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The Reality of War

Brian Mockenhaupt’s “The Last Patrol” (November Atlantic) clearly conveys the futility and waste of U.S. efforts in Afghanistan. Focusing just on the people we send there in infantry positions, one sees a sickening toll on these troops’ bodies and minds from fighting a so-called U.S. enemy while hampered by political limitations on military engagement. The Taliban fighters have no such limitations.

Repeatedly putting troops in frontline situations with inadequate preparation, supplies, and support and nonsensical rules of engagement constitutes heinous behavior on the part of our political and military leaders. What are they thinking when they expend the lives and mangle the bodies of the young men who carry out such infantry patrols?

I knew the situation in Afghanistan was bad, but I did not realize it was so intractable for the infantry soldiers. My heart goes out to them and to their families.

Michael L. Wood
Atlanta, Ga.

Brian Mockenhaupt’s article about the soldiers in C Company of 2-508 was superb. I received it from a friend with whom I’d been deployed out of Fort Lewis for a couple years back in ’06–07. The cold emotion of entering combat that the writer conveyed, which is oh so familiar, took me back to a place I had left three years ago. For a while after you leave combat, you forget about the reality of war. Sometimes, someone like Mockenhaupt brings it all back for us.

Chuck Rogers
Naperville, Ill.

How to Evaluate Medical Research

We applaud David H. Freedman’s “Lies, Damned Lies, and Medical Science” (November Atlantic), having long been admirers of professor John Ioannidis. We too evaluate medical evidence and train physicians and others in how to analyze studies for reliability and clinical usefulness. However, we believe the problem is larger, and the consequences of applying the results of misleading science more deleterious, than implied.

Low-quality science significantly contributes to lost care opportunities, illness burden, and mortality. For instance, in the 1980s, observational studies “reported” dramatic tumor shrinkage and reduced mortality in women with advanced breast cancer who were treated with high-dose chemotherapy and autologous bone-marrow transplant. But these studies are highly prone to bias; valid randomized controlled trials are required to prove efficacy of therapies. More than 30,000 women underwent these procedures before randomized controlled trials showed greater adverse events and mortality. And we believe less than 10 percent of such trials are reliable.

Individual biases have been shown to greatly distort study results, frequently in favor of the new treatment being studied. Yet few health-care professionals know the importance of bias in studies, or the basics of identifying it, and so are at high risk of being misled. In an informal tally, roughly 70 percent of physicians fail our basic test for critical appraisal, which should be a foundational discipline for all health-care professionals.

Sheri Ann Strite
Michael E. Stuart, M.D.
Delfini Group
Seattle, Wash.

David H. Freedman states, “Much of what medical researchers conclude in their studies is misleading, exaggerated, or flat-out wrong.” This inflammatory lead-in, and the article itself, are dangerously specious.

Freedman centers on John Ioannidis, whose principal research tool is meta-analysis. This method, Ioannidis claims, has uncovered widespread flaws in all types of clinical research. Freedman fails to mention, however, that meta-analysis itself has major problems, and is not accepted as a rigorous method of analysis by many leading statisticians. A major prob­lem is the pooling of data from different sources, which include different populations, ways of conducting clinical trials, and ways of appraising the results. This heterogeneous pool of information is blended into a statistical mayonnaise of strong studies and weak studies, for an analysis that is often impossible to evaluate with any degree of certainty. Ioannidis may claim to have mathematical methods that can account for these differences, but there will always remain doubts that he can deal with the inherent problems of meta-analysis.

The devastating consequences of untreated hypertension, the connection between type 2 diabetes and obesity, the prognosis of certain death in childhood leukemia, and poor survival in HIV/AIDS are just a few problems we no longer face because of high-quality clinical research. None of these achievements, or any others, were mentioned by Freedman, who went on a cherry-picking expedition in a field he doesn’t seem to understand.

Robert Schwartz, M.D.
Boston, Mass.

David H. Freedman replies:

Robert Schwartz has a right to consider my article inflammatory, but he offers no evidence that any of it is wrong, let alone specious. What’s more, he seems oblivious to the trap that anyone who tries to dismiss John Ioannidis’s work immediately falls into: if we are to maintain such a high regard for prominently published research findings, then we must take Ioannidis’s findings seriously, because they are prominently published; and if his work is negated by methodological flaws, then those same flaws negate most published findings. Ioannidis’s work is in fact frequently cited and even lauded by medical researchers of all stripes, including—contrary to what Schwartz implies—statisticians, with relatively few objections. The medical community should indeed be esteemed for its successes with the disorders Schwartz mentions. Tragically, there would not be space in this entire magazine to list the disorders that continue to plague us.

Modernizing Medical Records

In “Paging Dr. Luddite” (December Atlantic), Megan McArdle makes the astonishing pronouncement that physicians should be “altering their patient interactions so that they can talk and type at the same time.” I believe she may have confused the doctor-patient interaction with tweeting or texting at the dinner table. The Luddites were anti-technologists; physicians are some of the most highly trained technical experts in our society.

Physicians in private practice remain skeptics (not Luddites) about many of the electronic systems being foisted upon them. Many physicians can tell you that adding electronic medical records requires at least an hour of extra work each day, with more catch-up on the weekend. This time is not compensated. Physicians also resent becoming data-entry personnel, and society loses when such highly trained professionals spend their time in that way.

The current systems are still woefully technically inadequate. Billions are being directed toward better systems that will use voice recognition or even an electronic pen to let physicians work effectively while making the patient—not the data entry—the focus point of each encounter. And competing software systems still can’t communicate: “Your records are at Hospital A, Mrs. Jones. Hospital A’s electronic records and ours at Hospital B are not compatible. Sorry.” Ms. McArdle suggests that physicians are at fault for this problem. I think she may want to get in touch with a software engineer to work on that problem while physicians get back to caring for patients.

Bernd Kutzscher, M.D.
Daly City, Calif.

Megan McArdle’s review of the state of electronic medical records leaves the impression that physicians are holding back from using this technology due to a defensive “what’s in it for me?” attitude, which is not by any means the whole story. The onerous HIPAA privacy law makes transfer of medical information a convoluted process even at the speed of the U.S. mail; it is geometrically more so in an instantaneous, Internet-based system. Clearly, a law that questions which way my computer monitors should face, where my paper records should be stored, and whether my sign-in sheet should include last names needs to be rewritten for the information-transfer capabilities of the Internet age. It isn’t “Luddite” doctors who are holding back the electronic revolution in medicine; it is the lawmakers in Washington.

Shel Khipple, M.D.
Wilmette, Ill.

Legacy of Legalization

In “The Least We Can Do” (October Atlantic), Michael Kinsley mangled a column I wrote in 2009. He claimed that I advocated legalization of marijuana as the last Boomer political crusade. While I do favor legalization, my proposed “crusade” was more elaborate: the legalization of all drugs for people over the age of 80 if they turn in their driver’s licenses. This was a tongue-in-cheekish public-service suggestion, as evidenced by my proposed campaign slogan: Tune In, Turn On, Drop Dead. Sorry Kinsley missed the humorous intent.

Joe Klein
Time magazine
New York, N.Y.

Corrections

The map accompanying “Farthest North” (November Atlantic) placed the Arctic Circle at 75 degrees north latitude instead of 66 33 44 north latitude. “The Battle of Rio” (December Atlantic) identified bullets as .762- caliber, rather than 7.62-caliber. The article also stated that these bullets are illegal for traditional police use, which is misleading. In Brazil, only specialized units are trained to use them.


Log

2010’s Most-Responded-To Articles:

1. “The End of Men
       Hanna Rosin
       July/August
2. “The Point of No Return
       Jeffrey Goldberg
       September
3. “The Least We Can Do
       Michael Kinsley
       October
4. “Are Fathers Necessary?”
       Pamela Paul
       July/August
5. “The Danger of Cosmic Genius
       Kenneth Brower
       December

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