Kevin T. Powell, MD

Mark Twain said "It isn’t what you don’t know; it’s what you know that ain’t so that gets you into trouble." But this may be incorrect, because the quote is also attributed to Will Rogers and Yogi Berra, among others.

Regardless of who said it, that paradigm kept appearing this past month. Rather than reading about new advances in medicine, I came across a cluster of articles that suggested prior knowledge was aberrant. Now don’t get me wrong. I know (there is that word again) that medical knowledge changes. Ben Franklin said, "In this world nothing can be said to be certain, except death and taxes." Ben Franklin is less well known for his medical research, which concluded that wet clothing and cold, damp air did not cause the common cold, but breathing putrefied air from other people in close quarters did spread disease (J. R. Soc. Med. 2005;98:534-8). Unfortunately, Ben’s arguments, which preceded the discoveries of germs by Pasteur, Lister, and Koch, still haven’t convinced Dr. Mom.

I warn medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I have no reason to believe that my teaching is any better.

My favorite example of this has been the treatment of ulcers. My medical school curriculum emphasized quantitative physiology, so we had three lectures on the nature of the gastric mucosa, acid production, protective barriers, and the potential of new medications to heal ulcers that previously would perforate and require surgery. The technique of gastric freezing, used in the 1960s, had been discredited and supplanted with the use of antacids and a bland milk diet. Unfortunately, the intake of extra calcium actually stimulated a rebound in stomach acid production. The newly discovered H₂ receptor antagonists worked better. My professors also expounded on the latest research, which showed that a new class of medications could directly inhibit the proton pump. Finally, it seemed then, modern medicine would be able to control the acid that caused ulcers, thereby permitting healing, although relapses were common. These medications quickly became the best sellers for the next 20 years. That financial success didn’t stop someone from later claiming that ulcers were actually caused by an infection, not by stress, lifestyle, and excess acid. After 2 decades of ridiculing that suggestion, the medical establishment awarded Dr. Barry J. Marshall and Dr. J. Robin Warren a Nobel Prize in 2005 for discovering Helicobacter pylori.

So it isn’t unusual for me to read articles that tell me what I know ain’t so. My first example is entitled "Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments," and challenges the effectiveness of such influenza treatments as Tamiflu (BMJ 2014;348:g2545). Local ED doctors this past winter have not promoted use of the medication in otherwise healthy children. They suggest fluids, rest, and antipyretics seem to be almost as effective with fewer side effects.

My second example is an article that asserts that circumcision may be the best thing since sliced bread (Mayo Clinic Proceedings 2014;89:677-86). If not that good, at least it is medically justified and should be paid for by Medicaid, according to those authors.

The third article contradicts data published by the Centers for Disease Control and Prevention in February 2014 and suggests that the prevalence of childhood obesity has not peaked (JAMA Pediatr. 2014 [doi:10.1001/jamapediatrics.2014.21]).

I don’t have enough space here to debate those articles. Read them and decide for yourself. I am worried about the overall state of medical research, as outlined by Dr. Richard Smith, the former editor of BMJ in his blog entitled "Medical research – still a scandal." The typical pediatrician will not wield much influence over the forces to which Dr. Smith refers. But medical students, residents, and the average physician can – and must – develop better skills at critiquing what they read.

The history of the treatment of ulcers is an excellent example of how scientific progress is made. The examples in these three articles have a different nuance. They suggest that medical research is confounding, not advancing, knowledge. And that could definitely land us in trouble.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at [email protected].

Mark Twain said "It isn’t what you don’t know; it’s what you know that ain’t so that gets you into trouble." But this may be incorrect, because the quote is also attributed to Will Rogers and Yogi Berra, among others.

Regardless of who said it, that paradigm kept appearing this past month. Rather than reading about new advances in medicine, I came across a cluster of articles that suggested prior knowledge was aberrant. Now don’t get me wrong. I know (there is that word again) that medical knowledge changes. Ben Franklin said, "In this world nothing can be said to be certain, except death and taxes." Ben Franklin is less well known for his medical research, which concluded that wet clothing and cold, damp air did not cause the common cold, but breathing putrefied air from other people in close quarters did spread disease (J. R. Soc. Med. 2005;98:534-8). Unfortunately, Ben’s arguments, which preceded the discoveries of germs by Pasteur, Lister, and Koch, still haven’t convinced Dr. Mom.

I warn medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I have no reason to believe that my teaching is any better.

My favorite example of this has been the treatment of ulcers. My medical school curriculum emphasized quantitative physiology, so we had three lectures on the nature of the gastric mucosa, acid production, protective barriers, and the potential of new medications to heal ulcers that previously would perforate and require surgery. The technique of gastric freezing, used in the 1960s, had been discredited and supplanted with the use of antacids and a bland milk diet. Unfortunately, the intake of extra calcium actually stimulated a rebound in stomach acid production. The newly discovered H₂ receptor antagonists worked better. My professors also expounded on the latest research, which showed that a new class of medications could directly inhibit the proton pump. Finally, it seemed then, modern medicine would be able to control the acid that caused ulcers, thereby permitting healing, although relapses were common. These medications quickly became the best sellers for the next 20 years. That financial success didn’t stop someone from later claiming that ulcers were actually caused by an infection, not by stress, lifestyle, and excess acid. After 2 decades of ridiculing that suggestion, the medical establishment awarded Dr. Barry J. Marshall and Dr. J. Robin Warren a Nobel Prize in 2005 for discovering Helicobacter pylori.

So it isn’t unusual for me to read articles that tell me what I know ain’t so. My first example is entitled "Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments," and challenges the effectiveness of such influenza treatments as Tamiflu (BMJ 2014;348:g2545). Local ED doctors this past winter have not promoted use of the medication in otherwise healthy children. They suggest fluids, rest, and antipyretics seem to be almost as effective with fewer side effects.

My second example is an article that asserts that circumcision may be the best thing since sliced bread (Mayo Clinic Proceedings 2014;89:677-86). If not that good, at least it is medically justified and should be paid for by Medicaid, according to those authors.

The third article contradicts data published by the Centers for Disease Control and Prevention in February 2014 and suggests that the prevalence of childhood obesity has not peaked (JAMA Pediatr. 2014 [doi:10.1001/jamapediatrics.2014.21]).

I don’t have enough space here to debate those articles. Read them and decide for yourself. I am worried about the overall state of medical research, as outlined by Dr. Richard Smith, the former editor of BMJ in his blog entitled "Medical research – still a scandal." The typical pediatrician will not wield much influence over the forces to which Dr. Smith refers. But medical students, residents, and the average physician can – and must – develop better skills at critiquing what they read.

The history of the treatment of ulcers is an excellent example of how scientific progress is made. The examples in these three articles have a different nuance. They suggest that medical research is confounding, not advancing, knowledge. And that could definitely land us in trouble.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at [email protected].

Mark Twain said "It isn’t what you don’t know; it’s what you know that ain’t so that gets you into trouble." But this may be incorrect, because the quote is also attributed to Will Rogers and Yogi Berra, among others.

Regardless of who said it, that paradigm kept appearing this past month. Rather than reading about new advances in medicine, I came across a cluster of articles that suggested prior knowledge was aberrant. Now don’t get me wrong. I know (there is that word again) that medical knowledge changes. Ben Franklin said, "In this world nothing can be said to be certain, except death and taxes." Ben Franklin is less well known for his medical research, which concluded that wet clothing and cold, damp air did not cause the common cold, but breathing putrefied air from other people in close quarters did spread disease (J. R. Soc. Med. 2005;98:534-8). Unfortunately, Ben’s arguments, which preceded the discoveries of germs by Pasteur, Lister, and Koch, still haven’t convinced Dr. Mom.

I warn medical students and residents that half of what I was taught in medical school has since been proven obsolete or frankly wrong. I have no reason to believe that my teaching is any better.

My favorite example of this has been the treatment of ulcers. My medical school curriculum emphasized quantitative physiology, so we had three lectures on the nature of the gastric mucosa, acid production, protective barriers, and the potential of new medications to heal ulcers that previously would perforate and require surgery. The technique of gastric freezing, used in the 1960s, had been discredited and supplanted with the use of antacids and a bland milk diet. Unfortunately, the intake of extra calcium actually stimulated a rebound in stomach acid production. The newly discovered H₂ receptor antagonists worked better. My professors also expounded on the latest research, which showed that a new class of medications could directly inhibit the proton pump. Finally, it seemed then, modern medicine would be able to control the acid that caused ulcers, thereby permitting healing, although relapses were common. These medications quickly became the best sellers for the next 20 years. That financial success didn’t stop someone from later claiming that ulcers were actually caused by an infection, not by stress, lifestyle, and excess acid. After 2 decades of ridiculing that suggestion, the medical establishment awarded Dr. Barry J. Marshall and Dr. J. Robin Warren a Nobel Prize in 2005 for discovering Helicobacter pylori.

So it isn’t unusual for me to read articles that tell me what I know ain’t so. My first example is entitled "Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments," and challenges the effectiveness of such influenza treatments as Tamiflu (BMJ 2014;348:g2545). Local ED doctors this past winter have not promoted use of the medication in otherwise healthy children. They suggest fluids, rest, and antipyretics seem to be almost as effective with fewer side effects.

My second example is an article that asserts that circumcision may be the best thing since sliced bread (Mayo Clinic Proceedings 2014;89:677-86). If not that good, at least it is medically justified and should be paid for by Medicaid, according to those authors.

The third article contradicts data published by the Centers for Disease Control and Prevention in February 2014 and suggests that the prevalence of childhood obesity has not peaked (JAMA Pediatr. 2014 [doi:10.1001/jamapediatrics.2014.21]).

I don’t have enough space here to debate those articles. Read them and decide for yourself. I am worried about the overall state of medical research, as outlined by Dr. Richard Smith, the former editor of BMJ in his blog entitled "Medical research – still a scandal." The typical pediatrician will not wield much influence over the forces to which Dr. Smith refers. But medical students, residents, and the average physician can – and must – develop better skills at critiquing what they read.

The history of the treatment of ulcers is an excellent example of how scientific progress is made. The examples in these three articles have a different nuance. They suggest that medical research is confounding, not advancing, knowledge. And that could definitely land us in trouble.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at [email protected].

Uncertainty is one of the most difficult concepts to master in the art of medicine.

The prevailing paradigm, as portrayed on TV and feared by medical students, is that there must be some question to ask, or some exam finding to auscultate or palpate, or some lab test that could be ordered that will pinpoint the correct diagnosis and guide treatment. This mythos separates modern physicians from oracles reading entrails and shamans practicing magic.

It is a useful paradigm when it works. It fails rather frequently. An example is the teenage girl with chronic functional abdominal pain whose repeated blood tests and imaging have revealed no pathology. The paradigm of finding the root cause, choosing an appropriate treatment to remedy that cause, and then having the child return to school needs to be replaced by an alternative paradigm of managing symptoms, returning to the activities, and coping until the problem remits. In many cases, chronic pain won’t go away until regular activities have been resumed.

There is a third paradigm in the diagnostic regimen. It applies to an ever-increasing group of disorders. These disorders don’t have a pathognomonic finding or a gold standard test. Physicians have only a statistical probability that the patient has or will in the future get the disease. They must employ clinical judgment to weigh the risks and benefits of treatment.

Incomplete Kawasaki disease is one such diagnosis. A 5-year-old girl presents with 6 days of fever, chapped lips during the winter, and a rash. She is fussy. She has mild sterile pyuria, and her C-reactive protein level is elevated. Should she get intravenous immunoglobulin (IVIG)?

My approach is to explain to the parents that it is possible for me to both say, "I don’t think she has Kawasaki’s" and "I think we should treat." I find most parents, given a few extra minutes, grasp the general idea of number needed to treat [NNT] and number needed to harm [NNH], although I don’t use the jargon. This isn’t the first way in which most people approach decision making, but with explanation they can comprehend how, if there is a 10% risk of serious consequence and no perfect test to guide us, it makes sense to treat "just in case."

The concept is easier to understand if it is a test. ED doctors frequently state, "I don’t think it is broken, but we’ll get the x-ray to be sure." Concerns over radiation have reduced the number of head CTs performed for minor head bumps.

Although I find the general public can grasp the basics, they will depend on the physician to provide expertise in balancing the risks and consequences. Bayesian decision making is still an advanced concept for most medical students. When I assess the risks of sequelae from Kawasaki syndrome, I consider the risk that the patient really has Kawasaki times the risk of developing coronary changes times the risk those changes will progress to aneurysms times the risk aneurysms won’t heal spontaneously if ignored times the risk of an event happening because of the aneurysms times the risk that that event will be serious/catastrophic. It is a small number. This is analogous to the Drake equationin the search for extraterrestrial intelligence.

My first career experience with a patient receiving IVIG was a code blue featuring anaphylaxis, syncope, and apnea. My most recent was a patient who had 3 hours of excruciating headache during the infusion. The American Heart Association diagnostic criteria for Kawasakiemphasize high sensitivity, but they don’t adequately describe the NNT nor do they quantify the harms from overtreatment.

There is a bias to treat, even when the risk of adverse effects is greater than the risk of the disease. Factors include fear of malpractice, perceived culpability for errors of omission vs. commission, and economic gain. One of the most common error-producing biases I see in medicine is the response to a referral from an outlying hospital. I’ve worked both places. Tertiary centers find any possible reason to embark on diagnostic tests (particularly lucrative imaging) and treatment in order to justify or rationalize the transfer/admission and to keep the referring doctor happy and looking good in the patient’s/parent’s eyes. In low-risk, high-consequence Bayesian decision making, managing bias may be more important than improving the accuracy of the risk assessment.

Similar diagnostic and treatment dilemmas will occur even more frequently in the near future as genomic screening and exome sequencing become more common. Obstetrics has dealt with this for several years. Mothers are now frequently being confronted with low-specificity (positive predictive value of less than 5%) testing during pregnancy with triple and quad screens. Counseling for BRCA1 testing is the prototype for adult screening. In November 2013, the Food and Drug Administration cracked down on unregulated direct-to-consumer genomic screening. Pediatrics will soon see a large influx of this type of testing in the work-up of failure to thrive and developmental delay. Explaining these scenarios to parents will be a key, acquired professional skill.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at St. Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at [email protected].

Uncertainty is one of the most difficult concepts to master in the art of medicine.

The prevailing paradigm, as portrayed on TV and feared by medical students, is that there must be some question to ask, or some exam finding to auscultate or palpate, or some lab test that could be ordered that will pinpoint the correct diagnosis and guide treatment. This mythos separates modern physicians from oracles reading entrails and shamans practicing magic.

It is a useful paradigm when it works. It fails rather frequently. An example is the teenage girl with chronic functional abdominal pain whose repeated blood tests and imaging have revealed no pathology. The paradigm of finding the root cause, choosing an appropriate treatment to remedy that cause, and then having the child return to school needs to be replaced by an alternative paradigm of managing symptoms, returning to the activities, and coping until the problem remits. In many cases, chronic pain won’t go away until regular activities have been resumed.

There is a third paradigm in the diagnostic regimen. It applies to an ever-increasing group of disorders. These disorders don’t have a pathognomonic finding or a gold standard test. Physicians have only a statistical probability that the patient has or will in the future get the disease. They must employ clinical judgment to weigh the risks and benefits of treatment.

Incomplete Kawasaki disease is one such diagnosis. A 5-year-old girl presents with 6 days of fever, chapped lips during the winter, and a rash. She is fussy. She has mild sterile pyuria, and her C-reactive protein level is elevated. Should she get intravenous immunoglobulin (IVIG)?

My approach is to explain to the parents that it is possible for me to both say, "I don’t think she has Kawasaki’s" and "I think we should treat." I find most parents, given a few extra minutes, grasp the general idea of number needed to treat [NNT] and number needed to harm [NNH], although I don’t use the jargon. This isn’t the first way in which most people approach decision making, but with explanation they can comprehend how, if there is a 10% risk of serious consequence and no perfect test to guide us, it makes sense to treat "just in case."

The concept is easier to understand if it is a test. ED doctors frequently state, "I don’t think it is broken, but we’ll get the x-ray to be sure." Concerns over radiation have reduced the number of head CTs performed for minor head bumps.

Although I find the general public can grasp the basics, they will depend on the physician to provide expertise in balancing the risks and consequences. Bayesian decision making is still an advanced concept for most medical students. When I assess the risks of sequelae from Kawasaki syndrome, I consider the risk that the patient really has Kawasaki times the risk of developing coronary changes times the risk those changes will progress to aneurysms times the risk aneurysms won’t heal spontaneously if ignored times the risk of an event happening because of the aneurysms times the risk that that event will be serious/catastrophic. It is a small number. This is analogous to the Drake equationin the search for extraterrestrial intelligence.

My first career experience with a patient receiving IVIG was a code blue featuring anaphylaxis, syncope, and apnea. My most recent was a patient who had 3 hours of excruciating headache during the infusion. The American Heart Association diagnostic criteria for Kawasakiemphasize high sensitivity, but they don’t adequately describe the NNT nor do they quantify the harms from overtreatment.

There is a bias to treat, even when the risk of adverse effects is greater than the risk of the disease. Factors include fear of malpractice, perceived culpability for errors of omission vs. commission, and economic gain. One of the most common error-producing biases I see in medicine is the response to a referral from an outlying hospital. I’ve worked both places. Tertiary centers find any possible reason to embark on diagnostic tests (particularly lucrative imaging) and treatment in order to justify or rationalize the transfer/admission and to keep the referring doctor happy and looking good in the patient’s/parent’s eyes. In low-risk, high-consequence Bayesian decision making, managing bias may be more important than improving the accuracy of the risk assessment.

Similar diagnostic and treatment dilemmas will occur even more frequently in the near future as genomic screening and exome sequencing become more common. Obstetrics has dealt with this for several years. Mothers are now frequently being confronted with low-specificity (positive predictive value of less than 5%) testing during pregnancy with triple and quad screens. Counseling for BRCA1 testing is the prototype for adult screening. In November 2013, the Food and Drug Administration cracked down on unregulated direct-to-consumer genomic screening. Pediatrics will soon see a large influx of this type of testing in the work-up of failure to thrive and developmental delay. Explaining these scenarios to parents will be a key, acquired professional skill.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at St. Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at [email protected].

Uncertainty is one of the most difficult concepts to master in the art of medicine.

The prevailing paradigm, as portrayed on TV and feared by medical students, is that there must be some question to ask, or some exam finding to auscultate or palpate, or some lab test that could be ordered that will pinpoint the correct diagnosis and guide treatment. This mythos separates modern physicians from oracles reading entrails and shamans practicing magic.

It is a useful paradigm when it works. It fails rather frequently. An example is the teenage girl with chronic functional abdominal pain whose repeated blood tests and imaging have revealed no pathology. The paradigm of finding the root cause, choosing an appropriate treatment to remedy that cause, and then having the child return to school needs to be replaced by an alternative paradigm of managing symptoms, returning to the activities, and coping until the problem remits. In many cases, chronic pain won’t go away until regular activities have been resumed.

There is a third paradigm in the diagnostic regimen. It applies to an ever-increasing group of disorders. These disorders don’t have a pathognomonic finding or a gold standard test. Physicians have only a statistical probability that the patient has or will in the future get the disease. They must employ clinical judgment to weigh the risks and benefits of treatment.

Incomplete Kawasaki disease is one such diagnosis. A 5-year-old girl presents with 6 days of fever, chapped lips during the winter, and a rash. She is fussy. She has mild sterile pyuria, and her C-reactive protein level is elevated. Should she get intravenous immunoglobulin (IVIG)?

My approach is to explain to the parents that it is possible for me to both say, "I don’t think she has Kawasaki’s" and "I think we should treat." I find most parents, given a few extra minutes, grasp the general idea of number needed to treat [NNT] and number needed to harm [NNH], although I don’t use the jargon. This isn’t the first way in which most people approach decision making, but with explanation they can comprehend how, if there is a 10% risk of serious consequence and no perfect test to guide us, it makes sense to treat "just in case."

The concept is easier to understand if it is a test. ED doctors frequently state, "I don’t think it is broken, but we’ll get the x-ray to be sure." Concerns over radiation have reduced the number of head CTs performed for minor head bumps.

Although I find the general public can grasp the basics, they will depend on the physician to provide expertise in balancing the risks and consequences. Bayesian decision making is still an advanced concept for most medical students. When I assess the risks of sequelae from Kawasaki syndrome, I consider the risk that the patient really has Kawasaki times the risk of developing coronary changes times the risk those changes will progress to aneurysms times the risk aneurysms won’t heal spontaneously if ignored times the risk of an event happening because of the aneurysms times the risk that that event will be serious/catastrophic. It is a small number. This is analogous to the Drake equationin the search for extraterrestrial intelligence.

My first career experience with a patient receiving IVIG was a code blue featuring anaphylaxis, syncope, and apnea. My most recent was a patient who had 3 hours of excruciating headache during the infusion. The American Heart Association diagnostic criteria for Kawasakiemphasize high sensitivity, but they don’t adequately describe the NNT nor do they quantify the harms from overtreatment.

There is a bias to treat, even when the risk of adverse effects is greater than the risk of the disease. Factors include fear of malpractice, perceived culpability for errors of omission vs. commission, and economic gain. One of the most common error-producing biases I see in medicine is the response to a referral from an outlying hospital. I’ve worked both places. Tertiary centers find any possible reason to embark on diagnostic tests (particularly lucrative imaging) and treatment in order to justify or rationalize the transfer/admission and to keep the referring doctor happy and looking good in the patient’s/parent’s eyes. In low-risk, high-consequence Bayesian decision making, managing bias may be more important than improving the accuracy of the risk assessment.

Similar diagnostic and treatment dilemmas will occur even more frequently in the near future as genomic screening and exome sequencing become more common. Obstetrics has dealt with this for several years. Mothers are now frequently being confronted with low-specificity (positive predictive value of less than 5%) testing during pregnancy with triple and quad screens. Counseling for BRCA1 testing is the prototype for adult screening. In November 2013, the Food and Drug Administration cracked down on unregulated direct-to-consumer genomic screening. Pediatrics will soon see a large influx of this type of testing in the work-up of failure to thrive and developmental delay. Explaining these scenarios to parents will be a key, acquired professional skill.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at St. Louis University. He is also listserv moderator for the American Academy of Pediatrics Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. Dr. Powell said he had no relevant financial disclosures. E-mail him at [email protected].

In the academic world, ‘tis the season of interviews. The medical school’s admission committee is sorting through hundreds of applications, each one telling a story about one person’s journey. Fourth-year medical students are interviewing residency programs. They are looking for a match for the next 3 or more years. Then there are the job interviews to replace faculty who transfer or retire.

Part of the application/interview process is assessing knowledge and technical skills. There are test scores, such as MCAT (Medical College Admission Test) or Part One of the boards. Those are important, but not decisive data. There are letters of reference to review. Garrison Keillor notes that, in his fictional town of Lake Wobegon, all the children are above average. Based on letters of reference, nobody graduates in the bottom half of the class of medical school either.

The real purpose of the applications and interviewing is to go beyond knowledge and technical skills. There is an assessment of the person and his/her potential to be a fine physician. There are various interpretations of what that means. I think a big piece of it is empathy, defined as the ability to connect with the patient on an emotional level and truly understand what the patient is feeling and suffering. This summer and fall, there has been a flurry of books and articles noting how students enter medical school altruistic and compassionate but get most of that drummed out of them during medical school.

I don’t really understand the hubbub. This phenomenon was well known a generation ago. The sleep deprivation of residency used to be effective at eliminating any recalcitrant empathy. With the new duty hours, the sleep deprivation mechanism has been attenuated. There are no data yet on whether shorter duty hours produce more empathetic doctors. No data yet to indicate that they are making fewer mistakes, either.

There also has been a recent flurry of activity attempting to increase rational thinking in medical care. Not rationing, just being rational. Three years ago it was Provenge, which cost of $93,000 to add 4 months to the life of an elderly patient with metastatic prostate cancer. Medicare decided to cover the cost. Last year, the poster child was Zaltrap, with an estimate of $75,000 to add 42 days of life to someone with metastatic colon cancer. It was very expensive and marginally better than cheaper, older drugs. In an Oct. 14, 2012, op-ed in the New York Times, three physicians from Memorial Sloan-Kettering Cancer Center indicated that the hospital would not use the drug because of its poor value.

Now, this issue has simultaneously become the cover story for both New York magazine ("The Cost of Living," Oct. 20, 2013) and MIT Technology Review ("A Tale of Two Drugs," Oct. 22, 2013). Those are two extremely disparate magazines with very different target audiences, each addressing the same issue. Surely, that is a reason to sit up and take notice. There is a tipping point at which the cost of a medical therapy becomes irrational. The empathetic doctor of the future cannot hide behind a claim that life is priceless. A more nuanced understanding of the financial limits of care will be necessary.

Medications aren’t the only expensive medical care. Diagnostic tests also can be of poor value. Over the past 2 years, many states and hospital systems have introduced pulse oximetry screening of newborns before discharge to detect rare, asymptomatic critical congenital heart defects. Analysis put the cost at about $40,000 for each incremental case identified prior to discharge.

There are no data yet to indicate how many of those early detections translate into a life saved, and it is beyond the scope of this editorial to make such an evaluation. I would hope, however, that those promoting this policy change are nuanced in their thinking rather than being swayed by a photo opportunity for the governor to hold a baby identified by the program in New Jersey. Alas, that was not my impression at a recent American Academy of Pediatrics event. That doesn’t mean I’m against this practice. I’m just concerned about the quality and process of the policy making. New York magazine and MIT Technology Review have different approaches to the problem. Truth probably lies somewhere in between.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the AAP Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. E-mail him at [email protected].

In the academic world, ‘tis the season of interviews. The medical school’s admission committee is sorting through hundreds of applications, each one telling a story about one person’s journey. Fourth-year medical students are interviewing residency programs. They are looking for a match for the next 3 or more years. Then there are the job interviews to replace faculty who transfer or retire.

Part of the application/interview process is assessing knowledge and technical skills. There are test scores, such as MCAT (Medical College Admission Test) or Part One of the boards. Those are important, but not decisive data. There are letters of reference to review. Garrison Keillor notes that, in his fictional town of Lake Wobegon, all the children are above average. Based on letters of reference, nobody graduates in the bottom half of the class of medical school either.

The real purpose of the applications and interviewing is to go beyond knowledge and technical skills. There is an assessment of the person and his/her potential to be a fine physician. There are various interpretations of what that means. I think a big piece of it is empathy, defined as the ability to connect with the patient on an emotional level and truly understand what the patient is feeling and suffering. This summer and fall, there has been a flurry of books and articles noting how students enter medical school altruistic and compassionate but get most of that drummed out of them during medical school.

I don’t really understand the hubbub. This phenomenon was well known a generation ago. The sleep deprivation of residency used to be effective at eliminating any recalcitrant empathy. With the new duty hours, the sleep deprivation mechanism has been attenuated. There are no data yet on whether shorter duty hours produce more empathetic doctors. No data yet to indicate that they are making fewer mistakes, either.

There also has been a recent flurry of activity attempting to increase rational thinking in medical care. Not rationing, just being rational. Three years ago it was Provenge, which cost of $93,000 to add 4 months to the life of an elderly patient with metastatic prostate cancer. Medicare decided to cover the cost. Last year, the poster child was Zaltrap, with an estimate of $75,000 to add 42 days of life to someone with metastatic colon cancer. It was very expensive and marginally better than cheaper, older drugs. In an Oct. 14, 2012, op-ed in the New York Times, three physicians from Memorial Sloan-Kettering Cancer Center indicated that the hospital would not use the drug because of its poor value.

Now, this issue has simultaneously become the cover story for both New York magazine ("The Cost of Living," Oct. 20, 2013) and MIT Technology Review ("A Tale of Two Drugs," Oct. 22, 2013). Those are two extremely disparate magazines with very different target audiences, each addressing the same issue. Surely, that is a reason to sit up and take notice. There is a tipping point at which the cost of a medical therapy becomes irrational. The empathetic doctor of the future cannot hide behind a claim that life is priceless. A more nuanced understanding of the financial limits of care will be necessary.

Medications aren’t the only expensive medical care. Diagnostic tests also can be of poor value. Over the past 2 years, many states and hospital systems have introduced pulse oximetry screening of newborns before discharge to detect rare, asymptomatic critical congenital heart defects. Analysis put the cost at about $40,000 for each incremental case identified prior to discharge.

There are no data yet to indicate how many of those early detections translate into a life saved, and it is beyond the scope of this editorial to make such an evaluation. I would hope, however, that those promoting this policy change are nuanced in their thinking rather than being swayed by a photo opportunity for the governor to hold a baby identified by the program in New Jersey. Alas, that was not my impression at a recent American Academy of Pediatrics event. That doesn’t mean I’m against this practice. I’m just concerned about the quality and process of the policy making. New York magazine and MIT Technology Review have different approaches to the problem. Truth probably lies somewhere in between.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the AAP Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. E-mail him at [email protected].

In the academic world, ‘tis the season of interviews. The medical school’s admission committee is sorting through hundreds of applications, each one telling a story about one person’s journey. Fourth-year medical students are interviewing residency programs. They are looking for a match for the next 3 or more years. Then there are the job interviews to replace faculty who transfer or retire.

Part of the application/interview process is assessing knowledge and technical skills. There are test scores, such as MCAT (Medical College Admission Test) or Part One of the boards. Those are important, but not decisive data. There are letters of reference to review. Garrison Keillor notes that, in his fictional town of Lake Wobegon, all the children are above average. Based on letters of reference, nobody graduates in the bottom half of the class of medical school either.

The real purpose of the applications and interviewing is to go beyond knowledge and technical skills. There is an assessment of the person and his/her potential to be a fine physician. There are various interpretations of what that means. I think a big piece of it is empathy, defined as the ability to connect with the patient on an emotional level and truly understand what the patient is feeling and suffering. This summer and fall, there has been a flurry of books and articles noting how students enter medical school altruistic and compassionate but get most of that drummed out of them during medical school.

I don’t really understand the hubbub. This phenomenon was well known a generation ago. The sleep deprivation of residency used to be effective at eliminating any recalcitrant empathy. With the new duty hours, the sleep deprivation mechanism has been attenuated. There are no data yet on whether shorter duty hours produce more empathetic doctors. No data yet to indicate that they are making fewer mistakes, either.

There also has been a recent flurry of activity attempting to increase rational thinking in medical care. Not rationing, just being rational. Three years ago it was Provenge, which cost of $93,000 to add 4 months to the life of an elderly patient with metastatic prostate cancer. Medicare decided to cover the cost. Last year, the poster child was Zaltrap, with an estimate of $75,000 to add 42 days of life to someone with metastatic colon cancer. It was very expensive and marginally better than cheaper, older drugs. In an Oct. 14, 2012, op-ed in the New York Times, three physicians from Memorial Sloan-Kettering Cancer Center indicated that the hospital would not use the drug because of its poor value.

Now, this issue has simultaneously become the cover story for both New York magazine ("The Cost of Living," Oct. 20, 2013) and MIT Technology Review ("A Tale of Two Drugs," Oct. 22, 2013). Those are two extremely disparate magazines with very different target audiences, each addressing the same issue. Surely, that is a reason to sit up and take notice. There is a tipping point at which the cost of a medical therapy becomes irrational. The empathetic doctor of the future cannot hide behind a claim that life is priceless. A more nuanced understanding of the financial limits of care will be necessary.

Medications aren’t the only expensive medical care. Diagnostic tests also can be of poor value. Over the past 2 years, many states and hospital systems have introduced pulse oximetry screening of newborns before discharge to detect rare, asymptomatic critical congenital heart defects. Analysis put the cost at about $40,000 for each incremental case identified prior to discharge.

There are no data yet to indicate how many of those early detections translate into a life saved, and it is beyond the scope of this editorial to make such an evaluation. I would hope, however, that those promoting this policy change are nuanced in their thinking rather than being swayed by a photo opportunity for the governor to hold a baby identified by the program in New Jersey. Alas, that was not my impression at a recent American Academy of Pediatrics event. That doesn’t mean I’m against this practice. I’m just concerned about the quality and process of the policy making. New York magazine and MIT Technology Review have different approaches to the problem. Truth probably lies somewhere in between.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the AAP Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities. E-mail him at [email protected].

The long-awaited decision is finally here. At 21,000 words and 193 pages in PDF format, when printed, The Decision may become the longest ever. Even The Decision’s citation is so long as to be unwieldy. It is the Supreme Court’s June 28, 2012, decision on the Affordable Care Act.

The Decision directly affects 17% of the GDP and the insurance status of 30 million Americans, so such length might seem appropriate. But the Supreme Court doesn’t consider those impacts. In fact, it explicitly avoids evaluating them.

According to The Decision, "We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions."

The Decision is not a careful weighing of what will provide the best medical care, the greatest access to health care, or the fairest distributive justice. Seeking out that wisdom is the job of a legislature. The Supreme Court focused solely on what the federal government could and could not do constitutionally.

To be understood properly, The Decision should be read as a civics lesson. History provides the necessary context. As descendants of minority groups that were outcasts from Europe, the Founding Fathers were worried about government being too powerful. One of the great characteristics of the U.S. Constitution and American jurisprudence is its system of checks and balances, in which the tyranny of the majority through the legislature is tempered by a judiciary upholding constitutional liberties that protect the individual members of minorities. A majority vote does not always trump the minority’s interests.

As a further tempering of pure democracy, a representative government acknowledges that the popular vote can sometimes be misguided. Rather than using democratic town hall meetings, all legislation is created in a deliberative process with expert testimony. That design anticipates that experienced, devoted elected public servants will be wiser and more stable than public opinion polls. In the long run, public opinion will still influence an elected government. But the Constitution even created different terms of office – 2 years in the House, 6 years in the Senate – to provide a buffer against rapid changes in public opinion. For major changes, a two-thirds supermajority vote must be ratified by three-quarters of the states to alter the Constitution.

Limiting the power of government is yet another way of allowing minorities to live their lives according to their own values at a finite penalty for nonconformity. The federal government’s powers are specifically enumerated by the court: "By denying any one government complete jurisdiction over all the concerns of public life, federalism protects the liberty of the individual from arbitrary power."

Ultimately, the justices ruled 5-4 that Congress could not establish the individual mandate with a penalty fee under the Interstate Commerce Clause. Chief Justice Roberts asserted, however, that "every reasonable construction must be resorted to, in order to save a statute from unconstitutionality." He ruled that Congress could (and did) properly create a tax on individuals without insurance. So by that contorted 5-4 vote, the ACA’s individual mandate as a tax increase is upheld as constitutional.

The second key part of The Decision addresses the expansion of Medicaid. The ACA gives states the option of expanding health care coverage to millions more people under Medicaid. The ACA has the federal government reimbursing 100% of those increased program costs, at least initially until the states are addicted to the new funds. For that reason, many state governments have vowed not to expand coverage. The Supreme Court ruled that while Congress can incentivize the expansion, Congress may not penalize uncooperative states by suddenly revoking their current level of Medicaid funding, which accounts for 10% of all state government spending.

According to the court, "State sovereignty is not just an end in itself: Rather, federalism secures to citizens the liberties that derive from the diffusion of sovereign power."

This is not the last word on the ACA, also called Obamacare. The elections this fall offer one more opportunity for the public to express its opinion on the expansion. Democracy isn’t the sole means of setting policy. While elections are based on "one person, one vote," an alternative influence is the economic reality in which people vote with their money, "one dollar, one vote."

In the long run, I believe justice is best served when the power to influence decisions is proportional to the degree to which a stakeholder is impacted by the decision. There can be cogent and rational arguments for separating these two in the short term, but typically that separation results in more severe consequences in the long term. Consider, for instance, the current problems with sovereign debt in Europe and the United States.

So despite parts of it being found unconstitutional, for now the remainder of the ACA is the law of the land. The Supremes have spoken.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the AAP Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities.

The long-awaited decision is finally here. At 21,000 words and 193 pages in PDF format, when printed, The Decision may become the longest ever. Even The Decision’s citation is so long as to be unwieldy. It is the Supreme Court’s June 28, 2012, decision on the Affordable Care Act.

The Decision directly affects 17% of the GDP and the insurance status of 30 million Americans, so such length might seem appropriate. But the Supreme Court doesn’t consider those impacts. In fact, it explicitly avoids evaluating them.

According to The Decision, "We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions."

The Decision is not a careful weighing of what will provide the best medical care, the greatest access to health care, or the fairest distributive justice. Seeking out that wisdom is the job of a legislature. The Supreme Court focused solely on what the federal government could and could not do constitutionally.

To be understood properly, The Decision should be read as a civics lesson. History provides the necessary context. As descendants of minority groups that were outcasts from Europe, the Founding Fathers were worried about government being too powerful. One of the great characteristics of the U.S. Constitution and American jurisprudence is its system of checks and balances, in which the tyranny of the majority through the legislature is tempered by a judiciary upholding constitutional liberties that protect the individual members of minorities. A majority vote does not always trump the minority’s interests.

As a further tempering of pure democracy, a representative government acknowledges that the popular vote can sometimes be misguided. Rather than using democratic town hall meetings, all legislation is created in a deliberative process with expert testimony. That design anticipates that experienced, devoted elected public servants will be wiser and more stable than public opinion polls. In the long run, public opinion will still influence an elected government. But the Constitution even created different terms of office – 2 years in the House, 6 years in the Senate – to provide a buffer against rapid changes in public opinion. For major changes, a two-thirds supermajority vote must be ratified by three-quarters of the states to alter the Constitution.

Limiting the power of government is yet another way of allowing minorities to live their lives according to their own values at a finite penalty for nonconformity. The federal government’s powers are specifically enumerated by the court: "By denying any one government complete jurisdiction over all the concerns of public life, federalism protects the liberty of the individual from arbitrary power."

Ultimately, the justices ruled 5-4 that Congress could not establish the individual mandate with a penalty fee under the Interstate Commerce Clause. Chief Justice Roberts asserted, however, that "every reasonable construction must be resorted to, in order to save a statute from unconstitutionality." He ruled that Congress could (and did) properly create a tax on individuals without insurance. So by that contorted 5-4 vote, the ACA’s individual mandate as a tax increase is upheld as constitutional.

The second key part of The Decision addresses the expansion of Medicaid. The ACA gives states the option of expanding health care coverage to millions more people under Medicaid. The ACA has the federal government reimbursing 100% of those increased program costs, at least initially until the states are addicted to the new funds. For that reason, many state governments have vowed not to expand coverage. The Supreme Court ruled that while Congress can incentivize the expansion, Congress may not penalize uncooperative states by suddenly revoking their current level of Medicaid funding, which accounts for 10% of all state government spending.

According to the court, "State sovereignty is not just an end in itself: Rather, federalism secures to citizens the liberties that derive from the diffusion of sovereign power."

This is not the last word on the ACA, also called Obamacare. The elections this fall offer one more opportunity for the public to express its opinion on the expansion. Democracy isn’t the sole means of setting policy. While elections are based on "one person, one vote," an alternative influence is the economic reality in which people vote with their money, "one dollar, one vote."

In the long run, I believe justice is best served when the power to influence decisions is proportional to the degree to which a stakeholder is impacted by the decision. There can be cogent and rational arguments for separating these two in the short term, but typically that separation results in more severe consequences in the long term. Consider, for instance, the current problems with sovereign debt in Europe and the United States.

So despite parts of it being found unconstitutional, for now the remainder of the ACA is the law of the land. The Supremes have spoken.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the AAP Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities.

The long-awaited decision is finally here. At 21,000 words and 193 pages in PDF format, when printed, The Decision may become the longest ever. Even The Decision’s citation is so long as to be unwieldy. It is the Supreme Court’s June 28, 2012, decision on the Affordable Care Act.

The Decision directly affects 17% of the GDP and the insurance status of 30 million Americans, so such length might seem appropriate. But the Supreme Court doesn’t consider those impacts. In fact, it explicitly avoids evaluating them.

According to The Decision, "We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions."

The Decision is not a careful weighing of what will provide the best medical care, the greatest access to health care, or the fairest distributive justice. Seeking out that wisdom is the job of a legislature. The Supreme Court focused solely on what the federal government could and could not do constitutionally.

To be understood properly, The Decision should be read as a civics lesson. History provides the necessary context. As descendants of minority groups that were outcasts from Europe, the Founding Fathers were worried about government being too powerful. One of the great characteristics of the U.S. Constitution and American jurisprudence is its system of checks and balances, in which the tyranny of the majority through the legislature is tempered by a judiciary upholding constitutional liberties that protect the individual members of minorities. A majority vote does not always trump the minority’s interests.

As a further tempering of pure democracy, a representative government acknowledges that the popular vote can sometimes be misguided. Rather than using democratic town hall meetings, all legislation is created in a deliberative process with expert testimony. That design anticipates that experienced, devoted elected public servants will be wiser and more stable than public opinion polls. In the long run, public opinion will still influence an elected government. But the Constitution even created different terms of office – 2 years in the House, 6 years in the Senate – to provide a buffer against rapid changes in public opinion. For major changes, a two-thirds supermajority vote must be ratified by three-quarters of the states to alter the Constitution.

Limiting the power of government is yet another way of allowing minorities to live their lives according to their own values at a finite penalty for nonconformity. The federal government’s powers are specifically enumerated by the court: "By denying any one government complete jurisdiction over all the concerns of public life, federalism protects the liberty of the individual from arbitrary power."

Ultimately, the justices ruled 5-4 that Congress could not establish the individual mandate with a penalty fee under the Interstate Commerce Clause. Chief Justice Roberts asserted, however, that "every reasonable construction must be resorted to, in order to save a statute from unconstitutionality." He ruled that Congress could (and did) properly create a tax on individuals without insurance. So by that contorted 5-4 vote, the ACA’s individual mandate as a tax increase is upheld as constitutional.

The second key part of The Decision addresses the expansion of Medicaid. The ACA gives states the option of expanding health care coverage to millions more people under Medicaid. The ACA has the federal government reimbursing 100% of those increased program costs, at least initially until the states are addicted to the new funds. For that reason, many state governments have vowed not to expand coverage. The Supreme Court ruled that while Congress can incentivize the expansion, Congress may not penalize uncooperative states by suddenly revoking their current level of Medicaid funding, which accounts for 10% of all state government spending.

According to the court, "State sovereignty is not just an end in itself: Rather, federalism secures to citizens the liberties that derive from the diffusion of sovereign power."

This is not the last word on the ACA, also called Obamacare. The elections this fall offer one more opportunity for the public to express its opinion on the expansion. Democracy isn’t the sole means of setting policy. While elections are based on "one person, one vote," an alternative influence is the economic reality in which people vote with their money, "one dollar, one vote."

In the long run, I believe justice is best served when the power to influence decisions is proportional to the degree to which a stakeholder is impacted by the decision. There can be cogent and rational arguments for separating these two in the short term, but typically that separation results in more severe consequences in the long term. Consider, for instance, the current problems with sovereign debt in Europe and the United States.

So despite parts of it being found unconstitutional, for now the remainder of the ACA is the law of the land. The Supremes have spoken.

Dr. Powell practices as a hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He is associate professor of pediatrics at Saint Louis University. He is also listserv moderator for the AAP Section on Hospital Medicine and is a member of the Law and Bioethics Affinity Group of the American Society for Bioethics and Humanities.