When should doctors disclose their relationships with the wider medical industry?
By upholding the Patient Protection and Affordable Care Act, the Supreme Court has ensured that a host of other provisions and attached bills will go into effect. One that affects me personally is the Physician Payments Sunshine Act authored by Sen. Charles Grassley (R) and Herb Kohl (D). It's good legislation overall (If I was getting a knee replacement I'd want to know if my surgeon is a paid shill for the knee device she's implanting) but because the legislation offers no mechanism for doctors to explain themselves alongside the data, in many cases the Act will blow out a lot of suspicious smoke where there's no fire.
Every drug, device or medical supply company must report transfers of value that exceed $10 to the new federal database maintained by the Centers for Medicare and Medicaid Services (CMMS). Last month CMMS announced it's delaying implementation until January 2013 to allow it more time to create the needed infrastructure, but at least twelve companies are already reporting payments in a less uniform and streamlined fashion. A database maintained by ProPublica makes this data easy to search for interested citizens and health care reporters. The ProPublica database has raised important questions for academic medical centers replete with physicians who serve as pharmaceutical company spokespeople. But there are also cases where tight-lipped (or just busy) doctors see their motivations replaced by the reporter's innuendo of malfeasance. I think this genre of information-gap expose will spread like wildfire once Sunshine goes into full effect next year. The CMMS database, like ProPublica's, will list companies, doctors, dollar amounts and payment categories but no context.
"Our research shows hundreds of thousands of dollars in payments for everything from speaking, to travel, to meals from the very companies they could be prescribing to you," reports KOAA in Colorado Springs. The station went on to report from the only two doctors willing to defend themselves. The others "didn't want to talk about it."
Next year there'll be many more physicians in same situation as Dr. Madeleine Hernandez who found herself defending $355 in food she received over the course of a year from Pfizer. When the San Luis Obispo Tribune came calling her excuse went like this: "I don't care what they say or what they feed us -- if the product is not good, I will not use it."
Doctors everywhere had best recognize today that this information is coming to light tomorrow, and they'd better be pro-active in explaining their actions lest they get lumped together or singled out as examples of bad actors too cozy with industry.
As a doctor who sometimes writes about the medical-industrial complex I have a particular interest in holding onto both the reality and image of my own objectivity, but these relationships are everywhere; this is how American medicine works. It's not realistic for me, or in the best interests of my patients, to refuse every industry interaction. Recently I made tentative plans to attend an educational conference about a particular device that would benefit my patients, but I backed out when I realized my attendance would be reported as a gift from the company. Just last week I tried to log onto MerckMedicus.com, a website that offers free access to a few journals, medical news and a few other useful resources. I hadn't been to the site in a while and this time it prompted me to agree to have an educational gift from Merck reported. I clicked no. But at the same time I regularly use sites like Medscape and MedPageToday that are riddled with advertisements from companies like Merck. But because these third-party media companies stand between Merck and me, no reporting is required. If you surf these doctor-media sites you'll see there's no difference in the quality of the information (which often comes from third parties, like Reuters) whether the site as a whole is branded by Merck or Merck is buying a banner ad.
As far as I know, I don't currently show up in any physician payments database. But it's only a matter of time. One day I'll go ahead and click through to see a site like MerckMedicus.com. One day I'll attend the device seminar. I've been thinking about how and when I want to explain myself if somebody decides to inquire about the objectivity of my medical opinion. Will it be to the local paper, to ProPublica, or some other way, on my own terms?
Here's my idea.
Most practices (and individual docs) have websites. I propose that every private practice, hospital and clinic that's interested in how this information gets interpreted take the following measure this year. Simply create a web page called Physician Payments Sunshine Disclosure and update it with a running log of corporate interactions coupled with explanations. Are you consulting for a company? Tell your patients why you decided help that company. Did you attend a device company educational conference? How did this experience add to the care you give? Did you register for a pharmaceutical company educational website? What kind of information are you getting that might help your patients? Did a company support your research or provide free equipment to your clinic? Pro-actively tell the world why you made that choice, before ProPublica starts calling you.
Finally, if you find your explanations are getting a little too long and convoluted that's a good cue that it's time to re-think value of that industry relationship to yourself and your patients. Not everything will survive in the full glare of the sunlight the Supreme Court has forecast for next year.
Thicker ink, fewer smudges, and more strained hands: an Object Lesson
Recently, Bic launched acampaign to “save handwriting.” Named “Fight for Your Write,” it includes a pledge to “encourage the act of handwriting” in the pledge-taker’s home and community, and emphasizes putting more of the company’s ballpoints into classrooms.
As a teacher, I couldn’t help but wonder how anyone could think there’s a shortage. I find ballpoint pens all over the place: on classroom floors, behind desks. Dozens of castaways collect in cups on every teacher’s desk. They’re so ubiquitous that the word “ballpoint” is rarely used; they’re just “pens.” But despite its popularity, the ballpoint pen is relatively new in the history of handwriting, and its influence on popular handwriting is more complicated than the Bic campaign would imply.
In the name of emotional well-being, college students are increasingly demanding protection from words and ideas they don’t like. Here’s why that’s disastrous for education—and mental health.
Something strange is happening at America’s colleges and universities. A movement is arising, undirected and driven largely by students, to scrub campuses clean of words, ideas, and subjects that might cause discomfort or give offense. Last December, Jeannie Suk wrote in an online article for The New Yorker about law students asking her fellow professors at Harvard not to teach rape law—or, in one case, even use the word violate (as in “that violates the law”) lest it cause students distress. In February, Laura Kipnis, a professor at Northwestern University, wrote an essay in The Chronicle of Higher Education describing a new campus politics of sexual paranoia—and was then subjected to a long investigation after students who were offended by the article and by a tweet she’d sent filed Title IX complaints against her. In June, a professor protecting himself with a pseudonym wrote an essay for Vox describing how gingerly he now has to teach. “I’m a Liberal Professor, and My Liberal Students Terrify Me,” the headline said. A number of popular comedians, including Chris Rock, have stopped performing on college campuses (see Caitlin Flanagan’s article in this month’s issue). Jerry Seinfeld and Bill Maher have publicly condemned the oversensitivity of college students, saying too many of them can’t take a joke.
Wine snobs, string quartets, and the limits of intuition
Several months ago, this author sat at a classical music concert, trying to convince himself that wine is not bullshit.
That may seem like a strange thought to have while listening to Beethoven’s Symphony No. 7 in A major. But Priceonomics had recently posted an article investigating The Price of Wine, part of which reviewed research that cast doubt on both consumers’ and wine experts’ ability to distinguish between quality wine and table wine or identify different wines and their flavors. It seemed a slippery slope to the conclusion that wine culture is nothing more than actors performing a snobbish play.
Listening to an accomplished musician while lacking any musical experience resulted in a feeling familiar to casual wine drinkers imbibing an expensive bottle: Feeling somewhat ambivalent and wondering whether you are convincing yourself that you enjoy it so as not to appear uncultured.
The new drama series, which follows the Colombian kingpin’s rise to power, feels more like a well-researched documentary than the gripping saga it wants to be.
Netflix’s new series Narcos is possibly arriving at the wrong time: The doldrums of summer aren’t really the ideal moment for a narratively dense, documentary-like look at the rise and fall of the Colombian drug kingpin Pablo Escobar. Narrated in voiceover by DEA Agent Steve Murphy (Boyd Holbrook), the early hours of Narcos feel like a history lesson, though an visually sumptuous one.
As Netflix continues to expand its streaming empire, it’s making a concerted effort to appeal to worldwide audiences, and Narcos fits neatly into that plan, alongside last year’s expensive critical flop Marco Polo. Narcos was shot on location in Colombia and stars the acclaimed Brazilian actor Wagner Moura as Escobar. It takes full advantage of its setting, loaded with sweeping helicopter shots of the Colombian jungle where Escobar founded his cocaine empire, filling a power vacuum left by various political upheavals in late-’70s South America.
Dealing with misinformation, feeling powerless, and slowly getting better together
I thought the article would validate my husband’s experience. That’s why I emailed him the link to the decade-old New York magazine article about his alma mater, the American Boychoir School for vocal prodigies, where alumni from as late as the 1990s estimate that one in five boys were molested. Boys like Travis.
“It used to feel like an isolated incident that affected just me," Trav said.
It was the end of my workday on an October afternoon; I had just set my keys on the kitchen table. My coat was still buttoned.
“Now I know I spent nearly three years of my childhood at a boarding school not just with random pedophiles, but in a culture that allowed it.”
As his wife, how do I respond? That he survived? That he’s brave? That he’s a hero for letting me talk about it? That I will stand beside him with a personal mission and public vow that nobody will ever hurt him, physically or emotionally, again, the way they did during his 30 months as a choirboy from 1988 to 1990?.
A new study finds an algorithmic word analysis is flawless at determining whether a person will have a psychotic episode.
Although the language of thinking is deliberate—let me think, I have to do some thinking—the actual experience of having thoughts is often passive. Ideas pop up like dandelions; thoughts occur suddenly and escape without warning. People swim in and out of pools of thought in a way that can feel, paradoxically, mindless.
Most of the time, people don’t actively track the way one thought flows into the next. But in psychiatry, much attention is paid to such intricacies of thinking. For instance, disorganized thought, evidenced by disjointed patterns in speech, is considered a hallmark characteristic of schizophrenia. Several studies of at-risk youths have found that doctors are able to guess with impressive accuracy—the best predictive models hover around 79 percent—whether a person will develop psychosis based on tracking that person’s speech patterns in interviews.
The GOP frontrunner’s surprising staying power has inspired soul-searching and agony among party elites.
What is happening to the Republican Party? I put that question to Lindsey Graham, the senator from South Carolina and basement-dwelling presidential candidate, who was getting ready to hold a campaign event in Hooksett, New Hampshire. “Well, the front-runner is crazy,” Graham said.
He was referring, of course, to Donald Trump, the GOP’s seemingly unstoppable chart-topper, who has survived outrage after outrage that would have ruined a conventional candidate. He commands, on average, double the support, among potential Republican primary voters, of his nearest challenger. Graham—who is running in 15th place—calls him “a huckster billionaire whose political ideas are gibberish.” And while he expects voters eventually to come to their senses, he said, “I think a certain amount of damage has been done already.”
The Islamic State is no mere collection of psychopaths. It is a religious group with carefully considered beliefs, among them that it is a key agent of the coming apocalypse. Here’s what that means for its strategy—and for how to stop it.
What is the Islamic State?
Where did it come from, and what are its intentions? The simplicity of these questions can be deceiving, and few Western leaders seem to know the answers. In December, The New York Times published confidential comments by Major General Michael K. Nagata, the Special Operations commander for the United States in the Middle East, admitting that he had hardly begun figuring out the Islamic State’s appeal. “We have not defeated the idea,” he said. “We do not even understand the idea.” In the past year, President Obama has referred to the Islamic State, variously, as “not Islamic” and as al-Qaeda’s “jayvee team,” statements that reflected confusion about the group, and may have contributed to significant strategic errors.
Every time you shrug, you don’t need to Google, then copy, then paste.
Updated, 2:20 p.m.
All hail ¯\_(ツ)_/¯.
In its 11 strokes, the symbol encapsulates what it’s like to be an individual on the Internet. With raised arms and a half-turned smile, it exudes the melancholia, the malaise, the acceptance, and (finally) the embrace of knowing that something’s wrong on the Internet and you can’t do anything about it.
As Kyle Chayka writes in a new history of the symbol at The Awl, the meaning of the “the shruggie” is always two, if not three- or four-, fold. ¯\_(ツ)_/¯ represents nihilism, “bemused resignation,” and “a Zen-like tool to accept the chaos of universe.” It is Sisyphus in unicode. I use it at least 10 times a day.
For a long time, however, I used it with some difficulty. Unlike better-known emoticons like :) or ;), ¯\_(ツ)_/¯ borrows characters from the Japanese syllabary called katakana. That makes it a kaomoji, a Japanese emoticon; it also makes it, on Western alphabetical keyboards at least, very hard to type. But then I found a solution, and it saves me having to google “smiley sideways shrug” every time I want to quickly rail at the world’s inherent lack of meaning.
On the desperation behind the migrant tragedy in Austria
On Thursday, as Krishnadev Calamur has been tracking in The Atlantic’s new Notes section, Austrian authorities made a ghastly discovery: a truck abandoned in the emergency lane of a highway near the Hungarian border, packed with the decomposing bodies of 59 men, eight women, and four children. They are thoughtto be the corpses of migrants who suffocated to death, perhaps two days earlier, in the bowels of a vehicle whose back door was locked shut and refrigeration and ventilation systems weren’t functional. Stray identity documents suggest that at least some of the victims were Syrian—refugees from that country’s brutal civil war. The truck featured an image of a chicken and a slogan from the Slovakian poultry company that the lorry once belonged to: “I taste so good because they feed me so well.”