & Prevention figures that 80% of hospital-acquired infections are transmitted this way, costing billions of dollars annually to treat and killing thousands of people.
With this in mind, the University of Pittsburgh Medical Center's Presbyterian Hospital installed alcohol-wash dispensers in every room and allowed nurses to ban doctors who don't wash up from entering patients' rooms. Yet more than one-quarter of UPMC's doctors still haven't gotten the message, says Chief Medical Officer Loren H. Roth. Things have improved in recent years, "but a lot of physicians and residents are still not complying," he says.
One major cause for such huge gaps in care is that financial incentives can be skewed. Insurance companies, which have learned that high infection rates cost them money, are beginning to provide bonuses to encourage hospitals to make big improvements. Highmark Inc., which operates the Blue Cross/Blue Shield plans in Pittsburgh, will give UPMC $10 million this year for lowering infections.
But doctors don't have the same incentives. They are usually not hospital employees and are paid based on the number of patients they see and procedures they do. Repeatedly stopping to wash up may slow them down and cost them money. That has hospitals such as UPMC as well as private insurance companies and Medicare scrambling for new ideas. "How do we align incentives so we pay more for prevention than for solving the disaster after it happens?" asks Donald R. Fischer, chief medical officer at Highmark.
UPMC's Roth says that improving the quality of care may also mean challenging a bedrock belief: that each patient is unique and that doctors must bring individualized judgment to each case. This view "has a kind of appeal to it for both the profession and patients," says Roth, "but it is not so." Most illnesses and injuries can best be treated by standardizing care, he argues. The goal is to "industrialize every process we can."
This idea horrifies some doctors, but businesses and insurance companies, who pay many of the bills, are cheering Roth on. "We know if you take beta blockers, you are much less likely to have a heart attack," explains Helen Darling, president of the Washington-based National Business Group on Health, which represents major employers. "We can reward you for meeting those standards."
Independence Blue Cross has gone a step further. It gives physicians lists of members with chronic conditions such as diabetes and asthma. The list includes the recommended treatments and tells who has received them. "Then when a patient shows up, the missing services can be provided," explains Dr. I. Steven Udvarhelyi, senior vice-president at the insurer. Doctors, who were leery at first, have embraced the plan.
Of course, you have to get people into physicians' offices. To do this, several health plans and companies have teamed up with Health Dialog Analytic Solutions, which identifies employees or plan members with the greatest needs and reaches out through phone calls and mailings. "The touch is very soft," says Joe Checkley, director of global benefits at American Standard Cos (ASD ). "It's saying: 'Here are some tools for you, and what can I do to help?"'
The early results are good. At Independence Blue Cross, with about 2 million members, "we know that the program overall reduces medical costs by about 2%," says Udvarhelyi. "That's for the entire population, not just the people that we touch. For them the reduction is orders of magnitude larger." With efforts like these, treatments that do work are now getting to more of the people who need them.
Read article at the original source
Medical Guesswork | A Lumpectomy May Do It
Medical Guesswork | A Lumpectomy May Do It
BusinessWeek, May 29, 2006
For Jeanine Whitney, the diagnosis of breast cancer last June was bad enough. But when her doctor told her that her best chance was an immediate mastectomy, "I cried for 24 hours. I felt that part of my womanhood would have been taken," says Whitney, who works at an air conditioner factory in Rushville, Ind. Her employer, American Standard Cos., had a program to provide workers with unbiased information about the risks and benefits of potential treatments. Thanks to the program, Whitney learned that there was no evidence that a mastectomy would have a better outcome than a lumpectomy, provided the tissue around the lump was clear of cancer. Twenty years after treatment, the outcomes were the same, according to studies. "It was a total surprise," she recalls. She requested a lumpectomy, which was carried out in July, followed by seven weeks of radiation and six of recovery. Now, Whitney is grateful that she was able to get the information she needed to buck her doctor's recommendation. If Whitney had had to make a decision without that, she says she would have "ended up in the psychiatric ward."
Read article at the original source
BusinessWeek, May 29, 2006
For Jeanine Whitney, the diagnosis of breast cancer last June was bad enough. But when her doctor told her that her best chance was an immediate mastectomy, "I cried for 24 hours. I felt that part of my womanhood would have been taken," says Whitney, who works at an air conditioner factory in Rushville, Ind. Her employer, American Standard Cos., had a program to provide workers with unbiased information about the risks and benefits of potential treatments. Thanks to the program, Whitney learned that there was no evidence that a mastectomy would have a better outcome than a lumpectomy, provided the tissue around the lump was clear of cancer. Twenty years after treatment, the outcomes were the same, according to studies. "It was a total surprise," she recalls. She requested a lumpectomy, which was carried out in July, followed by seven weeks of radiation and six of recovery. Now, Whitney is grateful that she was able to get the information she needed to buck her doctor's recommendation. If Whitney had had to make a decision without that, she says she would have "ended up in the psychiatric ward."
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Medical Guesswork | Bypass That Operation?
Medical Guesswork | Bypass That Operation?
BusinessWeek, May 29, 2006
Each year doctors perform 400,000 bypass surgeries and 1 million angioplasties, where mesh tubes are placed in diseased arteries to hold them open. While most people believe that such surgery is life-saving, the available data say otherwise. Except for about 3% of people with severe heart disease, treatment with drugs alone works just as well to extend life and prevent heart attacks as surgery does.
"Cardiologists like to open up arteries," says Dr. David D. Waters, chief of cardiology at San Francisco General Hospital. "But there is no evidence that opening up chronically narrowed arteries reduces the risk of heart attack." Harvard Medical School's Dr. Roger J. Laham figures that at least 400,000 angioplasties a year are unnecessary. "I'm sure we are way overtreating our patients," he says. Surgery carries big risks, such as mental declines after bypass operations. The overuse is exacting a big toll on individual patients and the health-care system, argue such experts as Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill.
Read article at the original source
BusinessWeek, May 29, 2006
Each year doctors perform 400,000 bypass surgeries and 1 million angioplasties, where mesh tubes are placed in diseased arteries to hold them open. While most people believe that such surgery is life-saving, the available data say otherwise. Except for about 3% of people with severe heart disease, treatment with drugs alone works just as well to extend life and prevent heart attacks as surgery does.
"Cardiologists like to open up arteries," says Dr. David D. Waters, chief of cardiology at San Francisco General Hospital. "But there is no evidence that opening up chronically narrowed arteries reduces the risk of heart attack." Harvard Medical School's Dr. Roger J. Laham figures that at least 400,000 angioplasties a year are unnecessary. "I'm sure we are way overtreating our patients," he says. Surgery carries big risks, such as mental declines after bypass operations. The overuse is exacting a big toll on individual patients and the health-care system, argue such experts as Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill.
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Medical Guesswork | Leave Those Ears Alone
Leave Those Ears Alone
BusinessWeek, May 29, 2006
In the 1950s, kids routinely got their tonsils taken out. Then physicians such as Dr. Jack L. Paradise of the University of Pittsburgh School of Medicine showed that the procedure brought no benefits to most children.
In a study published last August, Paradise took on another common treatment: implanting tubes to drain the fluid in children's ears -- thought to hamper hearing and slow language development. Children with fluid do tend to have more speech problems. But Paradise believes the two conditions have a common cause: poor living conditions. "Medicine is fraught with error when people assume correlation is causality," he says. So Paradise did a study of 6,000 babies. By age three, 429 had persistent fluid in their ears. Half got ear tubes, the other half didn't -- and there was no difference in outcomes between the two groups.
Paradise's advice to parents of such kids: "Don't just do something. Sit there." Many doctors still perform the surgery, however. "People are reluctant to believe our results," Paradise says. Why? "You get paid for operating and not paid for not operating."
Read article at the original source
BusinessWeek, May 29, 2006
In the 1950s, kids routinely got their tonsils taken out. Then physicians such as Dr. Jack L. Paradise of the University of Pittsburgh School of Medicine showed that the procedure brought no benefits to most children.
In a study published last August, Paradise took on another common treatment: implanting tubes to drain the fluid in children's ears -- thought to hamper hearing and slow language development. Children with fluid do tend to have more speech problems. But Paradise believes the two conditions have a common cause: poor living conditions. "Medicine is fraught with error when people assume correlation is causality," he says. So Paradise did a study of 6,000 babies. By age three, 429 had persistent fluid in their ears. Half got ear tubes, the other half didn't -- and there was no difference in outcomes between the two groups.
Paradise's advice to parents of such kids: "Don't just do something. Sit there." Many doctors still perform the surgery, however. "People are reluctant to believe our results," Paradise says. Why? "You get paid for operating and not paid for not operating."
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Medical Guesswork | Curing Without Cutting
Medical Guesswork | Curing Without Cutting
BusinessWeek, May 29, 2006
Can you trust your doctor's recommendation to have surgery for an aching back? Make sure you have all the facts. Evidence says surgery does not fix the problem over the long term any better than time, physical therapy, and exercise. Indeed, says University of North Carolina's Dr. Nortin M. Hadler, pain clinics are full of people who have had back surgery and now are worse off. Geographic data suggest that such procedures may be a fad. In people with identical symptoms, operations like spinal fusion are performed 20 times as often in some parts of the U.S. as in others. 'Spinal fusion is the most variable condition in all of medicine,' says Dr. James N. Weinstein, editor of Spine magazine and chair of orthopedic surgery at Dartmouth.
Curing Without Cutting
Can you trust your doctor's recommendation to have surgery for an aching back? Make sure you have all the facts. Evidence says surgery does not fix the problem over the long term any better than time, physical therapy, and exercise. Indeed, says University of North Carolina's Dr. Nortin M. Hadler, pain clinics are full of people who have had back surgery and now are worse off. Geographic data suggest that such procedures may be a fad. In people with identical symptoms, operations like spinal fusion are performed 20 times as often in some parts of the U.S. as in others. 'Spinal fusion is the most variable condition in all of medicine,' says Dr. James N. Weinstein, editor of Spine magazine and chair of orthopedic surgery at Dartmouth."
Read article at the original source
BusinessWeek, May 29, 2006
Can you trust your doctor's recommendation to have surgery for an aching back? Make sure you have all the facts. Evidence says surgery does not fix the problem over the long term any better than time, physical therapy, and exercise. Indeed, says University of North Carolina's Dr. Nortin M. Hadler, pain clinics are full of people who have had back surgery and now are worse off. Geographic data suggest that such procedures may be a fad. In people with identical symptoms, operations like spinal fusion are performed 20 times as often in some parts of the U.S. as in others. 'Spinal fusion is the most variable condition in all of medicine,' says Dr. James N. Weinstein, editor of Spine magazine and chair of orthopedic surgery at Dartmouth.
Curing Without Cutting
Can you trust your doctor's recommendation to have surgery for an aching back? Make sure you have all the facts. Evidence says surgery does not fix the problem over the long term any better than time, physical therapy, and exercise. Indeed, says University of North Carolina's Dr. Nortin M. Hadler, pain clinics are full of people who have had back surgery and now are worse off. Geographic data suggest that such procedures may be a fad. In people with identical symptoms, operations like spinal fusion are performed 20 times as often in some parts of the U.S. as in others. 'Spinal fusion is the most variable condition in all of medicine,' says Dr. James N. Weinstein, editor of Spine magazine and chair of orthopedic surgery at Dartmouth."
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Medical Guesswork - the health industry knows little about which common treatments really work
Medical Guesswork
From heart surgery to prostate care, the health industry knows little about which common treatments really work
By John Carey
BusinessWeek, MAY 29, 2006
COVER STORY
The signs at the meeting were not propitious. Half the board members of Kaiser Permanente's Care Management Institute left before Dr. David Eddy finally got the 10 minutes he had pleaded for. But the message Eddy delivered was riveting. With a groundbreaking computer simulation, Eddy showed that the conventional approach to treating diabetes did little to prevent the heart attacks and strokes that are complications of the disease. In contrast, a simple regimen of aspirin and generic drugs to lower blood pressure and cholesterol sent the rate of such incidents plunging. The payoff: healthier lives and hundreds of millions in savings. "I told them: 'This is as good as it gets to improve care and lower costs, which doesn't happen often in medicine,"' Eddy recalls. "'If you don't implement this,' I said, 'you might as well close up shop."'
The message got through. Three years later, Kaiser is in the midst of a major initiative to change the treatment of the diabetics in its care. "We're trying to put nearly a million people on these drugs," says Dr. Paul Wallace, senior adviser to the Care Management Institute. The early results: The strategy is indeed improving care and cutting costs, just as Eddy's model predicted.
For Eddy, this is one small step toward solving the thorniest riddle in medicine -- a dark secret he has spent his career exposing. "The problem is that we don't know what we are doing," he says. Even today, with a high-tech health-care system that costs the nation $2 trillion a year, there is little or no evidence that many widely used treatments and procedures actually work better than various cheaper alternatives.
This judgment pertains to a shocking number of conditions or diseases, from cardiovascular woes to back pain to prostate cancer. During his long and controversial career proving that the practice of medicine is more guesswork than science, Eddy has repeatedly punctured cherished physician myths. He showed, for instance, that the annual chest X-ray was worthless, over the objections of doctors who made money off the regular visit. He proved that doctors had little clue about the success rate of procedures such as surgery for enlarged prostates. He traced one common practice -- preventing women from giving birth vaginally if they had previously had a cesarean -- to the recommendation of one lone doctor. Indeed, when he began taking on medicine's sacred cows, Eddy liked to cite a figure that only 15% of what doctors did was backed by hard evidence.
A great many doctors and health-care quality experts have come to endorse Eddy's critique. And while there has been progress in recent years, most of these physicians say the portion of medicine that has been proven effective is still outrageously low -- in the range of 20% to 25%. "We don't have the evidence [that treatments work], and we are not investing very much in getting the evidence," says Dr. Stephen C. Schoenbaum, executive vice-president of the Commonwealth Fund and former president of Harvard Pilgrim Health Care Inc. "Clearly, there is a lot in medicine we don't have definitive answers to," adds Dr. I. Steven Udvarhelyi, senior vice-president and chief medical officer at Pennsylvania's Independence Blue Cross.
What's required is a revolution called "evidence-based medicine," says Eddy, a heart surgeon turned mathematician and health-care economist. Tall, lean, and fit at 64, Eddy has the athletic stride and catlike reflexes of the ace rock climber he still is. He also exhibits the competitive drive of someone who once obsessively recorded his time on every training run, and who still likes to be first on a brisk walk up a hill near his home in Aspen, Colo. In his career, he has never been afraid to take a difficult path or an unpopular stand. "Evidence-based" is a term he coined in the early 1980s, and it has since become a rallying cry among medical reformers. The goal of this movement is to pierce the fog that envelops the practice of medicine -- a state of ignorance for which doctors cannot really be blamed. "The limitation is the human mind," Eddy says. Without extensive information on the outcomes of treatments, it's fiendishly difficult to know the best approach for care.
The human brain, Eddy explains, needs help to make sense of patients who have combinations of diseases, and of the complex probabilities involved in each. To provide that assistance, Eddy has spent the past 10 years leading a team to develop the computer model that helped him crack the diabetes puzzle. Dubbed Archimedes, this program seeks to mimic in equations the actual biology of the body, and make treatment recommendations as well as figure out what each approach costs. It is at least 10 times "better than the model we use now, which is called thinking," says Dr. Richard Kahn, chief scientific officer at the American Diabetes Assn.
WASTED RESOURCES
Can one computer program offset all the ill-advised treatment options for a whole range of different diseases? The milestones in Eddy's long personal crusade highlight the looming challenges, and may offer a sliver of hope. Coming from a family of four generations of doctors, Eddy went to medical school "because I didn't know what else to do," he confesses. As a resident at Stanford Medical Center in the 1970s, he picked cardiac surgery because "it was the biggest hill -- the glamour field."
But he soon became troubled. He began to ask if there was actual evidence to support what doctors were doing. The answer, he was surprised to hear, was no. Doctors decided whether or not to put a patient in intensive care or use a combination of drugs based on their best judgment and on rules and traditions handed down over the years, as opposed to real scientific proof. These rules and judgments weren't necessarily right. "I concluded that medicine was making decisions with an entirely different method from what we would call rational," says Eddy.
About the same time, the young resident discovered the beauty of mathematics, and its promise of answering medical questions. In just a couple of days, he devoured a calculus textbook (now framed on a shelf in his beautifully appointed home and office), then blasted through the books for a two-year math course in a couple of months. Next, he persuaded Stanford to accept him in a mathematically intense PhD program in the Engineering-Economics Systems Dept. "Dave came in -- just this amazing guy," recalls Richard Smallwood, then a Stanford professor. "He had decided he wanted to spend the rest of his life bringing logic and rationality to the medical system, but said he didn't have the math. I said: 'Why not just take it?' So he went out and aced all those math courses."
To augment his wife's earnings while getting his PhD, Eddy landed a job at Xerox Corp.'s (XRX ) legendary Palo Alto Research Center. "They hired weird people," he says. "Here was a heart surgeon doing math. That was weird enough."
Eddy used his newfound math skills to model cancer screening. His Stanford PhD thesis made front-page news in 1980 by overturning the guidelines of the time. It showed that annual chest X-rays and yearly Pap smears for women at low risk of cervical cancer were a waste of resources, and it won the most prestigious award in the field of operations research, the Frederick W. Lanchester prize. Based on his results, the American Cancer Society changed its guidelines. "He's smart as hell, with a towering clarity of thought," says Stanford health economist Allan Enthoven.
Dr. William H. Herman, director of the Michigan Diabetes Research & Training Center, has a competing computer model that clashes with Eddy's. Nonetheless, he says, "Dr. Eddy is one of my heroes. He's sort of the father of health economics -- and he might be right."
Appointed a full professor at Stanford, then recruited as chairman of the Center for Health Policy Research & Education at Duke University, Eddy proved again and again that the emperor had no clothes. In one study, he ferreted out decades of research evaluating treatment of high pressure in the eyeball, a condition that can lead to glaucoma and blindness. He found about a dozen studies that looked at outcomes with pressure-lowering medications used on millions of people. The studies actually suggested that the 100-year-old treatment was harmful, causing more cases of blindness, not fewer.
Eddy submitted a paper to the Journal of the American Medical Assn. (JAMA), whose editors sent it out to specialists for review. "It was amazing," Eddy recalls. "The tom-toms sounded among all the ophthalmologists," who marshaled a counterattack. "I felt like Salman Rushdie." Stanford ophthalmologist Kuldev Singh says: "Dr. Eddy challenged the community to prove that we actually had evidence. He did a service by stimulating clinical trials," which showed that the treatment does slow the disease in a minority of patients.
By 1985, Eddy was "burned out" by the administrative side of academia, he says. Lured by a poster of the Tetons, he gave up his prestigious post. He moved to Jackson, Wyo., so he could climb in his spare time. He and a friend even made a first ascent of a new route on the Grand Teton, now named after them. Meanwhile, he carved out a niche showing doctors at specialty society meetings that their cherished beliefs were dubious. "At each meeting I would do the same exercise," he says. He would ask doctors to think of a typical patient and typical treatment, then write down the results of that treatment. For urologists, for instance, what were the chances that a man with an enlarged prostate could urinate normally after having corrective surgery? Eddy then asked the society's president to read the predictions.
The results were startling. The predictions of success invariably ranged from 0% to 100%, with no clear pattern. "All the doctors were trying to estimate the same thing -- and they all gave different numbers," he says. "I've spent 25 years proving that what we lovingly call clinical judgment is woefully outmatched by the complexities of medicine." Think about the implications for helping patients make decisions, Eddy adds. "Go to one doctor, and get one answer. Go to another, and get a different one." Or think about expert testimony. "You don't have to hire an expert to lie. You can just find one who truly believes the number you want."
More important, the lack of evidence creates a costly clash. Americans and their doctors want access to any new treatment, and many doctors fervently believe such care is warranted. On the other hand, those beliefs can be flat wrong. As a consultant on Blue Cross's insurance coverage decisions, Eddy testified on the insurer's behalf in high-profile court cases, such as bone marrow transplants for breast cancer. Women and doctors demanded the treatment, even though there was no evidence it saved lives. Insurers who refused coverage usually lost in court. "I was the bad guy," Eddy recalls. When clinical trials were actually done, they showed that the treatment, costing from $50,000 to $150,000, didn't work. The doctors who pushed the painful, risky procedure on women "owe this country an apology," Eddy says.
Is medicine doing any better today? In recognizing the problem, yes. But in solving it, unfortunately, no. Take prostate cancer. Doctors now routinely test for levels of prostate-specific antigen (PSA) to try to diagnose the disease. But there's no evidence that using the test improves survival. Some experts believe that as many cancers would be detected through random biopsies. Then, once cancer is spotted, there's no way to know who needs treatment and who doesn't. Plus, there is a plethora of treatment choices -- four kinds of surgery, various types of implantable radioactive seeds, and competing external radiation regimens, notes Dr. Eric Klein, head of urologic oncology at the Cleveland Clinic. "How is a poor patient supposed to decide among those?" he asks. Most of the time, patients don't even know the options.
VESTED INTERESTS
"Because there are no definitive answers, you are at the whim of where you are and who you talk to," says Dr. Gary M. Kirsh at the Urology Group in Cincinnati. Kirsh does many brachytherapies -- implanting radioactive seeds. But "if you drive one and a half hours down the road to Indianapolis, there is almost no brachytherapy," he says. Head to Loma Linda, Calif., where the first proton-beam therapy machine was installed, in 1990, and the rates of proton-beam treatment are far higher than in most other parts of the country. Go to a surgeon, and he'll probably recommend surgery. Go to a radiologist, and the chances are high of getting radiation instead. "Doctors often assume that they know what a patient wants, leading them to recommend the treatment they know best," says Dr. David E. Wennberg, president of Health Dialog Analytic Solutions.
More troubling, many doctors hold not just a professional interest in which treatment to offer, but a financial one as well. "There is no question that the economic interests of the physician enter into the decision," says Kirsh. The bottom line: The conventional wisdom in prostate cancer -- that surgery is the gold standard and the best chance for a cure -- is unsustainable. Strangely enough, however, the choice may not matter very much. "There really isn't good evidence to suggest that one treatment is better than another," says Klein.
Compared with the skepticism Eddy faced in the 1990s, many physicians now concur that traditional treatments for serious illnesses often aren't best. Yet this message can be hard for Americans to believe. "When there is more than one medical option, people mistakenly think that the more aggressive procedure is the best," says Annette M. Cormier O'Connor, senior scientist in clinical epidemiology at the Ottawa Health Research Institute. The message flies in the face of America's infatuation with the latest advances. "As a nation, we always want the best, the most recent technology," explains Dr. Joe Thompson, health adviser to Arkansas Governor Mike Huckabee. "We spend a huge amount developing it, and we get a big increase in supply." New radiation machines for cancer or operating rooms for heart surgery are profit centers for hospitals, for instance (see BW Online, 07/18/05, "Is Heart Surgery Worth It?"). Once a hospital installs a shiny new catheter lab, it has a powerful incentive to refer more patients for the procedure. It's a classic case of increased supply driving demand, instead of the other way around. "Combine that with Americans' demand to be treated immediately, and it is a cauldron for overuse and inappropriate use," says Thompson.
The consequences for the U.S. are disturbing. This nation spends 2 1/2 times as much as any other country per person on health care. Yet middle-aged Americans are in far worse health than their British counterparts, who spend less than half as much and practice less intensive medicine, according to a new study. "The investment in health care in the U.S. is just not paying off," argues Gerard Anderson, director of the Center for Hospital Finance & Management at Johns Hopkins' Bloomberg School of Public Health. Speaking not for attribution, the head of health care at one of America's largest corporations puts it more bluntly: "There is a massive amount of spending on things that really don't help patients, and even put them at greater risk. Everyone that's informed on the topic knows it, but it is such a scary thing to discuss that people are not willing to talk about it openly."
Of course, there are plenty of areas of medicine, from antibiotics and vaccines to early detection of certain tumors, where the benefits are huge and incontrovertible. But if these effective treatments are black and white, much of the rest of medicine is a dark shade of gray. "A lot of things we absolutely believe at the moment based on our intuition are ultimately absolutely wrong," says Dr. Paul Wallace, of the Care Management Institute.
The best way to go from intuition to evidence is the randomized clinical trial. Patients with a particular condition are randomly assigned to competing treatments or, if appropriate, to a placebo. By monitoring the patients for months or years, doctors learn the relative risks and benefits of the treatment being studied.
But such trials take years and cost many millions of dollars. By the time the results come in, science and medicine may have moved on, making the findings less relevant. Moreover, patients in a clinical trial usually aren't representative of real people, who tend to have complex combinations of diseases and medical problems. And patients often don't stick with the program.
Such difficulties are highlighted by an eight-year study of low-fat diets that cost upward of $400 million. Most subjects failed to stick to the low-fat regimen, making it tough to draw conclusions. In addition, the study failed to take stock of different kinds of fats, some of which are now known to have beneficial effects. Many trials fall into similar traps. So it's no surprise that up to one-third of clinical studies lead to conclusions that are later overturned, according to a recent paper in JAMA.
Even when common treatments are proved to be dubious, physicians don't rush to change their practice. They may still firmly believe in the treatment -- or in the dollars it brings in. And doctors whose oxen get gored sometimes fight back. In 1993, the federal government's Agency for Health Care Policy & Research convened a panel to develop guidelines for back surgery. Fearing that the recommendations would cast doubt on what the doctors were doing, a prominent back surgeon protested to Congress, and lawmakers slashed funding for the agency. "Congress forced out the research," says Floyd J. Fowler Jr., president of the Foundation for Informed Medical Decision Making. "It was a national tragedy," he says -- and not an isolated incident. The agency's budget is often targeted "by special interest groups who had their specialty threatened," says Arkansas' Dr. Thompson.
With proof about medical outcomes lacking, one possible solution is educating patients about the uncertainties. "The popular version of evidence-based medicine is about proving things," says Kaiser's Wallace, "but it is really about transparency -- being clear about what we know and don't know." The Foundation for Informed Medical Decision Making produces booklets, videotapes, and other material to put the full picture in the hands of patients. Health Dialog markets the information to providers and companies, addressing back pain, breast cancer, uterine fibroids and bleeding, coronary heart disease, depression, osteoarthritis, and other conditions.
In studies where one group of patients hears the full story while other patients simply receive their doctors' instructions, a key difference emerges. The well-informed patients opt for more invasive, aggressive approaches 23% less often, on average, than the other group. In some cases, the drop is much bigger -- 50% to 60%. "Patients typically don't understand that they have options, and even if they do, they often wildly exaggerate the benefits of surgery and wildly minimize the chances of harm," says Ottawa's O'Connor, a leader in this field of so-called decision aids.
Eddy's computer simulation could help more patients attain appropriate care. His approach is to create a SimCity-like world in silicon, where virtual doctors conduct trials of virtual patients and figure out what treatments work. After getting funding from Kaiser Permanente in 1991, Eddy hired a particle physicist, Len Schlessinger, who knew how to write equations describing the complex interactions in biology. The pair selected diabetes as a test case. In their virtual world, each simulated person has a heart, liver, kidneys, blood, and other organs. As in real people, cells in the pancreas make insulin, which regulates the uptake of glucose in other cells. And as in the real disease, key cells can fail to respond to the insulin, causing high blood-sugar levels and a cascade of biological effects. The virtual patients come down with high blood pressure, heart disease, and poor circulation, which can lead to foot ulcers and amputations, blindness, and other ills. The model also assesses the costs of treating the complications.
Eddy dubbed the model Archimedes and tested it by comparing it with two dozen real trials. One clinical study compared cholesterol-lowering statin drugs to a placebo in diabetics. After 4 1/2 years, the drugs reduced heart attacks by 35%. The exact same thing happened in Eddy's simulated patients. "The Archimedes model is just fabulous in the validation studies," says the University of Michigan's Herman.
STANDARD OF CARE
The team then put Archimedes to work on a tough, real problem: how best to treat diabetes in people who have additional aliments. "One thing not yet adequately embraced by evidence-based medicine is what to do for someone with diabetes, hypertension, heart disease, and depression," explains Kaiser's Wallace. Doctors now typically try to treat the most pressing problems. "But we fail to pick the right ones consistently, so we have misdirected utilization and a great deal of waste," he says. Kaiser Permanente's Dr. Jim Dudl had a counterintuitive suggestion. With diabetics, doctors assume that keeping blood sugar levels low and consistent is the best way to ward off problems such as heart disease. But Dudl wondered what would happen if he flipped it around, aiming treatment at the downstream problems. The idea is to give patients a trio of generic medicines: aspirin, a cholesterol-lowering statin, and drugs called ACE inhibitors.
Using Archimedes and thousands of virtual patients, Eddy and Schlessinger compared the traditional approach with the drug combination. The model took about a half-hour to simulate a 30-year trial, and showed that the three-drug combination was "cost- and life-saving," says Kaiser's Wallace. The benefits far surpassed "what can be achieved with aggressive glucose control." Kaiser Permanente docs switched their standard of care for diabetes, adding these drugs to other interventions. It is too early to declare a victory, but the experience with patients seems to be mimicking Eddy's computer model. "It goes against our mental picture of the disease," says Wallace. But it also makes sense, he adds. "Cardiovascular disease is the worst complication of diabetes -- and what people die of."
Eddy readily concedes that this example is a small beginning. In its current state of development, Archimedes is like "the Wright brothers' plane. We're off the sand and flying to Raleigh." But it won't be long, he says, "before we're offering transcontinental flights, with movies."
The modeling approach allows each of us, in essence, to have an imaginary twin. We can use our twin to predict what our lives and state of health are likely to be with different lifestyles and approaches to care. Companies could create virtual clones of each employee, predicting what will occur with current care or with added prevention or treatment programs. "They can see what happens to such things as the complications suffered by diabetics, the lost time from work, the amount of angina or the rate of heart attacks, the number of deaths, and the cost of new employees if one dies," Eddy explains. "Our mission is that in 10 years, no one will make an important decision in health care without first asking: `What does Archimedes say?"'
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From heart surgery to prostate care, the health industry knows little about which common treatments really work
By John Carey
BusinessWeek, MAY 29, 2006
COVER STORY
The signs at the meeting were not propitious. Half the board members of Kaiser Permanente's Care Management Institute left before Dr. David Eddy finally got the 10 minutes he had pleaded for. But the message Eddy delivered was riveting. With a groundbreaking computer simulation, Eddy showed that the conventional approach to treating diabetes did little to prevent the heart attacks and strokes that are complications of the disease. In contrast, a simple regimen of aspirin and generic drugs to lower blood pressure and cholesterol sent the rate of such incidents plunging. The payoff: healthier lives and hundreds of millions in savings. "I told them: 'This is as good as it gets to improve care and lower costs, which doesn't happen often in medicine,"' Eddy recalls. "'If you don't implement this,' I said, 'you might as well close up shop."'
The message got through. Three years later, Kaiser is in the midst of a major initiative to change the treatment of the diabetics in its care. "We're trying to put nearly a million people on these drugs," says Dr. Paul Wallace, senior adviser to the Care Management Institute. The early results: The strategy is indeed improving care and cutting costs, just as Eddy's model predicted.
For Eddy, this is one small step toward solving the thorniest riddle in medicine -- a dark secret he has spent his career exposing. "The problem is that we don't know what we are doing," he says. Even today, with a high-tech health-care system that costs the nation $2 trillion a year, there is little or no evidence that many widely used treatments and procedures actually work better than various cheaper alternatives.
This judgment pertains to a shocking number of conditions or diseases, from cardiovascular woes to back pain to prostate cancer. During his long and controversial career proving that the practice of medicine is more guesswork than science, Eddy has repeatedly punctured cherished physician myths. He showed, for instance, that the annual chest X-ray was worthless, over the objections of doctors who made money off the regular visit. He proved that doctors had little clue about the success rate of procedures such as surgery for enlarged prostates. He traced one common practice -- preventing women from giving birth vaginally if they had previously had a cesarean -- to the recommendation of one lone doctor. Indeed, when he began taking on medicine's sacred cows, Eddy liked to cite a figure that only 15% of what doctors did was backed by hard evidence.
A great many doctors and health-care quality experts have come to endorse Eddy's critique. And while there has been progress in recent years, most of these physicians say the portion of medicine that has been proven effective is still outrageously low -- in the range of 20% to 25%. "We don't have the evidence [that treatments work], and we are not investing very much in getting the evidence," says Dr. Stephen C. Schoenbaum, executive vice-president of the Commonwealth Fund and former president of Harvard Pilgrim Health Care Inc. "Clearly, there is a lot in medicine we don't have definitive answers to," adds Dr. I. Steven Udvarhelyi, senior vice-president and chief medical officer at Pennsylvania's Independence Blue Cross.
What's required is a revolution called "evidence-based medicine," says Eddy, a heart surgeon turned mathematician and health-care economist. Tall, lean, and fit at 64, Eddy has the athletic stride and catlike reflexes of the ace rock climber he still is. He also exhibits the competitive drive of someone who once obsessively recorded his time on every training run, and who still likes to be first on a brisk walk up a hill near his home in Aspen, Colo. In his career, he has never been afraid to take a difficult path or an unpopular stand. "Evidence-based" is a term he coined in the early 1980s, and it has since become a rallying cry among medical reformers. The goal of this movement is to pierce the fog that envelops the practice of medicine -- a state of ignorance for which doctors cannot really be blamed. "The limitation is the human mind," Eddy says. Without extensive information on the outcomes of treatments, it's fiendishly difficult to know the best approach for care.
The human brain, Eddy explains, needs help to make sense of patients who have combinations of diseases, and of the complex probabilities involved in each. To provide that assistance, Eddy has spent the past 10 years leading a team to develop the computer model that helped him crack the diabetes puzzle. Dubbed Archimedes, this program seeks to mimic in equations the actual biology of the body, and make treatment recommendations as well as figure out what each approach costs. It is at least 10 times "better than the model we use now, which is called thinking," says Dr. Richard Kahn, chief scientific officer at the American Diabetes Assn.
WASTED RESOURCES
Can one computer program offset all the ill-advised treatment options for a whole range of different diseases? The milestones in Eddy's long personal crusade highlight the looming challenges, and may offer a sliver of hope. Coming from a family of four generations of doctors, Eddy went to medical school "because I didn't know what else to do," he confesses. As a resident at Stanford Medical Center in the 1970s, he picked cardiac surgery because "it was the biggest hill -- the glamour field."
But he soon became troubled. He began to ask if there was actual evidence to support what doctors were doing. The answer, he was surprised to hear, was no. Doctors decided whether or not to put a patient in intensive care or use a combination of drugs based on their best judgment and on rules and traditions handed down over the years, as opposed to real scientific proof. These rules and judgments weren't necessarily right. "I concluded that medicine was making decisions with an entirely different method from what we would call rational," says Eddy.
About the same time, the young resident discovered the beauty of mathematics, and its promise of answering medical questions. In just a couple of days, he devoured a calculus textbook (now framed on a shelf in his beautifully appointed home and office), then blasted through the books for a two-year math course in a couple of months. Next, he persuaded Stanford to accept him in a mathematically intense PhD program in the Engineering-Economics Systems Dept. "Dave came in -- just this amazing guy," recalls Richard Smallwood, then a Stanford professor. "He had decided he wanted to spend the rest of his life bringing logic and rationality to the medical system, but said he didn't have the math. I said: 'Why not just take it?' So he went out and aced all those math courses."
To augment his wife's earnings while getting his PhD, Eddy landed a job at Xerox Corp.'s (XRX ) legendary Palo Alto Research Center. "They hired weird people," he says. "Here was a heart surgeon doing math. That was weird enough."
Eddy used his newfound math skills to model cancer screening. His Stanford PhD thesis made front-page news in 1980 by overturning the guidelines of the time. It showed that annual chest X-rays and yearly Pap smears for women at low risk of cervical cancer were a waste of resources, and it won the most prestigious award in the field of operations research, the Frederick W. Lanchester prize. Based on his results, the American Cancer Society changed its guidelines. "He's smart as hell, with a towering clarity of thought," says Stanford health economist Allan Enthoven.
Dr. William H. Herman, director of the Michigan Diabetes Research & Training Center, has a competing computer model that clashes with Eddy's. Nonetheless, he says, "Dr. Eddy is one of my heroes. He's sort of the father of health economics -- and he might be right."
Appointed a full professor at Stanford, then recruited as chairman of the Center for Health Policy Research & Education at Duke University, Eddy proved again and again that the emperor had no clothes. In one study, he ferreted out decades of research evaluating treatment of high pressure in the eyeball, a condition that can lead to glaucoma and blindness. He found about a dozen studies that looked at outcomes with pressure-lowering medications used on millions of people. The studies actually suggested that the 100-year-old treatment was harmful, causing more cases of blindness, not fewer.
Eddy submitted a paper to the Journal of the American Medical Assn. (JAMA), whose editors sent it out to specialists for review. "It was amazing," Eddy recalls. "The tom-toms sounded among all the ophthalmologists," who marshaled a counterattack. "I felt like Salman Rushdie." Stanford ophthalmologist Kuldev Singh says: "Dr. Eddy challenged the community to prove that we actually had evidence. He did a service by stimulating clinical trials," which showed that the treatment does slow the disease in a minority of patients.
By 1985, Eddy was "burned out" by the administrative side of academia, he says. Lured by a poster of the Tetons, he gave up his prestigious post. He moved to Jackson, Wyo., so he could climb in his spare time. He and a friend even made a first ascent of a new route on the Grand Teton, now named after them. Meanwhile, he carved out a niche showing doctors at specialty society meetings that their cherished beliefs were dubious. "At each meeting I would do the same exercise," he says. He would ask doctors to think of a typical patient and typical treatment, then write down the results of that treatment. For urologists, for instance, what were the chances that a man with an enlarged prostate could urinate normally after having corrective surgery? Eddy then asked the society's president to read the predictions.
The results were startling. The predictions of success invariably ranged from 0% to 100%, with no clear pattern. "All the doctors were trying to estimate the same thing -- and they all gave different numbers," he says. "I've spent 25 years proving that what we lovingly call clinical judgment is woefully outmatched by the complexities of medicine." Think about the implications for helping patients make decisions, Eddy adds. "Go to one doctor, and get one answer. Go to another, and get a different one." Or think about expert testimony. "You don't have to hire an expert to lie. You can just find one who truly believes the number you want."
More important, the lack of evidence creates a costly clash. Americans and their doctors want access to any new treatment, and many doctors fervently believe such care is warranted. On the other hand, those beliefs can be flat wrong. As a consultant on Blue Cross's insurance coverage decisions, Eddy testified on the insurer's behalf in high-profile court cases, such as bone marrow transplants for breast cancer. Women and doctors demanded the treatment, even though there was no evidence it saved lives. Insurers who refused coverage usually lost in court. "I was the bad guy," Eddy recalls. When clinical trials were actually done, they showed that the treatment, costing from $50,000 to $150,000, didn't work. The doctors who pushed the painful, risky procedure on women "owe this country an apology," Eddy says.
Is medicine doing any better today? In recognizing the problem, yes. But in solving it, unfortunately, no. Take prostate cancer. Doctors now routinely test for levels of prostate-specific antigen (PSA) to try to diagnose the disease. But there's no evidence that using the test improves survival. Some experts believe that as many cancers would be detected through random biopsies. Then, once cancer is spotted, there's no way to know who needs treatment and who doesn't. Plus, there is a plethora of treatment choices -- four kinds of surgery, various types of implantable radioactive seeds, and competing external radiation regimens, notes Dr. Eric Klein, head of urologic oncology at the Cleveland Clinic. "How is a poor patient supposed to decide among those?" he asks. Most of the time, patients don't even know the options.
VESTED INTERESTS
"Because there are no definitive answers, you are at the whim of where you are and who you talk to," says Dr. Gary M. Kirsh at the Urology Group in Cincinnati. Kirsh does many brachytherapies -- implanting radioactive seeds. But "if you drive one and a half hours down the road to Indianapolis, there is almost no brachytherapy," he says. Head to Loma Linda, Calif., where the first proton-beam therapy machine was installed, in 1990, and the rates of proton-beam treatment are far higher than in most other parts of the country. Go to a surgeon, and he'll probably recommend surgery. Go to a radiologist, and the chances are high of getting radiation instead. "Doctors often assume that they know what a patient wants, leading them to recommend the treatment they know best," says Dr. David E. Wennberg, president of Health Dialog Analytic Solutions.
More troubling, many doctors hold not just a professional interest in which treatment to offer, but a financial one as well. "There is no question that the economic interests of the physician enter into the decision," says Kirsh. The bottom line: The conventional wisdom in prostate cancer -- that surgery is the gold standard and the best chance for a cure -- is unsustainable. Strangely enough, however, the choice may not matter very much. "There really isn't good evidence to suggest that one treatment is better than another," says Klein.
Compared with the skepticism Eddy faced in the 1990s, many physicians now concur that traditional treatments for serious illnesses often aren't best. Yet this message can be hard for Americans to believe. "When there is more than one medical option, people mistakenly think that the more aggressive procedure is the best," says Annette M. Cormier O'Connor, senior scientist in clinical epidemiology at the Ottawa Health Research Institute. The message flies in the face of America's infatuation with the latest advances. "As a nation, we always want the best, the most recent technology," explains Dr. Joe Thompson, health adviser to Arkansas Governor Mike Huckabee. "We spend a huge amount developing it, and we get a big increase in supply." New radiation machines for cancer or operating rooms for heart surgery are profit centers for hospitals, for instance (see BW Online, 07/18/05, "Is Heart Surgery Worth It?"). Once a hospital installs a shiny new catheter lab, it has a powerful incentive to refer more patients for the procedure. It's a classic case of increased supply driving demand, instead of the other way around. "Combine that with Americans' demand to be treated immediately, and it is a cauldron for overuse and inappropriate use," says Thompson.
The consequences for the U.S. are disturbing. This nation spends 2 1/2 times as much as any other country per person on health care. Yet middle-aged Americans are in far worse health than their British counterparts, who spend less than half as much and practice less intensive medicine, according to a new study. "The investment in health care in the U.S. is just not paying off," argues Gerard Anderson, director of the Center for Hospital Finance & Management at Johns Hopkins' Bloomberg School of Public Health. Speaking not for attribution, the head of health care at one of America's largest corporations puts it more bluntly: "There is a massive amount of spending on things that really don't help patients, and even put them at greater risk. Everyone that's informed on the topic knows it, but it is such a scary thing to discuss that people are not willing to talk about it openly."
Of course, there are plenty of areas of medicine, from antibiotics and vaccines to early detection of certain tumors, where the benefits are huge and incontrovertible. But if these effective treatments are black and white, much of the rest of medicine is a dark shade of gray. "A lot of things we absolutely believe at the moment based on our intuition are ultimately absolutely wrong," says Dr. Paul Wallace, of the Care Management Institute.
The best way to go from intuition to evidence is the randomized clinical trial. Patients with a particular condition are randomly assigned to competing treatments or, if appropriate, to a placebo. By monitoring the patients for months or years, doctors learn the relative risks and benefits of the treatment being studied.
But such trials take years and cost many millions of dollars. By the time the results come in, science and medicine may have moved on, making the findings less relevant. Moreover, patients in a clinical trial usually aren't representative of real people, who tend to have complex combinations of diseases and medical problems. And patients often don't stick with the program.
Such difficulties are highlighted by an eight-year study of low-fat diets that cost upward of $400 million. Most subjects failed to stick to the low-fat regimen, making it tough to draw conclusions. In addition, the study failed to take stock of different kinds of fats, some of which are now known to have beneficial effects. Many trials fall into similar traps. So it's no surprise that up to one-third of clinical studies lead to conclusions that are later overturned, according to a recent paper in JAMA.
Even when common treatments are proved to be dubious, physicians don't rush to change their practice. They may still firmly believe in the treatment -- or in the dollars it brings in. And doctors whose oxen get gored sometimes fight back. In 1993, the federal government's Agency for Health Care Policy & Research convened a panel to develop guidelines for back surgery. Fearing that the recommendations would cast doubt on what the doctors were doing, a prominent back surgeon protested to Congress, and lawmakers slashed funding for the agency. "Congress forced out the research," says Floyd J. Fowler Jr., president of the Foundation for Informed Medical Decision Making. "It was a national tragedy," he says -- and not an isolated incident. The agency's budget is often targeted "by special interest groups who had their specialty threatened," says Arkansas' Dr. Thompson.
With proof about medical outcomes lacking, one possible solution is educating patients about the uncertainties. "The popular version of evidence-based medicine is about proving things," says Kaiser's Wallace, "but it is really about transparency -- being clear about what we know and don't know." The Foundation for Informed Medical Decision Making produces booklets, videotapes, and other material to put the full picture in the hands of patients. Health Dialog markets the information to providers and companies, addressing back pain, breast cancer, uterine fibroids and bleeding, coronary heart disease, depression, osteoarthritis, and other conditions.
In studies where one group of patients hears the full story while other patients simply receive their doctors' instructions, a key difference emerges. The well-informed patients opt for more invasive, aggressive approaches 23% less often, on average, than the other group. In some cases, the drop is much bigger -- 50% to 60%. "Patients typically don't understand that they have options, and even if they do, they often wildly exaggerate the benefits of surgery and wildly minimize the chances of harm," says Ottawa's O'Connor, a leader in this field of so-called decision aids.
Eddy's computer simulation could help more patients attain appropriate care. His approach is to create a SimCity-like world in silicon, where virtual doctors conduct trials of virtual patients and figure out what treatments work. After getting funding from Kaiser Permanente in 1991, Eddy hired a particle physicist, Len Schlessinger, who knew how to write equations describing the complex interactions in biology. The pair selected diabetes as a test case. In their virtual world, each simulated person has a heart, liver, kidneys, blood, and other organs. As in real people, cells in the pancreas make insulin, which regulates the uptake of glucose in other cells. And as in the real disease, key cells can fail to respond to the insulin, causing high blood-sugar levels and a cascade of biological effects. The virtual patients come down with high blood pressure, heart disease, and poor circulation, which can lead to foot ulcers and amputations, blindness, and other ills. The model also assesses the costs of treating the complications.
Eddy dubbed the model Archimedes and tested it by comparing it with two dozen real trials. One clinical study compared cholesterol-lowering statin drugs to a placebo in diabetics. After 4 1/2 years, the drugs reduced heart attacks by 35%. The exact same thing happened in Eddy's simulated patients. "The Archimedes model is just fabulous in the validation studies," says the University of Michigan's Herman.
STANDARD OF CARE
The team then put Archimedes to work on a tough, real problem: how best to treat diabetes in people who have additional aliments. "One thing not yet adequately embraced by evidence-based medicine is what to do for someone with diabetes, hypertension, heart disease, and depression," explains Kaiser's Wallace. Doctors now typically try to treat the most pressing problems. "But we fail to pick the right ones consistently, so we have misdirected utilization and a great deal of waste," he says. Kaiser Permanente's Dr. Jim Dudl had a counterintuitive suggestion. With diabetics, doctors assume that keeping blood sugar levels low and consistent is the best way to ward off problems such as heart disease. But Dudl wondered what would happen if he flipped it around, aiming treatment at the downstream problems. The idea is to give patients a trio of generic medicines: aspirin, a cholesterol-lowering statin, and drugs called ACE inhibitors.
Using Archimedes and thousands of virtual patients, Eddy and Schlessinger compared the traditional approach with the drug combination. The model took about a half-hour to simulate a 30-year trial, and showed that the three-drug combination was "cost- and life-saving," says Kaiser's Wallace. The benefits far surpassed "what can be achieved with aggressive glucose control." Kaiser Permanente docs switched their standard of care for diabetes, adding these drugs to other interventions. It is too early to declare a victory, but the experience with patients seems to be mimicking Eddy's computer model. "It goes against our mental picture of the disease," says Wallace. But it also makes sense, he adds. "Cardiovascular disease is the worst complication of diabetes -- and what people die of."
Eddy readily concedes that this example is a small beginning. In its current state of development, Archimedes is like "the Wright brothers' plane. We're off the sand and flying to Raleigh." But it won't be long, he says, "before we're offering transcontinental flights, with movies."
The modeling approach allows each of us, in essence, to have an imaginary twin. We can use our twin to predict what our lives and state of health are likely to be with different lifestyles and approaches to care. Companies could create virtual clones of each employee, predicting what will occur with current care or with added prevention or treatment programs. "They can see what happens to such things as the complications suffered by diabetics, the lost time from work, the amount of angina or the rate of heart attacks, the number of deaths, and the cost of new employees if one dies," Eddy explains. "Our mission is that in 10 years, no one will make an important decision in health care without first asking: `What does Archimedes say?"'
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Doctors say drugmakers are "disease-mongering" to boost sales
Hey, You Don't Look So Good
As diagnoses of once-rare illnesses soar, doctors say drugmakers are "disease-mongering" to boost sales
By Catherine Arnst
BusinessWeek, MAY 8, 2006
If you have high blood pressure, you may be at risk for heart disease. And given that an estimated 65 million Americans have hypertension, it's not surprising that drugs to treat it are among the most prescribed medicines in the world. But why stop at prescribing drugs to people whose readings are 140/90 or higher, the standard definition of high blood pressure? In the Apr. 20 issue of The New England Journal of Medicine, a research team reported on "prehypertension," the condition of being in danger of developing hypertension.
Prehypertension was first identified in 2003, and some studies claim as many as 50 million U.S. adults have the condition, defined as blood pressure readings from 120/80 to 139/89. This risk of being at risk can be modified with diet and exercise, but the NEJM study reports that it can also be treated with Atacand, a drug from AstraZeneca Pharmaceuticals PLC (AZN ).
To a growing chorus of physicians and health-care specialists, the very idea of treating the risk of a risk is wrong. They have labeled the phenomenon "disease-mongering," defined as the corporate-sponsored creation or exaggeration of maladies for the purpose of selling more drugs. Prehypertension "is a classic case of a risk factor being turned into the disease," says Dr. Steven Woloshin of the Veterans Affairs Outcomes Group in White River Junction, Vt. "If you make a cut-off for blood pressure that's close to the normal range, then just about everyone can be diagnosed." An AstraZeneca spokesman responds that the trial was considered important enough to be published in the prestigious NEJM. "I think that speaks for itself."
DEMAND FOR A QUICK FIX
According to critics, disease-mongering is on the rise. It starts when a drug is developed for some once-rare condition. Then heavily promoted disease-awareness campaigns kick into gear, leading to increasing numbers of diagnoses and prescriptions. The list of suspects includes restless legs syndrome, social anxiety disorder, premenstrual dystrophic disorder, irritable bowel syndrome, female sexual dysfunction, and more. "Of course, some people have these diseases very seriously," says Dr. Robert L. Klitzman, a psychiatrist and bioethicist at Columbia University. "The problem is that mild cases are being made to seem more serious than they are."
The other problem, say the anti-disease-mongerers, is that the vagaries of everyday life, such as sadness, shyness, forgetfulness, and the occasional upset stomach, are being turned into medical conditions. Before Pfizer Inc.'s (PFE ) Viagra was introduced, erectile dysfunction was a medical problem only when associated with an underlying biological cause, such as diabetes or prostate cancer. Now, Pfizer's Web site claims that half of all men over 40 have problems getting or maintaining an erection. Social anxiety disorder, defined as severe shyness, was rarely seen until GlaxoSmithKline PLC's (GSK ) Paxil was approved to treat it. A disease-awareness campaign by Glaxo in the late 1990s, with the tag line "imagine being allergic to people," was quickly followed by rising prevalence estimates.
Disease promotion is not just the purview of drug companies. "Doctors should set more boundaries," asserts Dr. David Henry, a pharmacology professor at the University of Newcastle in Australia and a leading critic of disease-mongering. Then there are patients seeking a quick fix for conditions that might better be treated through lifestyle changes. "Drug companies are playing off the desire we all have to get rid of things that bother us," says Klitzman. But ridding oneself of bothersome symptoms without changing the behaviors that contribute to them can mean taking a pill every day for years, a proposition that is both risky and costly.
YOUNGER AND YOUNGER
Also of concern are efforts to expand the definition of serious diseases to cover more and more people. Loosened criteria for bipolar disorder, a dire psychological disease once thought to affect only 0.1% of the population, have led some experts to claim prevalence rates of anywhere from 5% to 10%. Dr. David Healy of Cardiff University in Wales says the higher estimates are based on ill-defined surveys that followed the introduction in the mid-1990s of mood stabilizer drugs, promising relief even for people with mild emotional swings. In the U.S., children as young as age 2 are being diagnosed as bipolar even though, in the classic definition of the illness, symptoms don't usually show up until the teens. "These young kids are started on two or three medicines when there isn't even any evidence that any of them work in children," says Dr. Jon McClellan at the University of Washington in Seattle.
Disease-mongering isn't new. The term was coined by Lynn Payer in her 1994 book Disease-Mongers: How Doctors, Drug Companies, and Insurers are Making You Feel Sick. But the advent of direct-to-consumer advertising in the U.S. in 1999 fanned the trend, say drug industry critics. Their complaints reached a critical mass this spring. The April issue of the journal PLoS Medicine ran 11 articles on disease-mongering to coincide with the first conference devoted to the topic, held Apr. 11-13 in Newcastle.
Drugmakers say they're only trying to educate patients who are struggling with serious illnesses. "We realize that not every medicine is for every person," says a spokeswoman for Glaxo, which makes drugs for restless legs syndrome, social anxiety disorder, and other diagnoses that are under fire. "The labels contain important information about whether it's appropriate, and we're confident that doctors consulting with patients will assess their health-care issues and the risks and rewards and make an appropriate decision."
The skeptics aren't convinced that doctors will be so discriminating, in part because many get their information about disease treatment from the drug industry. Pharmaceutical companies routinely subsidize continuing medical education courses for doctors. They fund research for diseases that then gets published in medical journals, and they underwrite patient advocate groups, which in turn promote the underwriter's drugs on their Web sites. Witness the Child & Adolescent Bipolar Foundation: It lists four pharmaceutical companies as major donors, including Eli Lilly & Co. and Janssen LP, makers of leading mood stabilizers.
All these factors come into play with restless legs syndrome, a case history detailed in PLoS Medicine. Defined as the urge to constantly move one's legs, the condition can be truly disruptive for people with severe symptoms, but such severity is considered rare. That didn't stop GlaxoSmithKline from launching a disease awareness campaign in 2003. The company kicked off the blitz with a press release stating that a "new survey reveals a common yet underrecognized disorder -- restless legs syndrome -- is keeping Americans awake at night." News articles proliferated, most stating that the condition affects up to 10% of adults in the U.S., based on the study Glaxo promoted.
In 2005, Glaxo's Requip, a treatment for Parkinson's disease, was approved for restless legs. At the same time the Restless Legs Syndrome Foundation, which receives funding from Glaxo, issued a press release about "a new national survey that shows [the] syndrome is largely underrecognized and poorly understood." A Glaxo spokeswoman says that most Requip prescriptions are written for Parkinson's.
The VA's Dr. Woloshin grants that some people are helped by Requip, Paxil, and Viagra. But he worries that overtreatment drains money from research into more serious illnesses. "None of these companies is coming up with a cure for TB," he notes. That's a disease no one is trying to monger.
Read article at original source
As diagnoses of once-rare illnesses soar, doctors say drugmakers are "disease-mongering" to boost sales
By Catherine Arnst
BusinessWeek, MAY 8, 2006
If you have high blood pressure, you may be at risk for heart disease. And given that an estimated 65 million Americans have hypertension, it's not surprising that drugs to treat it are among the most prescribed medicines in the world. But why stop at prescribing drugs to people whose readings are 140/90 or higher, the standard definition of high blood pressure? In the Apr. 20 issue of The New England Journal of Medicine, a research team reported on "prehypertension," the condition of being in danger of developing hypertension.
Prehypertension was first identified in 2003, and some studies claim as many as 50 million U.S. adults have the condition, defined as blood pressure readings from 120/80 to 139/89. This risk of being at risk can be modified with diet and exercise, but the NEJM study reports that it can also be treated with Atacand, a drug from AstraZeneca Pharmaceuticals PLC (AZN ).
To a growing chorus of physicians and health-care specialists, the very idea of treating the risk of a risk is wrong. They have labeled the phenomenon "disease-mongering," defined as the corporate-sponsored creation or exaggeration of maladies for the purpose of selling more drugs. Prehypertension "is a classic case of a risk factor being turned into the disease," says Dr. Steven Woloshin of the Veterans Affairs Outcomes Group in White River Junction, Vt. "If you make a cut-off for blood pressure that's close to the normal range, then just about everyone can be diagnosed." An AstraZeneca spokesman responds that the trial was considered important enough to be published in the prestigious NEJM. "I think that speaks for itself."
DEMAND FOR A QUICK FIX
According to critics, disease-mongering is on the rise. It starts when a drug is developed for some once-rare condition. Then heavily promoted disease-awareness campaigns kick into gear, leading to increasing numbers of diagnoses and prescriptions. The list of suspects includes restless legs syndrome, social anxiety disorder, premenstrual dystrophic disorder, irritable bowel syndrome, female sexual dysfunction, and more. "Of course, some people have these diseases very seriously," says Dr. Robert L. Klitzman, a psychiatrist and bioethicist at Columbia University. "The problem is that mild cases are being made to seem more serious than they are."
The other problem, say the anti-disease-mongerers, is that the vagaries of everyday life, such as sadness, shyness, forgetfulness, and the occasional upset stomach, are being turned into medical conditions. Before Pfizer Inc.'s (PFE ) Viagra was introduced, erectile dysfunction was a medical problem only when associated with an underlying biological cause, such as diabetes or prostate cancer. Now, Pfizer's Web site claims that half of all men over 40 have problems getting or maintaining an erection. Social anxiety disorder, defined as severe shyness, was rarely seen until GlaxoSmithKline PLC's (GSK ) Paxil was approved to treat it. A disease-awareness campaign by Glaxo in the late 1990s, with the tag line "imagine being allergic to people," was quickly followed by rising prevalence estimates.
Disease promotion is not just the purview of drug companies. "Doctors should set more boundaries," asserts Dr. David Henry, a pharmacology professor at the University of Newcastle in Australia and a leading critic of disease-mongering. Then there are patients seeking a quick fix for conditions that might better be treated through lifestyle changes. "Drug companies are playing off the desire we all have to get rid of things that bother us," says Klitzman. But ridding oneself of bothersome symptoms without changing the behaviors that contribute to them can mean taking a pill every day for years, a proposition that is both risky and costly.
YOUNGER AND YOUNGER
Also of concern are efforts to expand the definition of serious diseases to cover more and more people. Loosened criteria for bipolar disorder, a dire psychological disease once thought to affect only 0.1% of the population, have led some experts to claim prevalence rates of anywhere from 5% to 10%. Dr. David Healy of Cardiff University in Wales says the higher estimates are based on ill-defined surveys that followed the introduction in the mid-1990s of mood stabilizer drugs, promising relief even for people with mild emotional swings. In the U.S., children as young as age 2 are being diagnosed as bipolar even though, in the classic definition of the illness, symptoms don't usually show up until the teens. "These young kids are started on two or three medicines when there isn't even any evidence that any of them work in children," says Dr. Jon McClellan at the University of Washington in Seattle.
Disease-mongering isn't new. The term was coined by Lynn Payer in her 1994 book Disease-Mongers: How Doctors, Drug Companies, and Insurers are Making You Feel Sick. But the advent of direct-to-consumer advertising in the U.S. in 1999 fanned the trend, say drug industry critics. Their complaints reached a critical mass this spring. The April issue of the journal PLoS Medicine ran 11 articles on disease-mongering to coincide with the first conference devoted to the topic, held Apr. 11-13 in Newcastle.
Drugmakers say they're only trying to educate patients who are struggling with serious illnesses. "We realize that not every medicine is for every person," says a spokeswoman for Glaxo, which makes drugs for restless legs syndrome, social anxiety disorder, and other diagnoses that are under fire. "The labels contain important information about whether it's appropriate, and we're confident that doctors consulting with patients will assess their health-care issues and the risks and rewards and make an appropriate decision."
The skeptics aren't convinced that doctors will be so discriminating, in part because many get their information about disease treatment from the drug industry. Pharmaceutical companies routinely subsidize continuing medical education courses for doctors. They fund research for diseases that then gets published in medical journals, and they underwrite patient advocate groups, which in turn promote the underwriter's drugs on their Web sites. Witness the Child & Adolescent Bipolar Foundation: It lists four pharmaceutical companies as major donors, including Eli Lilly & Co. and Janssen LP, makers of leading mood stabilizers.
All these factors come into play with restless legs syndrome, a case history detailed in PLoS Medicine. Defined as the urge to constantly move one's legs, the condition can be truly disruptive for people with severe symptoms, but such severity is considered rare. That didn't stop GlaxoSmithKline from launching a disease awareness campaign in 2003. The company kicked off the blitz with a press release stating that a "new survey reveals a common yet underrecognized disorder -- restless legs syndrome -- is keeping Americans awake at night." News articles proliferated, most stating that the condition affects up to 10% of adults in the U.S., based on the study Glaxo promoted.
In 2005, Glaxo's Requip, a treatment for Parkinson's disease, was approved for restless legs. At the same time the Restless Legs Syndrome Foundation, which receives funding from Glaxo, issued a press release about "a new national survey that shows [the] syndrome is largely underrecognized and poorly understood." A Glaxo spokeswoman says that most Requip prescriptions are written for Parkinson's.
The VA's Dr. Woloshin grants that some people are helped by Requip, Paxil, and Viagra. But he worries that overtreatment drains money from research into more serious illnesses. "None of these companies is coming up with a cure for TB," he notes. That's a disease no one is trying to monger.
Read article at original source
Wednesday, October 18, 2006
Invasive Procedures: Less is More ... And Better
Invasive Procedures: Less is More ... And Better
By Donald M. Berwick, M.D.
Newsweek, October 16, 2006
The modern hospital is the cathedral of our time—gleaming, mystical, intimidating, even majestic. It seems to contain miracles and, sometimes, it does; bioscientific breakthroughs have changed the course of illness, curing cases of leukemia, fixing hearts, transplanting organs. It is easy to be in awe. We want whatever the magic of health care can give us—the more, the better.
So it comes as a surprise to most people that the facts often suggest otherwise, as researchers at Dartmouth Medical School—led by Profs. John Wennberg and Elliott Fisher—have been showing for years in the so-called Dartmouth Atlas project. They sort the United States into 307 geographically defined "hospital service areas," and study how often Medicare patients in those areas get specific medical and surgical procedures.
For many procedures, the variation is stunning. Compared with the lowest-use areas, people in the highest-use areas get 10 times as many prostate operations, six times as many back surgeries, seven times as many coronary angioplasties and 10 times as many hospital days if they have heart failure. It all raises an obvious question: if medical technology is being used so differently, who's right?
A lot of the variation depends not on clear-cut scientific evidence that one treatment is better than another, but on the beliefs of specialists in the area and the supply of doctors and hospital beds. The use of specialist visits varies by 660 percent, and what best predicts the rate is the number of specialists per capita. The more doctors, the more doctor visits. The more hospital beds, the more days spent in the hospital.
Are you lucky if you live in a high-use region? Not necessarily. Landmark studies by Fisher showed that high use did not mean better quality of care and outcomes. In fact, for many measures, quality and outcomes were best in the low-use areas and worst in the high-use areas. The less, the better.
Fisher and Wennberg suggest that the rates of use of health-care procedures and treatments should, indeed, vary a lot, but not according to where you live. Rather, variation should reflect the preferences of patients ("Would you rather wait a bit to see if your back pain gets better, Mr. Smith, or try surgery now?") instead of the local habits of doctors or, worse, the local supply of specialists. When patients are actually invited to participate in decisions about their care—"shared decision-making"—both costs and rates of use of expensive, invasive procedures tend to fall, and outcomes and satisfaction improve. The Dartmouth team calls this "preference-sensitive care," and it thinks health care driven by necessity rather than supply could be both more responsive to our needs and, overall, far less costly.
A shortlist of "high variation" surgical procedures in the Dartmouth Atlas includes gallbladder removal; coronary-artery bypass and coronary angioplasty (in people with minimal symptoms); hip replacement; carotid-artery surgery; radical breast surgery (instead of lumpectomy) for localized breast cancer, and prostate removal for benign enlargement of the gland. If you or a loved one is scheduled for one of these, you might pause and ask some questions. Do you understand the alternatives to surgery? Would a period of "watchful waiting" help? Is the decision to operate based on your own assessment of your options? Or does it reflect mainly the local habits of the medical-care system? Surgery may be the right choice, but that ought to depend on the patient's preferences as well as the scientific facts.
Berwick is clinical professor of pediatrics at Children's Hospital and Harvard Medical School, and CEO of the Institute for HealthcareImprovement. For health information from Harvard, go to health.harvard.edu
Read article at orignal source
By Donald M. Berwick, M.D.
Newsweek, October 16, 2006
The modern hospital is the cathedral of our time—gleaming, mystical, intimidating, even majestic. It seems to contain miracles and, sometimes, it does; bioscientific breakthroughs have changed the course of illness, curing cases of leukemia, fixing hearts, transplanting organs. It is easy to be in awe. We want whatever the magic of health care can give us—the more, the better.
So it comes as a surprise to most people that the facts often suggest otherwise, as researchers at Dartmouth Medical School—led by Profs. John Wennberg and Elliott Fisher—have been showing for years in the so-called Dartmouth Atlas project. They sort the United States into 307 geographically defined "hospital service areas," and study how often Medicare patients in those areas get specific medical and surgical procedures.
For many procedures, the variation is stunning. Compared with the lowest-use areas, people in the highest-use areas get 10 times as many prostate operations, six times as many back surgeries, seven times as many coronary angioplasties and 10 times as many hospital days if they have heart failure. It all raises an obvious question: if medical technology is being used so differently, who's right?
A lot of the variation depends not on clear-cut scientific evidence that one treatment is better than another, but on the beliefs of specialists in the area and the supply of doctors and hospital beds. The use of specialist visits varies by 660 percent, and what best predicts the rate is the number of specialists per capita. The more doctors, the more doctor visits. The more hospital beds, the more days spent in the hospital.
Are you lucky if you live in a high-use region? Not necessarily. Landmark studies by Fisher showed that high use did not mean better quality of care and outcomes. In fact, for many measures, quality and outcomes were best in the low-use areas and worst in the high-use areas. The less, the better.
Fisher and Wennberg suggest that the rates of use of health-care procedures and treatments should, indeed, vary a lot, but not according to where you live. Rather, variation should reflect the preferences of patients ("Would you rather wait a bit to see if your back pain gets better, Mr. Smith, or try surgery now?") instead of the local habits of doctors or, worse, the local supply of specialists. When patients are actually invited to participate in decisions about their care—"shared decision-making"—both costs and rates of use of expensive, invasive procedures tend to fall, and outcomes and satisfaction improve. The Dartmouth team calls this "preference-sensitive care," and it thinks health care driven by necessity rather than supply could be both more responsive to our needs and, overall, far less costly.
A shortlist of "high variation" surgical procedures in the Dartmouth Atlas includes gallbladder removal; coronary-artery bypass and coronary angioplasty (in people with minimal symptoms); hip replacement; carotid-artery surgery; radical breast surgery (instead of lumpectomy) for localized breast cancer, and prostate removal for benign enlargement of the gland. If you or a loved one is scheduled for one of these, you might pause and ask some questions. Do you understand the alternatives to surgery? Would a period of "watchful waiting" help? Is the decision to operate based on your own assessment of your options? Or does it reflect mainly the local habits of the medical-care system? Surgery may be the right choice, but that ought to depend on the patient's preferences as well as the scientific facts.
Berwick is clinical professor of pediatrics at Children's Hospital and Harvard Medical School, and CEO of the Institute for HealthcareImprovement. For health information from Harvard, go to health.harvard.edu
Read article at orignal source
The Toll on Patients - Injuries and deaths resulting from preventable errors in medical care
An alarming number of injuries and deaths result from preventable errors in medical care
Newsweek, October 16, 2006
An alarming number of injuries and deaths result from preventable errors in medical care
1.5 million Americans are harmed or killed by medication-related mistakes each year
$3.5 billion in extra medical costs is spent annually to treat injuries caused by drug-related errors.
44,000 to 98,000 Americans die each year of medical errors, such as wrong-site surgery.
18,000 Americans die each year of heart attacks because they didn't receive preventative drugs.
See statistics at original source
Newsweek, October 16, 2006
An alarming number of injuries and deaths result from preventable errors in medical care
1.5 million Americans are harmed or killed by medication-related mistakes each year
$3.5 billion in extra medical costs is spent annually to treat injuries caused by drug-related errors.
44,000 to 98,000 Americans die each year of medical errors, such as wrong-site surgery.
18,000 Americans die each year of heart attacks because they didn't receive preventative drugs.
See statistics at original source
Friday, July 21, 2006
Medication errors injure more than 1.5 million yearly, study finds
Medication errors injure more than 1.5 million yearly, study finds
Hospital patients said at risk for at least one drug mistake daily
AP, July 20, 2006
Medication mistakes injure well over 1.5 million Americans every year, a toll too often unrecognized and unfought, says a sobering call to action.
At least a quarter of the errors are preventable, the Institute of Medicine said Thursday in urging major steps by the government, health providers and patients alike.
Topping the list: All prescriptions should be written electronically by 2010, a move one specialist called as crucial to safe care as X-ray machines.
Perhaps the report's most stunning finding was that, on average, a hospitalized patient is subject to at least one medication error per day.
A serious drug error can add more than $5,800 to the hospital bill of a single patient. Assuming that hospitals commit 400,000 preventable drug errors each year, that's $3.5 billion -- not counting lost productivity and other costs -- from hospitals alone, the report concluded.
"I'm a patient-safety researcher (yet) I was surprised and shocked at just how common and how serious a problem this is," said Dr. Albert Wu of Johns Hopkins University, co-author of Thursday's report.
Worse, there's too little incentive for health providers to invest in technology that could prevent some errors today, added Dr. J. Lyle Bootman, the University of Arizona's pharmacy dean, who co-chaired the IOM probe.
"We're paid whether these errors occur or not," lamented Bootman, who recently experienced the threat firsthand as his son-in-law dodged some drug near-misses while in intensive care in a reputable hospital.
The new probe couldn't say how many of the injuries are serious, or how many victims die. A 1999 estimate put deaths, conservatively, at 7,000 a year.
Even the total injury estimate is conservative, Bootman stressed. It includes drug errors in hospitals, nursing homes and among Medicare outpatients, but it doesn't attempt to count mix-ups in most doctors' offices or by patients themselves.
There have been efforts to improve patient safety in the six years since the IOM first spotlighted medical mistakes of all kinds, including recent bar-coding of drugs to minimize mix-ups in hospitals and pharmacies.
But clearly more are needed, and the new report highlights how the nation's fragmented health care system is conducive to drug errors, said Dr. Donald Berwick, a Harvard professor who heads the nonprofit Institute for Healthcare Improvement.
"This isn't a matter of doctors and nurses trying harder not to harm people," Berwick cautioned. "Safety isn't automatic. It has to be designed into the system."
Medications' sheer volume and complexity illustrate the difficulty. More than 10,000 prescription drugs are on the market, and 300,000 over-the-counter products. It's impossible to memorize their different usage and dosage instructions, which may vary according to the patient's age, weight and other risk factors, such as bad kidneys.
Plus, four of every five U.S. adults take at least one medication or dietary supplement every day; almost a third take at least five. The more you use, the greater your risk of bad interactions, especially if multiple doctors prescribe different drugs without knowing what you already take.
Add doctors' notoriously bad handwriting and sound-alike drug names: Was that order for 10 milligrams or 10 migrams? The hormone Premarin or the antibiotic Primaxin?
Moreover, consumer instructions are woefully inadequate, the report concludes. One study found parents gave their children the wrong dose of over-the-counter fever medicines 47 percent of the time.
Then there was man with newly diagnosed asthma wondering why his inhaler didn't work. Asked how he used it, the middle-age man squirted two puffs into the air and tried to breathe the mist. His original doctor had demonstrated the inhaler without telling him to spray it inside his mouth.
Among the report's recommendations:
•The government should speed electronic prescribing, including fostering technology improvements so that the myriad computer programs used by doctors, hospitals and drugstores are compatible.
Fewer than about 20 percent of prescriptions are electronic, said report co-author Michael Cohen, president of the Institute for Safe Medication Practices. E-prescribing does more than counter bad handwriting. The computer programs can be linked to databases that flash an alert if the prescribed dose seems high or if the patient's records show use of another drug that can dangerously interact.
•The government should speed electronic prescribing, including fostering technology improvements so that the myriad computer programs used by doctors, hospitals and drugstores are compatible.
Fewer than about 20 percent of prescriptions are electronic, said report co-author Michael Cohen, president of the Institute for Safe Medication Practices. E-prescribing does more than counter bad handwriting. The computer programs can be linked to databases that flash an alert if the prescribed dose seems high or if the patient's records show use of another drug that can dangerously interact.
•Patients and their families must be aggressive in questioning doctors, nurses and pharmacists about medications. Get a list of each drug you're prescribed, why and the dose from each doctor and pharmacy you use, and show it at every doctor visit.
"Take active steps to make sure you know what you're getting, and is it what you need," said report co-author Dr. Wilson Pace of the University of Colorado.
•The nation should invest about $100 million annually on research into drug errors and how to prevent them. Among the most-needed studies is the impact of free drug samples, which often lack proper labeling, on medication safety.
•The Food and Drug Administration should improve the quality of drug information leaflets that accompany prescription drugs, but often have incomplete information or are written in consumer-confusing jargon.
•The government should establish national telephone hotlines to help patients unable to understand printed drug information because of illiteracy, language barriers or other problems.
Read article at the original source
Hospital patients said at risk for at least one drug mistake daily
AP, July 20, 2006
Medication mistakes injure well over 1.5 million Americans every year, a toll too often unrecognized and unfought, says a sobering call to action.
At least a quarter of the errors are preventable, the Institute of Medicine said Thursday in urging major steps by the government, health providers and patients alike.
Topping the list: All prescriptions should be written electronically by 2010, a move one specialist called as crucial to safe care as X-ray machines.
Perhaps the report's most stunning finding was that, on average, a hospitalized patient is subject to at least one medication error per day.
A serious drug error can add more than $5,800 to the hospital bill of a single patient. Assuming that hospitals commit 400,000 preventable drug errors each year, that's $3.5 billion -- not counting lost productivity and other costs -- from hospitals alone, the report concluded.
"I'm a patient-safety researcher (yet) I was surprised and shocked at just how common and how serious a problem this is," said Dr. Albert Wu of Johns Hopkins University, co-author of Thursday's report.
Worse, there's too little incentive for health providers to invest in technology that could prevent some errors today, added Dr. J. Lyle Bootman, the University of Arizona's pharmacy dean, who co-chaired the IOM probe.
"We're paid whether these errors occur or not," lamented Bootman, who recently experienced the threat firsthand as his son-in-law dodged some drug near-misses while in intensive care in a reputable hospital.
The new probe couldn't say how many of the injuries are serious, or how many victims die. A 1999 estimate put deaths, conservatively, at 7,000 a year.
Even the total injury estimate is conservative, Bootman stressed. It includes drug errors in hospitals, nursing homes and among Medicare outpatients, but it doesn't attempt to count mix-ups in most doctors' offices or by patients themselves.
There have been efforts to improve patient safety in the six years since the IOM first spotlighted medical mistakes of all kinds, including recent bar-coding of drugs to minimize mix-ups in hospitals and pharmacies.
But clearly more are needed, and the new report highlights how the nation's fragmented health care system is conducive to drug errors, said Dr. Donald Berwick, a Harvard professor who heads the nonprofit Institute for Healthcare Improvement.
"This isn't a matter of doctors and nurses trying harder not to harm people," Berwick cautioned. "Safety isn't automatic. It has to be designed into the system."
Medications' sheer volume and complexity illustrate the difficulty. More than 10,000 prescription drugs are on the market, and 300,000 over-the-counter products. It's impossible to memorize their different usage and dosage instructions, which may vary according to the patient's age, weight and other risk factors, such as bad kidneys.
Plus, four of every five U.S. adults take at least one medication or dietary supplement every day; almost a third take at least five. The more you use, the greater your risk of bad interactions, especially if multiple doctors prescribe different drugs without knowing what you already take.
Add doctors' notoriously bad handwriting and sound-alike drug names: Was that order for 10 milligrams or 10 migrams? The hormone Premarin or the antibiotic Primaxin?
Moreover, consumer instructions are woefully inadequate, the report concludes. One study found parents gave their children the wrong dose of over-the-counter fever medicines 47 percent of the time.
Then there was man with newly diagnosed asthma wondering why his inhaler didn't work. Asked how he used it, the middle-age man squirted two puffs into the air and tried to breathe the mist. His original doctor had demonstrated the inhaler without telling him to spray it inside his mouth.
Among the report's recommendations:
•The government should speed electronic prescribing, including fostering technology improvements so that the myriad computer programs used by doctors, hospitals and drugstores are compatible.
Fewer than about 20 percent of prescriptions are electronic, said report co-author Michael Cohen, president of the Institute for Safe Medication Practices. E-prescribing does more than counter bad handwriting. The computer programs can be linked to databases that flash an alert if the prescribed dose seems high or if the patient's records show use of another drug that can dangerously interact.
•The government should speed electronic prescribing, including fostering technology improvements so that the myriad computer programs used by doctors, hospitals and drugstores are compatible.
Fewer than about 20 percent of prescriptions are electronic, said report co-author Michael Cohen, president of the Institute for Safe Medication Practices. E-prescribing does more than counter bad handwriting. The computer programs can be linked to databases that flash an alert if the prescribed dose seems high or if the patient's records show use of another drug that can dangerously interact.
•Patients and their families must be aggressive in questioning doctors, nurses and pharmacists about medications. Get a list of each drug you're prescribed, why and the dose from each doctor and pharmacy you use, and show it at every doctor visit.
"Take active steps to make sure you know what you're getting, and is it what you need," said report co-author Dr. Wilson Pace of the University of Colorado.
•The nation should invest about $100 million annually on research into drug errors and how to prevent them. Among the most-needed studies is the impact of free drug samples, which often lack proper labeling, on medication safety.
•The Food and Drug Administration should improve the quality of drug information leaflets that accompany prescription drugs, but often have incomplete information or are written in consumer-confusing jargon.
•The government should establish national telephone hotlines to help patients unable to understand printed drug information because of illiteracy, language barriers or other problems.
Read article at the original source
Monday, May 29, 2006
Medical Guesswork
Medical Guesswork
From heart surgery to prostate care, the health industry knows little about which common treatments really work
By John Carey, BusinessWeek, May 29, 2006
The signs at the meeting were not propitious. Half the board members of Kaiser Permanente's Care Management Institute left before Dr. David Eddy finally got the 10 minutes he had pleaded for. But the message Eddy delivered was riveting. With a groundbreaking computer simulation, Eddy showed that the conventional approach to treating diabetes did little to prevent the heart attacks and strokes that are complications of the disease. In contrast, a simple regimen of aspirin and generic drugs to lower blood pressure and cholesterol sent the rate of such incidents plunging. The payoff: healthier lives and hundreds of millions in savings. "I told them: 'This is as good as it gets to improve care and lower costs, which doesn't happen often in medicine,"' Eddy recalls. "'If you don't implement this,' I said, 'you might as well close up shop."'
The message got through. Three years later, Kaiser is in the midst of a major initiative to change the treatment of the diabetics in its care. "We're trying to put nearly a million people on these drugs," says Dr. Paul Wallace, senior adviser to the Care Management Institute. The early results: The strategy is indeed improving care and cutting costs, just as Eddy's model predicted.
For Eddy, this is one small step toward solving the thorniest riddle in medicine -- a dark secret he has spent his career exposing. "The problem is that we don't know what we are doing," he says. Even today, with a high-tech health-care system that costs the nation $2 trillion a year, there is little or no evidence that many widely used treatments and procedures actually work better than various cheaper alternatives.
This judgment pertains to a shocking number of conditions or diseases, from cardiovascular woes to back pain to prostate cancer. During his long and controversial career proving that the practice of medicine is more guesswork than science, Eddy has repeatedly punctured cherished physician myths. He showed, for instance, that the annual chest X-ray was worthless, over the objections of doctors who made money off the regular visit. He proved that doctors had little clue about the success rate of procedures such as surgery for enlarged prostates. He traced one common practice -- preventing women from giving birth vaginally if they had previously had a cesarean -- to the recommendation of one lone doctor. Indeed, when he began taking on medicine's sacred cows, Eddy liked to cite a figure that only 15% of what doctors did was backed by hard evidence.
A great many doctors and health-care quality experts have come to endorse Eddy's critique. And while there has been progress in recent years, most of these physicians say the portion of medicine that has been proven effective is still outrageously low -- in the range of 20% to 25%. "We don't have the evidence [that treatments work], and we are not investing very much in getting the evidence," says Dr. Stephen C. Schoenbaum, executive vice-president of the Commonwealth Fund and former president of Harvard Pilgrim Health Care Inc. "Clearly, there is a lot in medicine we don't have definitive answers to," adds Dr. I. Steven Udvarhelyi, senior vice-president and chief medical officer at Pennsylvania's Independence Blue Cross.
What's required is a revolution called "evidence-based medicine," says Eddy, a heart surgeon turned mathematician and health-care economist. Tall, lean, and fit at 64, Eddy has the athletic stride and catlike reflexes of the ace rock climber he still is. He also exhibits the competitive drive of someone who once obsessively recorded his time on every training run, and who still likes to be first on a brisk walk up a hill near his home in Aspen, Colo. In his career, he has never been afraid to take a difficult path or an unpopular stand. "Evidence-based" is a term he coined in the early 1980s, and it has since become a rallying cry among medical reformers. The goal of this movement is to pierce the fog that envelops the practice of medicine -- a state of ignorance for which doctors cannot really be blamed. "The limitation is the human mind," Eddy says. Without extensive information on the outcomes of treatments, it's fiendishly difficult to know the best approach for care.
The human brain, Eddy explains, needs help to make sense of patients who have combinations of diseases, and of the complex probabilities involved in each. To provide that assistance, Eddy has spent the past 10 years leading a team to develop the computer model that helped him crack the diabetes puzzle. Dubbed Archimedes, this program seeks to mimic in equations the actual biology of the body, and make treatment recommendations as well as figure out what each approach costs. It is at least 10 times "better than the model we use now, which is called thinking," says Dr. Richard Kahn, chief scientific officer at the American Diabetes Assn.
Can one computer program offset all the ill-advised treatment options for a whole range of different diseases?
Read the entire article at the original source
From heart surgery to prostate care, the health industry knows little about which common treatments really work
By John Carey, BusinessWeek, May 29, 2006
The signs at the meeting were not propitious. Half the board members of Kaiser Permanente's Care Management Institute left before Dr. David Eddy finally got the 10 minutes he had pleaded for. But the message Eddy delivered was riveting. With a groundbreaking computer simulation, Eddy showed that the conventional approach to treating diabetes did little to prevent the heart attacks and strokes that are complications of the disease. In contrast, a simple regimen of aspirin and generic drugs to lower blood pressure and cholesterol sent the rate of such incidents plunging. The payoff: healthier lives and hundreds of millions in savings. "I told them: 'This is as good as it gets to improve care and lower costs, which doesn't happen often in medicine,"' Eddy recalls. "'If you don't implement this,' I said, 'you might as well close up shop."'
The message got through. Three years later, Kaiser is in the midst of a major initiative to change the treatment of the diabetics in its care. "We're trying to put nearly a million people on these drugs," says Dr. Paul Wallace, senior adviser to the Care Management Institute. The early results: The strategy is indeed improving care and cutting costs, just as Eddy's model predicted.
For Eddy, this is one small step toward solving the thorniest riddle in medicine -- a dark secret he has spent his career exposing. "The problem is that we don't know what we are doing," he says. Even today, with a high-tech health-care system that costs the nation $2 trillion a year, there is little or no evidence that many widely used treatments and procedures actually work better than various cheaper alternatives.
This judgment pertains to a shocking number of conditions or diseases, from cardiovascular woes to back pain to prostate cancer. During his long and controversial career proving that the practice of medicine is more guesswork than science, Eddy has repeatedly punctured cherished physician myths. He showed, for instance, that the annual chest X-ray was worthless, over the objections of doctors who made money off the regular visit. He proved that doctors had little clue about the success rate of procedures such as surgery for enlarged prostates. He traced one common practice -- preventing women from giving birth vaginally if they had previously had a cesarean -- to the recommendation of one lone doctor. Indeed, when he began taking on medicine's sacred cows, Eddy liked to cite a figure that only 15% of what doctors did was backed by hard evidence.
A great many doctors and health-care quality experts have come to endorse Eddy's critique. And while there has been progress in recent years, most of these physicians say the portion of medicine that has been proven effective is still outrageously low -- in the range of 20% to 25%. "We don't have the evidence [that treatments work], and we are not investing very much in getting the evidence," says Dr. Stephen C. Schoenbaum, executive vice-president of the Commonwealth Fund and former president of Harvard Pilgrim Health Care Inc. "Clearly, there is a lot in medicine we don't have definitive answers to," adds Dr. I. Steven Udvarhelyi, senior vice-president and chief medical officer at Pennsylvania's Independence Blue Cross.
What's required is a revolution called "evidence-based medicine," says Eddy, a heart surgeon turned mathematician and health-care economist. Tall, lean, and fit at 64, Eddy has the athletic stride and catlike reflexes of the ace rock climber he still is. He also exhibits the competitive drive of someone who once obsessively recorded his time on every training run, and who still likes to be first on a brisk walk up a hill near his home in Aspen, Colo. In his career, he has never been afraid to take a difficult path or an unpopular stand. "Evidence-based" is a term he coined in the early 1980s, and it has since become a rallying cry among medical reformers. The goal of this movement is to pierce the fog that envelops the practice of medicine -- a state of ignorance for which doctors cannot really be blamed. "The limitation is the human mind," Eddy says. Without extensive information on the outcomes of treatments, it's fiendishly difficult to know the best approach for care.
The human brain, Eddy explains, needs help to make sense of patients who have combinations of diseases, and of the complex probabilities involved in each. To provide that assistance, Eddy has spent the past 10 years leading a team to develop the computer model that helped him crack the diabetes puzzle. Dubbed Archimedes, this program seeks to mimic in equations the actual biology of the body, and make treatment recommendations as well as figure out what each approach costs. It is at least 10 times "better than the model we use now, which is called thinking," says Dr. Richard Kahn, chief scientific officer at the American Diabetes Assn.
Can one computer program offset all the ill-advised treatment options for a whole range of different diseases?
Read the entire article at the original source
Wednesday, April 26, 2006
Drugs companies 'inventing diseases to boost their profits' - World - Times Online
Drugs companies 'inventing diseases to boost their profits'
Drugs companies 'inventing diseases to boost their profits'
By Mark Henderson, Science Correspondent, The Times, April 11, 2006
Pharmaceutical companies are systematically creating diseases in order to sell more of their products, turning healthy people into patients and placing many at risk of harm, a special edition of a leading medical journal claims today.
The practice of “diseasemongering” by the drug industry is promoting non-existent illnesses or exaggerating minor ones for the sake of profits, according to a set of essays published by the open-access journal Public Library of Science Medicine.
The special issue, edited by David Henry, of Newcastle University in Australia, and Ray Moynihan, an Australian journalist, reports that conditions such as female sexual dysfunction, attention deficit hyperactivity disorder (ADHD) and “restless legs syndrome” have been promoted by companies hoping to sell more of their drugs.
Other minor problems that are a normal part of life, such as symptoms of the menopause, are also becoming increasingly “medicalised”, while risk factors such as high cholesterol levels or osteoporosis are being presented as diseases in their own right, according to the editors.
“Disease-mongering turns healthy people into patients, wastes precious resources and causes iatrogenic (medically induced) harm,” they say. “Like the marketing strategies that drive it, disease-mongering poses a global challenge to those interested in public health, demanding in turn a global response.”
Doctors, patients and support groups need to be more aware that pharmaceutical companies are taking this approach, and more research is needed into the changing ways in which conditions are presented, according to the writers.
Disease-awareness campaigns are often funded by drug companies, and “more often designed to sell drugs than to illuminate or inform or educate about the prevention of illness or the maintenance of health”, they say.
Particular conditions that are highlighted in the journal include sexual function in both men and women. The prevalence of female sexual dysfunction, one paper claims, has been highly exaggerated to provide a new market for drugs, while the makers of anti-impotence medicines, such as Viagra and Cialis, have been involved with their presentation as lifestyle drugs that can boost the sexual prowess of healthy men.
Ordinary shyness is routinely presented as a social anxiety disorder and treated with antidepressants, while newly identified conditions such as “restless legs syndrome” — a constant urge to move one’s legs — are presented as being much more common than they really are.
Richard Ley, of the Association of the British Pharmaceutical Industry, rejected the accusations, pointing out that Britain has firm safeguards against disease-mongering. Many of the authors’ criticisms, he said, were aimed squarely at countries such as the United States, where pharmaceuticals can be openly advertised directly to patients.
“Drug companies are not allowed to communicate directly with patients, and we do not invent diseases,” he said.
“We provide information that there are treatments out there that might help certain conditions, but at the end of the day it is down to health professionals to decide if they are appropriate.
“The best safeguard is that the doctor who knows the product and knows the patient’s history is the one who decides what to prescribe.”
TRICK OR TREAT?
MENOPAUSE
Symptoms include hot flushes, night sweats and loss of libido
Criticism too often “medicalised” as part of a “disorder” when it is a normal phase of life
IRRITABLE BOWEL SYNDROME
Symptoms include constipation, cramps and diarrhoea
Criticism promoted by drug companies as a serious illness needing therapy, when it is usually a mild problem
SEXUAL DYSFUNCTION
Symptoms impotence in men, lack of libido or difficulty becoming aroused in women
Criticism drugs such as Viagra marketed not only for treating genuine erectile dysfunction caused by medical problems but as lifestyle improvers
OSTEOPOROSIS
Symptoms thinning of the bones, particularly among postmenopausal women
Criticism portrayed as a disease in its own right, when it is really a risk factor for broken bones
RESTLESS LEGS
Symptoms urge to move legs because of unpleasant feelings, often at night
Criticism prevalence of a relatively rare condition exaggerated by the media, along with the need for treatment
Read at the original source
Drugs companies 'inventing diseases to boost their profits'
By Mark Henderson, Science Correspondent, The Times, April 11, 2006
Pharmaceutical companies are systematically creating diseases in order to sell more of their products, turning healthy people into patients and placing many at risk of harm, a special edition of a leading medical journal claims today.
The practice of “diseasemongering” by the drug industry is promoting non-existent illnesses or exaggerating minor ones for the sake of profits, according to a set of essays published by the open-access journal Public Library of Science Medicine.
The special issue, edited by David Henry, of Newcastle University in Australia, and Ray Moynihan, an Australian journalist, reports that conditions such as female sexual dysfunction, attention deficit hyperactivity disorder (ADHD) and “restless legs syndrome” have been promoted by companies hoping to sell more of their drugs.
Other minor problems that are a normal part of life, such as symptoms of the menopause, are also becoming increasingly “medicalised”, while risk factors such as high cholesterol levels or osteoporosis are being presented as diseases in their own right, according to the editors.
“Disease-mongering turns healthy people into patients, wastes precious resources and causes iatrogenic (medically induced) harm,” they say. “Like the marketing strategies that drive it, disease-mongering poses a global challenge to those interested in public health, demanding in turn a global response.”
Doctors, patients and support groups need to be more aware that pharmaceutical companies are taking this approach, and more research is needed into the changing ways in which conditions are presented, according to the writers.
Disease-awareness campaigns are often funded by drug companies, and “more often designed to sell drugs than to illuminate or inform or educate about the prevention of illness or the maintenance of health”, they say.
Particular conditions that are highlighted in the journal include sexual function in both men and women. The prevalence of female sexual dysfunction, one paper claims, has been highly exaggerated to provide a new market for drugs, while the makers of anti-impotence medicines, such as Viagra and Cialis, have been involved with their presentation as lifestyle drugs that can boost the sexual prowess of healthy men.
Ordinary shyness is routinely presented as a social anxiety disorder and treated with antidepressants, while newly identified conditions such as “restless legs syndrome” — a constant urge to move one’s legs — are presented as being much more common than they really are.
Richard Ley, of the Association of the British Pharmaceutical Industry, rejected the accusations, pointing out that Britain has firm safeguards against disease-mongering. Many of the authors’ criticisms, he said, were aimed squarely at countries such as the United States, where pharmaceuticals can be openly advertised directly to patients.
“Drug companies are not allowed to communicate directly with patients, and we do not invent diseases,” he said.
“We provide information that there are treatments out there that might help certain conditions, but at the end of the day it is down to health professionals to decide if they are appropriate.
“The best safeguard is that the doctor who knows the product and knows the patient’s history is the one who decides what to prescribe.”
TRICK OR TREAT?
MENOPAUSE
Symptoms include hot flushes, night sweats and loss of libido
Criticism too often “medicalised” as part of a “disorder” when it is a normal phase of life
IRRITABLE BOWEL SYNDROME
Symptoms include constipation, cramps and diarrhoea
Criticism promoted by drug companies as a serious illness needing therapy, when it is usually a mild problem
SEXUAL DYSFUNCTION
Symptoms impotence in men, lack of libido or difficulty becoming aroused in women
Criticism drugs such as Viagra marketed not only for treating genuine erectile dysfunction caused by medical problems but as lifestyle improvers
OSTEOPOROSIS
Symptoms thinning of the bones, particularly among postmenopausal women
Criticism portrayed as a disease in its own right, when it is really a risk factor for broken bones
RESTLESS LEGS
Symptoms urge to move legs because of unpleasant feelings, often at night
Criticism prevalence of a relatively rare condition exaggerated by the media, along with the need for treatment
Read at the original source
Friday, February 17, 2006
When Trust in Doctors Erodes, Other Treatments Fill the Void
When Trust in Doctors Erodes, Other Treatments Fill the Void
By BENEDICT CAREY, New York Times, February 3, 2006
A few moments before boarding a plane from Los Angeles to New York in January, Charlene Solomon performed her usual preflight ritual: she chewed a small tablet that contained trace amounts of several herbs, including extracts from daisy and chamomile plants.
Ms. Solomon, 56, said she had no way to know whether the tablet, an herb-based remedy for jet lag, worked as advertised. Researchers have found no evidence that such preparations are effective, and Ms. Solomon knows that most doctors would scoff that she was wasting her money.
Yet she swears by the tablets, as well as other alternative remedies, for reasons she acknowledges are partly psychological.
"I guess I do believe in the power of simply paying attention to your health, which in a way is what I'm doing," said Ms. Solomon, who runs a Web consulting business in Los Angeles. "But I also believe there are simply a lot of unknowns when it comes to staying healthy, and if there's a possibility something will help I'm willing to try it."
Besides, she added, "whatever I'm doing is working, so I'm going to keep doing it."
The most telling evidence of Americans' dissatisfaction with traditional health care is the more than $27 billion they spend annually on alternative and complementary medicine, according to government estimates. In ways large and small, millions of people are taking active steps to venture outside the mainstream, whether by taking the herbal remedy echinacea for a cold or by placing their last hopes for cancer cure in alternative treatment, as did Coretta Scott King, who died this week at an alternative hospice clinic in Mexico.
They do not appear to care that there is little, if any, evidence that many of the therapies work. Nor do they seem to mind that alternative therapy practitioners have a fraction of the training mainstream doctors do or that vitamin and herb makers are as profit-driven as drug makers.
This straying from conventional medicine is often rooted in a sense of disappointment, even betrayal, many patients and experts say. When patients see conventional medicine's inadequacies up close — a misdiagnosis, an intolerable drug, failed surgery, even a dismissive doctor — many find the experience profoundly disillusioning, or at least eye-opening.
Haggles with insurance providers, conflicting findings from medical studies and news reports of drug makers' covering up product side effects all feed their disaffection, to the point where many people begin to question not only the health care system but also the science behind it. Soon, intuition and the personal experience of friends and family may seem as trustworthy as advice from a doctor in diagnosing an illness or judging a treatment.
Experts say that people with serious medical problems like diabetes or cancer are least likely to take their chances with natural medicine, unless their illness is terminal. Consumers generally know that quackery is widespread in alternative practices, that there is virtually no government oversight of so-called natural remedies and that some treatments, like enemas, can be dangerous.
Still, 48 percent of American adults used at least one alternative or complementary therapy in 2004, up from 42 percent a decade ago, a figure that includes students and retirees, soccer moms and truckers, New Age seekers and religious conservatives. The numbers continue to grow, experts say, for reasons that have as much to do with increasing distrust of mainstream medicine and the psychological appeal of nontraditional approaches as with the therapeutic properties of herbs or other supplements.
"I think there is a powerful element of nostalgia at work for many people, for home remedies — for what healing is supposed to be — combined with an idealized vision of what is natural and whole and good, " said Dr. Linda Barnes, a medical anthropologist at Boston University School of Medicine.
Dr. Barnes added, "People look around and feel that the conventional system does not measure up, and that something deeper about their well-being is not being addressed at all."
Healthy and Dabbling
Ms. Solomon's first small steps outside the mainstream came in 1991, after she watched her mother die of complications from a hysterectomy.
"I saw doctors struggling to save her," she said. "They were trying really hard, and I have great respect for what they do, but at that point I realized the doctors could only do so much."
She decided then that she needed to take more responsibility for her own health, by eating better, exercising more and seeking out health aids that she thought of as natural, meaning not prescribed by a doctor or developed by a pharmaceutical company.
"I usually stay away from drugs if I can, because the side effects even of cough and cold medicines can be pretty strong," she said.
The herbal preparations she uses, she said, "have no side effects, and the difference in my view is that they help support my own body's natural capability, to fight off disease" rather than treat symptoms.
If these sentiments are present in someone like Ms. Solomon, who regularly consults her internist and describes herself as "pretty mainstream," they run far deeper in millions of other people who use nontraditional therapies more often.
In interviews and surveys, these patients often described prescription drugs as poisons that mostly mask symptoms without improving their underlying cause.
Many extend their suspicions further. In a 2004 study, researchers at the University of Arizona conducted interviews with a group of men and women in Tucson who suffered from chronic arthritis, most of whom regularly used alternative therapies. Those who used alternative methods exclusively valued the treatments on the "rightness of fit" above other factors, and they were inherently skeptical of the health care system.
Distrust in the medical industrial complex, as some patients call it, stems in part from suspicions that insurers warp medical decision making, and in part from the belief that drug companies are out to sell as many drugs as possible, regardless of patients' needs, interviews show.
"I do partly blame the drug companies and the money they make" for the breakdown in trust in the medical system, said Joyce Newman, 74, of Lynnwood Wash., who sees a natural medicine specialist as her primary doctor. "The time when you would listen to your doctor and do whatever he said — that time is long gone, in my opinion. You have to learn to use your own head."
From here it is a small step to begin doubting medical science. If Western medicine is imperfect and sometimes corrupt, then mainstream doctors may not be the best judge of treatments after all, many patients conclude. People's actual experience — the personal testimony of friends and family, in particular — feels more truthful.
To best way to validate this, said Ms. Newman and many others who regularly use nontraditional therapies, is simply to try a remedy "and listen to your own body."
Opting Out
Cynthia Riley effectively opted out of mainstream medicine when it seemed that doctors were not listening to her.
During a nine-year period that ended in 2004, Ms. Riley, 47, visited almost 20 doctors, for a variety of intermittent and strange health complaints: blurred vision, urinary difficulties, balance problems so severe that at times she wobbled like a drunk.
She felt unwell most of the time, but doctors could not figure out what she had.
Each specialist ordered different tests, depending on the symptom, Ms. Riley said, but they were usually rushed and seemed to solicit her views only as a formality.
Undeterred, Ms. Riley, an event planner who lives near New London, Conn., typed out a four-page description of her ordeal, including her suspicion that she suffered from lead poisoning. One neurologist waved the report away as if insulted; another barely skimmed it, she said.
"I remember sitting in one doctor's office and realizing, 'He thinks I'm crazy,' " Ms. Riley said. "I was getting absolutely nowhere in conventional medicine, and I was determined to get to the root of my problems."
Through word of mouth, Ms. Riley heard about Deirdre O'Connor, a naturopath with a thriving practice in nearby Mystic, Conn., and made an appointment.
In recent years, people searching for something outside of conventional medicine have increasingly turned to naturopaths, herbal specialists who must complete a degree that includes some standard medical training in order to be licensed, experts say. Fourteen states, including California and Connecticut, now license naturopaths to practice medicine. Natural medicine groups are pushing for similar legislation in other states, including New York.
Licensed naturopaths can prescribe drugs from an approved list in some states, but have no prescribing rights in others.
Right away, Ms. Riley said, she noticed a difference in the level of service. Before even visiting the office, she received a fat envelope in the mail containing a four-page questionnaire, she said. In addition to asking detailed questions about medical history — standard information — it asked about energy level, foods she craved, sensitivity to weather and self-image: "Please list adjectives that describe you," read one item.
"It felt right, from the beginning," Ms. Riley said.
Her first visit lasted an hour and a half, and Ms. O'Connor, the naturopath, agreed that metal exposure was a possible cause of her symptoms. It emerged in their interview that Ms. Riley had worked in the steel industry, and tests of her hair and urine showed elevated levels of both lead and mercury, Ms. O'Connor said.
After taking a combination of herbs, vitamins and regular doses of a drug called dimercaptosuccinic acid, or DMSA, to treat lead poisoning, Ms. Riley said, she began to feel better, and the symptoms subsided.
Along the way, Ms. O'Connor explained the treatments to Ms. Riley, sometimes using drawings, and called her patient regularly to check in, especially during the first few months, Ms. Riley said.
Other doctors said they could not comment on Ms. Riley's case because they had not examined her. Researchers who specialize in lead poisoning say that it is rare in adults but that it can cause neurological symptoms and bladder problems and is often missed by primary care doctors.
Dr. Herbert Needleman, a psychiatrist who directs the lead research group at the University of Pittsburgh, said DMSA was the pharmaceutical treatment of choice for high blood lead levels.
Researchers say there is little or no evidence that vitamins or herbs can relieve symptoms like Ms. Riley's. Still, she said, "I look and feel better than I have in years."
Life and Death
Diane Paradise bet her life on the uncertain benefits of natural medicine, after being burned physically and emotionally by conventional doctors.
In 1995, doctors told Ms. Paradise, now 35, that she had Hodgkin's disease. After a six-month course of chemotherapy and radiation, she said, she was declared cancer free, and she remained healthy for five years.
But in 2001 the cancer reappeared, more advanced, and her doctors recommended a 10-month course of drugs and radiation, plus a marrow transplant, she said.
Ms. Paradise, a marketing consultant in Rochester, N.Y., balked.
"I was burned badly the first time around, third-degree burns, and now they were talking about 10 months," she said in an interview, "and they were giving me no guarantees; they said it was experimental. That's when I started looking around. I really had nothing to lose, and I was focused on quality of life at that point, not quantity."
When she told one of her doctors that she was considering an alternative treatment in Arizona, the man exploded, she said.
"His exact words were, 'That's not treatment, that's a vacation — you're wasting your time!' " she said.
And so ended the relationship. With help from friends, Ms. Paradise raised about $40,000 to pay for the Arizona clinic's treatment, plus living expenses while there.
"I had absolutely no scientific reason for choosing this route, none," she said. "I just think there are times in our life when we are asked to make decisions based on our intuition, on our gut instinct, not based on evidence put in front of us, and for me this was one of those moments."
Cancer researchers say that there is no evidence that vitamins, herbs or other alternative therapies can cure cancer, and they caution that some regimens may worsen the disease.
But Ms. Paradise said that her relationship with the natural medicine specialist in Arizona had been collaborative and that she had felt "more empowered, more involved" in the treatment plan, which included large doses of vitamins, as well as changes in diet and sleep routines. After four months on the regimen, she said, she felt much better.
But the cancer was not cured. It has resurfaced recently and spread, and this time Ms. Paradise has started an experimental treatment with an oncologist in New York.
She is complementing this treatment, she said, with another course of alternative therapy in Arizona. She moved in with friends near Phoenix and started the alternative regime in January.
"It's 79 degrees and beautiful here," she said by phone in mid-January. "Let's hope that's a good sign."
For all their suspicions and questions about conventional medicine, those who venture outside the mainstream tend to have one thing in abundance, experts say: hope. In a 1998 survey of more than 1,000 adults from around the country, researchers found that having an interest in "personal growth or spirituality" predicted alternative medicine use.
Nontraditional healers know this, and they often offer some spiritual element in their practice, if they think it is appropriate. David Wood, a naturopath who with his wife, Cheryl, runs a large, Christian-oriented practice in Lynnwood, Wash., said he treated patients of all faiths.
"We pray with patients, with their permission," said Mr. Wood, who also works with local medical doctors when necessary. "If patients would not like us to pray for them, we don't, but it's there if needed."
He added, "Our goal here is to help people get really well, not merely free of symptoms."
That is exactly the sentiment that many Americans say they feel is missing from conventional medicine. Whatever the benefits and risks of its many concoctions and methods, alternative medicine offers them at least the promise of affectionate care, unhurried service, freedom from prescription drug side effects and the potential for feeling not just better but also spiritually recharged.
"I don't hate doctors or anything," Ms. Newman said. "I just know they can make mistakes, and so often they refer you on to see another doctor, and another."
Seeing a naturopath, she said, "I feel I'm known, they see me as a whole person, they listen to what I say."
Read at the original source
By BENEDICT CAREY, New York Times, February 3, 2006
A few moments before boarding a plane from Los Angeles to New York in January, Charlene Solomon performed her usual preflight ritual: she chewed a small tablet that contained trace amounts of several herbs, including extracts from daisy and chamomile plants.
Ms. Solomon, 56, said she had no way to know whether the tablet, an herb-based remedy for jet lag, worked as advertised. Researchers have found no evidence that such preparations are effective, and Ms. Solomon knows that most doctors would scoff that she was wasting her money.
Yet she swears by the tablets, as well as other alternative remedies, for reasons she acknowledges are partly psychological.
"I guess I do believe in the power of simply paying attention to your health, which in a way is what I'm doing," said Ms. Solomon, who runs a Web consulting business in Los Angeles. "But I also believe there are simply a lot of unknowns when it comes to staying healthy, and if there's a possibility something will help I'm willing to try it."
Besides, she added, "whatever I'm doing is working, so I'm going to keep doing it."
The most telling evidence of Americans' dissatisfaction with traditional health care is the more than $27 billion they spend annually on alternative and complementary medicine, according to government estimates. In ways large and small, millions of people are taking active steps to venture outside the mainstream, whether by taking the herbal remedy echinacea for a cold or by placing their last hopes for cancer cure in alternative treatment, as did Coretta Scott King, who died this week at an alternative hospice clinic in Mexico.
They do not appear to care that there is little, if any, evidence that many of the therapies work. Nor do they seem to mind that alternative therapy practitioners have a fraction of the training mainstream doctors do or that vitamin and herb makers are as profit-driven as drug makers.
This straying from conventional medicine is often rooted in a sense of disappointment, even betrayal, many patients and experts say. When patients see conventional medicine's inadequacies up close — a misdiagnosis, an intolerable drug, failed surgery, even a dismissive doctor — many find the experience profoundly disillusioning, or at least eye-opening.
Haggles with insurance providers, conflicting findings from medical studies and news reports of drug makers' covering up product side effects all feed their disaffection, to the point where many people begin to question not only the health care system but also the science behind it. Soon, intuition and the personal experience of friends and family may seem as trustworthy as advice from a doctor in diagnosing an illness or judging a treatment.
Experts say that people with serious medical problems like diabetes or cancer are least likely to take their chances with natural medicine, unless their illness is terminal. Consumers generally know that quackery is widespread in alternative practices, that there is virtually no government oversight of so-called natural remedies and that some treatments, like enemas, can be dangerous.
Still, 48 percent of American adults used at least one alternative or complementary therapy in 2004, up from 42 percent a decade ago, a figure that includes students and retirees, soccer moms and truckers, New Age seekers and religious conservatives. The numbers continue to grow, experts say, for reasons that have as much to do with increasing distrust of mainstream medicine and the psychological appeal of nontraditional approaches as with the therapeutic properties of herbs or other supplements.
"I think there is a powerful element of nostalgia at work for many people, for home remedies — for what healing is supposed to be — combined with an idealized vision of what is natural and whole and good, " said Dr. Linda Barnes, a medical anthropologist at Boston University School of Medicine.
Dr. Barnes added, "People look around and feel that the conventional system does not measure up, and that something deeper about their well-being is not being addressed at all."
Healthy and Dabbling
Ms. Solomon's first small steps outside the mainstream came in 1991, after she watched her mother die of complications from a hysterectomy.
"I saw doctors struggling to save her," she said. "They were trying really hard, and I have great respect for what they do, but at that point I realized the doctors could only do so much."
She decided then that she needed to take more responsibility for her own health, by eating better, exercising more and seeking out health aids that she thought of as natural, meaning not prescribed by a doctor or developed by a pharmaceutical company.
"I usually stay away from drugs if I can, because the side effects even of cough and cold medicines can be pretty strong," she said.
The herbal preparations she uses, she said, "have no side effects, and the difference in my view is that they help support my own body's natural capability, to fight off disease" rather than treat symptoms.
If these sentiments are present in someone like Ms. Solomon, who regularly consults her internist and describes herself as "pretty mainstream," they run far deeper in millions of other people who use nontraditional therapies more often.
In interviews and surveys, these patients often described prescription drugs as poisons that mostly mask symptoms without improving their underlying cause.
Many extend their suspicions further. In a 2004 study, researchers at the University of Arizona conducted interviews with a group of men and women in Tucson who suffered from chronic arthritis, most of whom regularly used alternative therapies. Those who used alternative methods exclusively valued the treatments on the "rightness of fit" above other factors, and they were inherently skeptical of the health care system.
Distrust in the medical industrial complex, as some patients call it, stems in part from suspicions that insurers warp medical decision making, and in part from the belief that drug companies are out to sell as many drugs as possible, regardless of patients' needs, interviews show.
"I do partly blame the drug companies and the money they make" for the breakdown in trust in the medical system, said Joyce Newman, 74, of Lynnwood Wash., who sees a natural medicine specialist as her primary doctor. "The time when you would listen to your doctor and do whatever he said — that time is long gone, in my opinion. You have to learn to use your own head."
From here it is a small step to begin doubting medical science. If Western medicine is imperfect and sometimes corrupt, then mainstream doctors may not be the best judge of treatments after all, many patients conclude. People's actual experience — the personal testimony of friends and family, in particular — feels more truthful.
To best way to validate this, said Ms. Newman and many others who regularly use nontraditional therapies, is simply to try a remedy "and listen to your own body."
Opting Out
Cynthia Riley effectively opted out of mainstream medicine when it seemed that doctors were not listening to her.
During a nine-year period that ended in 2004, Ms. Riley, 47, visited almost 20 doctors, for a variety of intermittent and strange health complaints: blurred vision, urinary difficulties, balance problems so severe that at times she wobbled like a drunk.
She felt unwell most of the time, but doctors could not figure out what she had.
Each specialist ordered different tests, depending on the symptom, Ms. Riley said, but they were usually rushed and seemed to solicit her views only as a formality.
Undeterred, Ms. Riley, an event planner who lives near New London, Conn., typed out a four-page description of her ordeal, including her suspicion that she suffered from lead poisoning. One neurologist waved the report away as if insulted; another barely skimmed it, she said.
"I remember sitting in one doctor's office and realizing, 'He thinks I'm crazy,' " Ms. Riley said. "I was getting absolutely nowhere in conventional medicine, and I was determined to get to the root of my problems."
Through word of mouth, Ms. Riley heard about Deirdre O'Connor, a naturopath with a thriving practice in nearby Mystic, Conn., and made an appointment.
In recent years, people searching for something outside of conventional medicine have increasingly turned to naturopaths, herbal specialists who must complete a degree that includes some standard medical training in order to be licensed, experts say. Fourteen states, including California and Connecticut, now license naturopaths to practice medicine. Natural medicine groups are pushing for similar legislation in other states, including New York.
Licensed naturopaths can prescribe drugs from an approved list in some states, but have no prescribing rights in others.
Right away, Ms. Riley said, she noticed a difference in the level of service. Before even visiting the office, she received a fat envelope in the mail containing a four-page questionnaire, she said. In addition to asking detailed questions about medical history — standard information — it asked about energy level, foods she craved, sensitivity to weather and self-image: "Please list adjectives that describe you," read one item.
"It felt right, from the beginning," Ms. Riley said.
Her first visit lasted an hour and a half, and Ms. O'Connor, the naturopath, agreed that metal exposure was a possible cause of her symptoms. It emerged in their interview that Ms. Riley had worked in the steel industry, and tests of her hair and urine showed elevated levels of both lead and mercury, Ms. O'Connor said.
After taking a combination of herbs, vitamins and regular doses of a drug called dimercaptosuccinic acid, or DMSA, to treat lead poisoning, Ms. Riley said, she began to feel better, and the symptoms subsided.
Along the way, Ms. O'Connor explained the treatments to Ms. Riley, sometimes using drawings, and called her patient regularly to check in, especially during the first few months, Ms. Riley said.
Other doctors said they could not comment on Ms. Riley's case because they had not examined her. Researchers who specialize in lead poisoning say that it is rare in adults but that it can cause neurological symptoms and bladder problems and is often missed by primary care doctors.
Dr. Herbert Needleman, a psychiatrist who directs the lead research group at the University of Pittsburgh, said DMSA was the pharmaceutical treatment of choice for high blood lead levels.
Researchers say there is little or no evidence that vitamins or herbs can relieve symptoms like Ms. Riley's. Still, she said, "I look and feel better than I have in years."
Life and Death
Diane Paradise bet her life on the uncertain benefits of natural medicine, after being burned physically and emotionally by conventional doctors.
In 1995, doctors told Ms. Paradise, now 35, that she had Hodgkin's disease. After a six-month course of chemotherapy and radiation, she said, she was declared cancer free, and she remained healthy for five years.
But in 2001 the cancer reappeared, more advanced, and her doctors recommended a 10-month course of drugs and radiation, plus a marrow transplant, she said.
Ms. Paradise, a marketing consultant in Rochester, N.Y., balked.
"I was burned badly the first time around, third-degree burns, and now they were talking about 10 months," she said in an interview, "and they were giving me no guarantees; they said it was experimental. That's when I started looking around. I really had nothing to lose, and I was focused on quality of life at that point, not quantity."
When she told one of her doctors that she was considering an alternative treatment in Arizona, the man exploded, she said.
"His exact words were, 'That's not treatment, that's a vacation — you're wasting your time!' " she said.
And so ended the relationship. With help from friends, Ms. Paradise raised about $40,000 to pay for the Arizona clinic's treatment, plus living expenses while there.
"I had absolutely no scientific reason for choosing this route, none," she said. "I just think there are times in our life when we are asked to make decisions based on our intuition, on our gut instinct, not based on evidence put in front of us, and for me this was one of those moments."
Cancer researchers say that there is no evidence that vitamins, herbs or other alternative therapies can cure cancer, and they caution that some regimens may worsen the disease.
But Ms. Paradise said that her relationship with the natural medicine specialist in Arizona had been collaborative and that she had felt "more empowered, more involved" in the treatment plan, which included large doses of vitamins, as well as changes in diet and sleep routines. After four months on the regimen, she said, she felt much better.
But the cancer was not cured. It has resurfaced recently and spread, and this time Ms. Paradise has started an experimental treatment with an oncologist in New York.
She is complementing this treatment, she said, with another course of alternative therapy in Arizona. She moved in with friends near Phoenix and started the alternative regime in January.
"It's 79 degrees and beautiful here," she said by phone in mid-January. "Let's hope that's a good sign."
For all their suspicions and questions about conventional medicine, those who venture outside the mainstream tend to have one thing in abundance, experts say: hope. In a 1998 survey of more than 1,000 adults from around the country, researchers found that having an interest in "personal growth or spirituality" predicted alternative medicine use.
Nontraditional healers know this, and they often offer some spiritual element in their practice, if they think it is appropriate. David Wood, a naturopath who with his wife, Cheryl, runs a large, Christian-oriented practice in Lynnwood, Wash., said he treated patients of all faiths.
"We pray with patients, with their permission," said Mr. Wood, who also works with local medical doctors when necessary. "If patients would not like us to pray for them, we don't, but it's there if needed."
He added, "Our goal here is to help people get really well, not merely free of symptoms."
That is exactly the sentiment that many Americans say they feel is missing from conventional medicine. Whatever the benefits and risks of its many concoctions and methods, alternative medicine offers them at least the promise of affectionate care, unhurried service, freedom from prescription drug side effects and the potential for feeling not just better but also spiritually recharged.
"I don't hate doctors or anything," Ms. Newman said. "I just know they can make mistakes, and so often they refer you on to see another doctor, and another."
Seeing a naturopath, she said, "I feel I'm known, they see me as a whole person, they listen to what I say."
Read at the original source
Thursday, February 16, 2006
Help make awareness and prevention of global warming a priority in 2006.
Help make awareness and prevention of global warming a priority in 2006.
Rank of 2005 as hottest year on record
(tied with 1998), according to NASA.
Increase in intensity and duration
of hurricanes and tropical storms
since the 1970's, according to a 2005 MIT study.
Estimate of damage caused by
hurricanes hitting the U.S. coast in 2005
alone, according to the National Climatic Data Center.
Year by which Glacier National Park will have no glaciers left, according to the U.S. Geological Survey predictions.
Square miles of Arctic sea ice that have melted in the last 30 years (roughly the size of Texas), threatening polar bear habitats and further accelerating global warming worldwide, according to the Arctic Climate Impact Assessment.
Amount of plant and animal species that global warming could wipe out by 2050.
Rank of the United States as global warming polluter
compared to other large nations.
Number of former U.S. Environmental Protection Agency leaders who say the U.S. is not doing enough to fight global warming.
Number of bills passed by Congress to cut global
warming pollution.
Number of times President Bush has mentioned the words "global warming," or "climate change" in previous State of the Union addresses.
If you are unable to view this list, please visit our website.
Sources: NASA's Goddard Institute for Space Studies, Massachusetts Institute of Technology 2005 Study, Nature Magazine January 2004, National Climatic Data Center, U.S. Geological Survey, Arctic Climate Impact Assessment.
Thursday, January 26, 2006
Amory Lovins has a vision: The U.S. economy keeps going and going and going - without any oil
The Energizer - Amory Lovins
Amory Lovins has a vision: The U.S. economy keeps going and going and going - without any oil
By Cal Fussman
DISCOVER Vol. 27 No. 02 | February 2006 | Environment
AMORY LOVINS is a physicist, economist, inventor, automobile designer, consultant to 18 heads of state, author of 29 books, and cofounder of Rocky Mountain Institute, an environmental think tank. most of all, he's a man who takes pride in saving energy. The electricity bill at his 4,000-square-foot home in Old Snowmass, Colorado, is five dollars a month, and he's convinced he can do the same for all of us. His book winning the oil endgame shows how the United States can save as much oil as it gets from the Persian gulf by 2015 and how all oil imports can be eliminated by 2040. And that's just for starters.
As told to Cal Fussman
When I give talks about energy, the audience already knows about the problems. That's not what they've come to hear. So I don't talk about problems, only solutions. But after a while, during the question period, someone in the back will get up and give a long riff about all the bad things that are happening—most of which are basically true. There's only one way I've found to deal with that. After this person calms down, I gently ask whether feeling that way makes him more effective.
As René Dubos, the famous biologist, once said, "Despair is a sin."
ENERGY
I used to work for Edwin Land, the father of Polaroid photography. Land said that invention was the sudden cessation of stupidity. He also said that people who seem to have had a new idea often have just stopped having an old idea. So I suppose if I bring something unusual to this business, it's that maybe I find it easier to stop having old ideas.
I can't point to any one moment in particular from my past that made me who I am. It's been more like seeing the world through an evolving lens. Gradually, I've learned to ask different questions and look at problems from different angles than most people.
I'm probably best known for having redefined the energy problem in 1976 with a Foreign Affairs article titled "Energy Strategy: The Road Not Taken?"
Until then, the energy problem was generally considered to be: Where do we get more energy? People were preoccupied with where we could get more energy of any kind, from any sources, for any price—as if all our needs were the same. I started instead at the other end of the problem: What do we want the energy for?
You don't generally want lumps of coal or barrels of sticky black goo. You want comfort, illumination, mobility, baked bread, and so on. And for each of these end uses we should ask: How much energy, of what quality, at what scale, from what source will do the job in the cheapest way? That's now called the end-use/least-cost approach, and a lot of the work we do at Rocky Mountain Institute involves applying it to a wide range of situations.
End-use/least-cost analysis begins with a simple question: What are you really trying to do? If you go to the hardware store looking for a drill, chances are what you really want is not a drill but a hole. And then there's a reason you want the hole. If you ask enough layers of "Why?"—as Taiichi Ohno, the inventor of the Toyota production system, told us—you typically get to the root of the problem.
OIL
Let's start with one basic problem. Saudi Arabia has a quarter of the world's oil reserves. It is the sole swing producer with significant capacity to increase output, and therefore it controls the world price.
Two-thirds of Saudi oil flows through one processing plant and two terminals that are in the crosshairs of terrorists. That stuff could go down any day for a long time. And that would presumably crash both the House of Saud and the Western economy. So for the bad guys it's a twofer. They would love to do that, and they've already had a couple of cracks at it.
Now, this should make you uncomfortable. But we don't have to continue on our current path. We can go a different way.
Let's look at oil through a historic analogy. Around 1850, the biggest or second-biggest industry in America was whaling. Most buildings were lit with whale oil. But in the nine years before Edwin Drake struck oil in 1859 in Pennsylvania and made kerosene ubiquitous, at least five-sixths of the whale oil–lighting market had already been lost to competing products made from coal. This was elicited by the relatively high price of whale oil as the whales got shy and scarce.
The whalers were astounded that they ran out of customers before they ran out of whales. They didn't see this coming because they hadn't added up the competitors. Oil fields can be like this today.
The United States today wrings twice as much work from each barrel of oil as it did in 1975. With even more advanced technologies, we can double oil efficiency all over again at a cost averaging $12 a barrel. We can replace the rest of our oil needs with advanced biofuels and saved natural gas at a cost averaging $18 a barrel. Combined, these two approaches average out at a cost of $15 a barrel. That's a lot cheaper than the $61 per barrel oil was the other day or even the $26 that's officially forecast for the year 2025.
How much cheaper than $26 a barrel? Well, about $70 billion a year, plus a million jobs, mostly in rural and small-town America. Plus a million saved jobs now at risk, mainly in the automaking states.
We've got a choice: Either we're going to continue importing efficient cars to help replace foreign oil, or we're going to employ our own people to make efficient cars and import neither the oil nor the car—which sounds like a better idea.
WEIGHT
A modern car, after 120 years of devoted engineering effort since Gottlieb Daimler built the first gasoline-powered vehicle, uses less than 1 percent of its fuel to move the driver. How does that happen?
Well, only an eighth of the fuel energy reaches the wheels. The rest of it is lost in the engine, drivetrain, and accessories, or wasted while the car is idling. Of the one-eighth that reaches the wheels, over half heats the tires on the road or the air that the car pushes aside. So only 6 percent of the original fuel energy accelerates the car. But remember, about 95 percent of the mass being accelerated is the car—not the driver. Hence, less than 1 percent of the fuel energy moves the driver. This is not very gratifying.
Well, the solution is equally inherent in the basic physics I just described. Three-quarters of the fuel usage is caused by the car's weight. Every unit of energy you save at the wheels by making the car a lot lighter will save an additional seven units of fuel that you don't need to waste getting it to the wheels.
So you can get this roughly eightfold leverage (three- to fourfold in the case of a hybrid) from the wheels back to the fuel tank by starting with the physics of the car, making it lighter and with lower drag. And indeed you can make the car radically lighter. We've figured out a cost-effective way to do that so you can end up with a 66-mile-per-gallon uncompromised SUV that has half the normal weight, has a third the normal fuel use, is safer, and repays the extra cost that comes with being a hybrid in less than two years.
PLASTIC
Henry Ford said you don't need weight for strength. If you did need weight for strength, your bicycle helmet would be made of steel, not carbon fiber. And if you want to know how strong a very light material can be, try eating an Atlantic lobster with no tools.
The auto industry needs to move toward ultralight, ultrastrong carbon-fiber composites, almost certainly using thermoplastics that flow when heated and that can be easily molded—instead of the more brittle, expensive thermosets that need chemistry, baking, or some other change to set the resin into its final hard form. Thermoplastics are incredibly tough. They can absorb 12 times as much crash energy per pound as steel. So even though your car will be only half as heavy as it was before, it will still be safer when whacked by a heavier one.
With such materials, you can decouple size from weight. You can make the car big—protected and comfortable. But it won't be heavy—hostile and inefficient. This can save oil and lives at the same time, and it turns out you can greatly improve the economics of making the car because you might have in a carbon SUV only 14 body parts—instead of 140 to 280 in a steel auto body—each needing one low-pressure die set, instead of an average of four high-pressure steel-stamping die sets in the steel body. The parts snap together precisely in the right positions for gluing, like assembling a kid's toy, so you don't need all those jigs and robots. You basically get rid of the body shop this way, and then by laying color in the mold, you get rid of the paint shop too. There go the two hardest and costliest parts of making the car.
New jobs come partly by having a vibrantly competitive car industry rather than a failing one and partly due to the logical evolution of the auto industry toward computerization. Imagine the aftermarket for improved and customized software. The industry structure would be different, but we don't think there would be a net loss of jobs. The jobs would be safer, healthier, and better distributed. And the same revolution that's coming to automaking from advanced materials also applies to anything else that moves.
HYDROGEN
Many automakers are starting to understand that whoever goes ultralight first will take the lead in the hydrogen fuel-cell race.
The winning strategy will be improving the physics of the car. They still need to make a cheap, durable fuel cell. But if they can reduce the fuel cell and the hydrogen storage volume by three times, the cost reduces threefold.
That said, superefficient cars need hydrogen a lot less than hydrogen needs superefficient cars. If you have, say, an ultralight hybrid SUV burning gasoline at 66 miles per gallon, that isn't so bad—at least not compared to a similar one getting 18.5 miles per gallon on the road today.
If you then combine that with E85 fuel, which is 15 percent gasoline and 85 percent ethanol, you just got a 320-mile-per-gallon SUV because the efficiency times the biofuel saving of oil multiplies.
For that matter, if every car or light truck on the road in 2025 is only as efficient as the best hybrid cars and SUVs now in the showrooms, that would save twice as much oil as we currently import from the Persian Gulf. So it's not a very ambitious goal—and it doesn't even involve making vehicles ultralight.
Very efficient vehicles can get most of the same benefits without hydrogen by using today's gasoline/hybrid propulsion. However, once you have such vehicles, there is a robust business case for running them on hydrogen. Until you have those efficient vehicles, that business case is not very convincing.
I think hydrogen will be an important if not dominant energy carrier by 2050. In Winning the Oil Endgame, the comprehensive strategy we've developed at Rocky Mountain Institute for ending oil dependence, we see hydrogen as an optional add-on. It would be the most profitable and efficient way to use and save natural gas. But it's not necessary to get the country off oil at a profit; it's just icing on the cake.
ELECTRICITY
A question I ask a lot is, What's the right size for the job? I have a book called Small Is Profitable: The Hidden Economic Benefits of Making Electrical Resources the Right Size. It points out 207 benefits of distributed resources, such as solar and wind power. When I begin to describe them, you'll find them really obvious:
Renewables, such as wind energy, have less financial risk from volatile fuel prices than fossil-fuel power plants because they don't need any fuel.
Small resources like solar cells or wind turbines have less financial risk than giant power plants that take many years to build.
Portable resources like solar panels have less financial risk than stationary power plants, because if the system evolves differently than you'd expected and you'd rather put it somewhere else, you simply stick it on a truck and move it.
This is all blindingly obvious, yet it hasn't been taken into account by the utility industry while buying its half trillion dollars' worth of assets.
Here's what happened: For the first century of the electricity business, the power plants were costlier and less reliable than the grid, so it made sense to build a bunch of big power plants backing each other up through the grid. Well—surprise—over the last 20 years, power plants have become cheaper and more reliable than the grid. Ninety-nine percent of our power failures originate in the grid—mostly in distribution. So now if you want to deliver reliable, affordable electricity, you need to make it at or near the customer's location.
Many people didn't notice this happening. But despite the market's not yet recognizing the benefits, the decentralized low- or no-carbon generators turn out to be greater in capacity and output than nuclear power worldwide. David already beat Goliath, but nobody noticed.
The nuclear advocates frequently state that only nuclear is big and fast enough to deal with global warming. Well, five years from now the official industry forecast suggests that decentralized low- and no-carbon generators will be adding 160 times as much capacity as nuclear will add up to that year. So those who think that the decentralized generators are small, slow, and futuristic or have an unacceptable risk of not being adopted at scale in the market have some serious explaining to do.
WIND
If I could do just one thing to solve our energy problems, I would allow energy to compete fairly at honest prices regardless of which kind it is, what technology it uses, how big it is, or who owns it. If we did that, we wouldn't have an oil problem, a climate problem, or a nuclear proliferation problem. Those are all artifacts of public policies that have distorted the market into buying things it wouldn't otherwise have bought because they were turkeys.
We have more than enough cost-effective wind power just on available land in the Dakotas to meet the United States' electricity needs. We wouldn't necessarily want to do it all in two states, and there are cheaper combinations of other technologies to do the whole job, but it's an enormous resource.
Germany and Spain each install over 2,000 megawatts of wind power every year. That figure exceeds the average global net addition of nuclear power every year in this decade. Denmark is now one-fifth wind powered; Germany, about a tenth.
Wind power is doubling every three years worldwide and solar power every two, and not because some countries subsidize it strongly. In fact, the subsidies are being phased out slowly in Germany and rapidly in Japan because they have achieved their purpose of creating world-class industries that will be able to make it on their own.
If everything competed solely on merit, wind energy in the United States would be a lot better off. It gets subsidized less than its competitors, and its subsidies are temporary, while its competitors' are permanent. In other words, the fossil and nuclear subsidies—nuclear being the biggest—are permanent, while renewable subsidies are temporary.
Congress's brief and irregular renewals of the tax credit for wind power have several times bankrupted wind-turbine manufacturers in the United States. Similar misguided policies have diminished the solar-cell industry. Half of the solar cells sold in the United States a decade ago were domestically made. Now that figure is only 8 percent.
DEFENSE
A major player in our energy future will be the Pentagon. Here's why: Trailing behind every half-mile-a-gallon Abrams tank—a peerless fighting machine if you can get it there—are two unarmored fuel trucks. Guess what the bad guys shoot at?
This is a very teachable moment—when the Pentagon becomes acutely aware of the cost and the risk of delivering fuel on the battlefield. They obviously need much lighter, more agile, radically more fuel-efficient forces.
A military transformation will have a much bigger payoff, in exactly the same way the Pentagon's research and development created the Internet, global positioning systems, the modern microchip industry, and advanced aero engines.
If you align military science and technology investments to capture this enormous improvement at a tactical, operational, and strategic level, guess what? You thereby transform the car, truck, and plane industries to get the country off oil, so we won't need to fight over the oil because we won't be using it. Mission unnecessary.
BANANAS
When we designed the research facilities at Rocky Mountain Institute, we didn't plan on having a banana farm inside. We're up 7,100 feet in the Rockies, and it has gotten as low as –47 degrees in the winter.
We planned about 900 square feet of jungle space with five different kinds of energy collection: heat, hot air, hot water, light, and photosynthesis. The arch that holds it up has 12 different functions, but I paid for it only once. The whole building exemplifies design integration: getting multiple benefits from single expenditures. It saves about 99 percent of the normal need for space- and water-heating energy, about 90 percent of the household electricity, and half the water. All that efficiency paid for itself in 10 months—and that's with 1983 technology! Now we can do a lot better.
Anyway, we weren't planning on growing bananas here, but somebody who owed me something gave me a banana tree to settle the obligation. He said it would grow to six feet and never fruit—but he forgot to tell the tree. When it got 12-year-old horse manure, it went bananas, grew to 25 feet, put out nine crops in the first year and a half, and tried to go through the roof. Then it tried to eat the fishpond.
I was afraid of a hydraulic disaster, so we chopped it down, dug it up, and put a steel fence between what was left of the root-ball and the fishpond. But it grew back and put out another 18 crops. Eventually, a few years ago, it wore out at twice its designed life, so we took it out for good and put in a variety of young banana trees. We've also done mangoes, grapes, papayas, and passion fruit—here in the Rocky Mountains.
The tangled tale of the banana tree offers a very simple lesson: Be open to possibilities.
Read at the original source
Amory Lovins has a vision: The U.S. economy keeps going and going and going - without any oil
By Cal Fussman
DISCOVER Vol. 27 No. 02 | February 2006 | Environment
AMORY LOVINS is a physicist, economist, inventor, automobile designer, consultant to 18 heads of state, author of 29 books, and cofounder of Rocky Mountain Institute, an environmental think tank. most of all, he's a man who takes pride in saving energy. The electricity bill at his 4,000-square-foot home in Old Snowmass, Colorado, is five dollars a month, and he's convinced he can do the same for all of us. His book winning the oil endgame shows how the United States can save as much oil as it gets from the Persian gulf by 2015 and how all oil imports can be eliminated by 2040. And that's just for starters.
As told to Cal Fussman
When I give talks about energy, the audience already knows about the problems. That's not what they've come to hear. So I don't talk about problems, only solutions. But after a while, during the question period, someone in the back will get up and give a long riff about all the bad things that are happening—most of which are basically true. There's only one way I've found to deal with that. After this person calms down, I gently ask whether feeling that way makes him more effective.
As René Dubos, the famous biologist, once said, "Despair is a sin."
ENERGY
I used to work for Edwin Land, the father of Polaroid photography. Land said that invention was the sudden cessation of stupidity. He also said that people who seem to have had a new idea often have just stopped having an old idea. So I suppose if I bring something unusual to this business, it's that maybe I find it easier to stop having old ideas.
I can't point to any one moment in particular from my past that made me who I am. It's been more like seeing the world through an evolving lens. Gradually, I've learned to ask different questions and look at problems from different angles than most people.
I'm probably best known for having redefined the energy problem in 1976 with a Foreign Affairs article titled "Energy Strategy: The Road Not Taken?"
Until then, the energy problem was generally considered to be: Where do we get more energy? People were preoccupied with where we could get more energy of any kind, from any sources, for any price—as if all our needs were the same. I started instead at the other end of the problem: What do we want the energy for?
You don't generally want lumps of coal or barrels of sticky black goo. You want comfort, illumination, mobility, baked bread, and so on. And for each of these end uses we should ask: How much energy, of what quality, at what scale, from what source will do the job in the cheapest way? That's now called the end-use/least-cost approach, and a lot of the work we do at Rocky Mountain Institute involves applying it to a wide range of situations.
End-use/least-cost analysis begins with a simple question: What are you really trying to do? If you go to the hardware store looking for a drill, chances are what you really want is not a drill but a hole. And then there's a reason you want the hole. If you ask enough layers of "Why?"—as Taiichi Ohno, the inventor of the Toyota production system, told us—you typically get to the root of the problem.
OIL
Let's start with one basic problem. Saudi Arabia has a quarter of the world's oil reserves. It is the sole swing producer with significant capacity to increase output, and therefore it controls the world price.
Two-thirds of Saudi oil flows through one processing plant and two terminals that are in the crosshairs of terrorists. That stuff could go down any day for a long time. And that would presumably crash both the House of Saud and the Western economy. So for the bad guys it's a twofer. They would love to do that, and they've already had a couple of cracks at it.
Now, this should make you uncomfortable. But we don't have to continue on our current path. We can go a different way.
Let's look at oil through a historic analogy. Around 1850, the biggest or second-biggest industry in America was whaling. Most buildings were lit with whale oil. But in the nine years before Edwin Drake struck oil in 1859 in Pennsylvania and made kerosene ubiquitous, at least five-sixths of the whale oil–lighting market had already been lost to competing products made from coal. This was elicited by the relatively high price of whale oil as the whales got shy and scarce.
The whalers were astounded that they ran out of customers before they ran out of whales. They didn't see this coming because they hadn't added up the competitors. Oil fields can be like this today.
The United States today wrings twice as much work from each barrel of oil as it did in 1975. With even more advanced technologies, we can double oil efficiency all over again at a cost averaging $12 a barrel. We can replace the rest of our oil needs with advanced biofuels and saved natural gas at a cost averaging $18 a barrel. Combined, these two approaches average out at a cost of $15 a barrel. That's a lot cheaper than the $61 per barrel oil was the other day or even the $26 that's officially forecast for the year 2025.
How much cheaper than $26 a barrel? Well, about $70 billion a year, plus a million jobs, mostly in rural and small-town America. Plus a million saved jobs now at risk, mainly in the automaking states.
We've got a choice: Either we're going to continue importing efficient cars to help replace foreign oil, or we're going to employ our own people to make efficient cars and import neither the oil nor the car—which sounds like a better idea.
WEIGHT
A modern car, after 120 years of devoted engineering effort since Gottlieb Daimler built the first gasoline-powered vehicle, uses less than 1 percent of its fuel to move the driver. How does that happen?
Well, only an eighth of the fuel energy reaches the wheels. The rest of it is lost in the engine, drivetrain, and accessories, or wasted while the car is idling. Of the one-eighth that reaches the wheels, over half heats the tires on the road or the air that the car pushes aside. So only 6 percent of the original fuel energy accelerates the car. But remember, about 95 percent of the mass being accelerated is the car—not the driver. Hence, less than 1 percent of the fuel energy moves the driver. This is not very gratifying.
Well, the solution is equally inherent in the basic physics I just described. Three-quarters of the fuel usage is caused by the car's weight. Every unit of energy you save at the wheels by making the car a lot lighter will save an additional seven units of fuel that you don't need to waste getting it to the wheels.
So you can get this roughly eightfold leverage (three- to fourfold in the case of a hybrid) from the wheels back to the fuel tank by starting with the physics of the car, making it lighter and with lower drag. And indeed you can make the car radically lighter. We've figured out a cost-effective way to do that so you can end up with a 66-mile-per-gallon uncompromised SUV that has half the normal weight, has a third the normal fuel use, is safer, and repays the extra cost that comes with being a hybrid in less than two years.
PLASTIC
Henry Ford said you don't need weight for strength. If you did need weight for strength, your bicycle helmet would be made of steel, not carbon fiber. And if you want to know how strong a very light material can be, try eating an Atlantic lobster with no tools.
The auto industry needs to move toward ultralight, ultrastrong carbon-fiber composites, almost certainly using thermoplastics that flow when heated and that can be easily molded—instead of the more brittle, expensive thermosets that need chemistry, baking, or some other change to set the resin into its final hard form. Thermoplastics are incredibly tough. They can absorb 12 times as much crash energy per pound as steel. So even though your car will be only half as heavy as it was before, it will still be safer when whacked by a heavier one.
With such materials, you can decouple size from weight. You can make the car big—protected and comfortable. But it won't be heavy—hostile and inefficient. This can save oil and lives at the same time, and it turns out you can greatly improve the economics of making the car because you might have in a carbon SUV only 14 body parts—instead of 140 to 280 in a steel auto body—each needing one low-pressure die set, instead of an average of four high-pressure steel-stamping die sets in the steel body. The parts snap together precisely in the right positions for gluing, like assembling a kid's toy, so you don't need all those jigs and robots. You basically get rid of the body shop this way, and then by laying color in the mold, you get rid of the paint shop too. There go the two hardest and costliest parts of making the car.
New jobs come partly by having a vibrantly competitive car industry rather than a failing one and partly due to the logical evolution of the auto industry toward computerization. Imagine the aftermarket for improved and customized software. The industry structure would be different, but we don't think there would be a net loss of jobs. The jobs would be safer, healthier, and better distributed. And the same revolution that's coming to automaking from advanced materials also applies to anything else that moves.
HYDROGEN
Many automakers are starting to understand that whoever goes ultralight first will take the lead in the hydrogen fuel-cell race.
The winning strategy will be improving the physics of the car. They still need to make a cheap, durable fuel cell. But if they can reduce the fuel cell and the hydrogen storage volume by three times, the cost reduces threefold.
That said, superefficient cars need hydrogen a lot less than hydrogen needs superefficient cars. If you have, say, an ultralight hybrid SUV burning gasoline at 66 miles per gallon, that isn't so bad—at least not compared to a similar one getting 18.5 miles per gallon on the road today.
If you then combine that with E85 fuel, which is 15 percent gasoline and 85 percent ethanol, you just got a 320-mile-per-gallon SUV because the efficiency times the biofuel saving of oil multiplies.
For that matter, if every car or light truck on the road in 2025 is only as efficient as the best hybrid cars and SUVs now in the showrooms, that would save twice as much oil as we currently import from the Persian Gulf. So it's not a very ambitious goal—and it doesn't even involve making vehicles ultralight.
Very efficient vehicles can get most of the same benefits without hydrogen by using today's gasoline/hybrid propulsion. However, once you have such vehicles, there is a robust business case for running them on hydrogen. Until you have those efficient vehicles, that business case is not very convincing.
I think hydrogen will be an important if not dominant energy carrier by 2050. In Winning the Oil Endgame, the comprehensive strategy we've developed at Rocky Mountain Institute for ending oil dependence, we see hydrogen as an optional add-on. It would be the most profitable and efficient way to use and save natural gas. But it's not necessary to get the country off oil at a profit; it's just icing on the cake.
ELECTRICITY
A question I ask a lot is, What's the right size for the job? I have a book called Small Is Profitable: The Hidden Economic Benefits of Making Electrical Resources the Right Size. It points out 207 benefits of distributed resources, such as solar and wind power. When I begin to describe them, you'll find them really obvious:
Renewables, such as wind energy, have less financial risk from volatile fuel prices than fossil-fuel power plants because they don't need any fuel.
Small resources like solar cells or wind turbines have less financial risk than giant power plants that take many years to build.
Portable resources like solar panels have less financial risk than stationary power plants, because if the system evolves differently than you'd expected and you'd rather put it somewhere else, you simply stick it on a truck and move it.
This is all blindingly obvious, yet it hasn't been taken into account by the utility industry while buying its half trillion dollars' worth of assets.
Here's what happened: For the first century of the electricity business, the power plants were costlier and less reliable than the grid, so it made sense to build a bunch of big power plants backing each other up through the grid. Well—surprise—over the last 20 years, power plants have become cheaper and more reliable than the grid. Ninety-nine percent of our power failures originate in the grid—mostly in distribution. So now if you want to deliver reliable, affordable electricity, you need to make it at or near the customer's location.
Many people didn't notice this happening. But despite the market's not yet recognizing the benefits, the decentralized low- or no-carbon generators turn out to be greater in capacity and output than nuclear power worldwide. David already beat Goliath, but nobody noticed.
The nuclear advocates frequently state that only nuclear is big and fast enough to deal with global warming. Well, five years from now the official industry forecast suggests that decentralized low- and no-carbon generators will be adding 160 times as much capacity as nuclear will add up to that year. So those who think that the decentralized generators are small, slow, and futuristic or have an unacceptable risk of not being adopted at scale in the market have some serious explaining to do.
WIND
If I could do just one thing to solve our energy problems, I would allow energy to compete fairly at honest prices regardless of which kind it is, what technology it uses, how big it is, or who owns it. If we did that, we wouldn't have an oil problem, a climate problem, or a nuclear proliferation problem. Those are all artifacts of public policies that have distorted the market into buying things it wouldn't otherwise have bought because they were turkeys.
We have more than enough cost-effective wind power just on available land in the Dakotas to meet the United States' electricity needs. We wouldn't necessarily want to do it all in two states, and there are cheaper combinations of other technologies to do the whole job, but it's an enormous resource.
Germany and Spain each install over 2,000 megawatts of wind power every year. That figure exceeds the average global net addition of nuclear power every year in this decade. Denmark is now one-fifth wind powered; Germany, about a tenth.
Wind power is doubling every three years worldwide and solar power every two, and not because some countries subsidize it strongly. In fact, the subsidies are being phased out slowly in Germany and rapidly in Japan because they have achieved their purpose of creating world-class industries that will be able to make it on their own.
If everything competed solely on merit, wind energy in the United States would be a lot better off. It gets subsidized less than its competitors, and its subsidies are temporary, while its competitors' are permanent. In other words, the fossil and nuclear subsidies—nuclear being the biggest—are permanent, while renewable subsidies are temporary.
Congress's brief and irregular renewals of the tax credit for wind power have several times bankrupted wind-turbine manufacturers in the United States. Similar misguided policies have diminished the solar-cell industry. Half of the solar cells sold in the United States a decade ago were domestically made. Now that figure is only 8 percent.
DEFENSE
A major player in our energy future will be the Pentagon. Here's why: Trailing behind every half-mile-a-gallon Abrams tank—a peerless fighting machine if you can get it there—are two unarmored fuel trucks. Guess what the bad guys shoot at?
This is a very teachable moment—when the Pentagon becomes acutely aware of the cost and the risk of delivering fuel on the battlefield. They obviously need much lighter, more agile, radically more fuel-efficient forces.
A military transformation will have a much bigger payoff, in exactly the same way the Pentagon's research and development created the Internet, global positioning systems, the modern microchip industry, and advanced aero engines.
If you align military science and technology investments to capture this enormous improvement at a tactical, operational, and strategic level, guess what? You thereby transform the car, truck, and plane industries to get the country off oil, so we won't need to fight over the oil because we won't be using it. Mission unnecessary.
BANANAS
When we designed the research facilities at Rocky Mountain Institute, we didn't plan on having a banana farm inside. We're up 7,100 feet in the Rockies, and it has gotten as low as –47 degrees in the winter.
We planned about 900 square feet of jungle space with five different kinds of energy collection: heat, hot air, hot water, light, and photosynthesis. The arch that holds it up has 12 different functions, but I paid for it only once. The whole building exemplifies design integration: getting multiple benefits from single expenditures. It saves about 99 percent of the normal need for space- and water-heating energy, about 90 percent of the household electricity, and half the water. All that efficiency paid for itself in 10 months—and that's with 1983 technology! Now we can do a lot better.
Anyway, we weren't planning on growing bananas here, but somebody who owed me something gave me a banana tree to settle the obligation. He said it would grow to six feet and never fruit—but he forgot to tell the tree. When it got 12-year-old horse manure, it went bananas, grew to 25 feet, put out nine crops in the first year and a half, and tried to go through the roof. Then it tried to eat the fishpond.
I was afraid of a hydraulic disaster, so we chopped it down, dug it up, and put a steel fence between what was left of the root-ball and the fishpond. But it grew back and put out another 18 crops. Eventually, a few years ago, it wore out at twice its designed life, so we took it out for good and put in a variety of young banana trees. We've also done mangoes, grapes, papayas, and passion fruit—here in the Rocky Mountains.
The tangled tale of the banana tree offers a very simple lesson: Be open to possibilities.
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