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.
A wedding is no longer the first step into adulthood that it once was, but, often, the last.
The decline of marriage is upon us. Or, at least, that’s what the zeitgeist would have us believe. In 2010, when Time magazine and the Pew Research Center famously asked Americans whether they thought marriage was becoming obsolete, 39 percent said yes. That was up from 28 percent when Time asked the question in 1978. Also, since 2010, the Census Bureau has reported that married couples have made up less than half of all households; in 1950 they made up 78 percent. Data such as these have led to much collective handwringing about the fate of the embattled institution.
But there is one statistical tidbit that flies in the face of this conventional wisdom: A clear majority of same-sex couples who are living together are now married. Same-sex marriage was illegal in every state until Massachusetts legalized it in 2004, and it did not become legal nationwide until the Supreme Court decision Obergefell v. Hodges in 2015. Two years after that decision, 61 percent of same-sex couples who were sharing a household were married, according to a set of surveys by Gallup. That’s a high take-up rate: Just because same-sex couples are able to marry doesn’t mean that they have to; and yet large numbers have seized the opportunity. (That’s compared with 89 percent of different-sex couples.)
Hundreds of thousands of Americans are taking to the streets today in hundreds of coordinated protests, calling for lawmakers to address school safety and gun violence.
Spurred into action after the shooting at Marjory Stoneman Douglas High School in Florida last month, hundreds of thousands of Americans are taking to the streets today in hundreds of coordinated protests, calling for legislators to address school safety and gun violence. More than 800 March for Our Lives events are planned across the United States and around the world. Gathered here, images from rallies overseas and across the United States.
Three of the young women who spoke on Saturday made silence awkward. And shameful. And, in all that, striking.
Political marches are typically meant to make noise: voices raised, anger articulated, struggles for justice made loud and unavoidable. The March for Our Lives, held on Saturday in Washington, D.C., and in satellite events across the United States, followed, in that sense, activist tradition: It included speeches, rousing and passionate. Its participants carried signs, their messages clever and biting. Yolanda Renee King, the 9-year-old granddaughter of Martin Luther King, Jr. and Coretta Scott King, made a surprise appearance on the march’s main stage: a symbolic passing of the torch of political activism to the next generation of American leaders. “Spread the word,” King said, inviting the crowd to speak along with her, “have you heard? / all across the nation / we are going to be / a great generation.”
Gigantic piles of impounded, abandoned, and broken bicycles have become a familiar sight in many Chinese cities, after a rush to build up its new bike-sharing industry vastly overreached.
Last year, bike sharing took off in China, with dozens of bike-share companies quickly flooding city streets with millions of brightly colored rental bicycles. However, the rapid growth vastly outpaced immediate demand and overwhelmed Chinese cities, where infrastructure and regulations were not prepared to handle a sudden flood of millions of shared bicycles. Riders would park bikes anywhere, or just abandon them, resulting in bicycles piling up and blocking already-crowded streets and pathways. As cities impounded derelict bikes by the thousands, they moved quickly to cap growth and regulate the industry. Vast piles of impounded, abandoned, and broken bicycles have become a familiar sight in many big cities. As some of the companies who jumped in too big and too early have begun to fold, their huge surplus of bicycles can be found collecting dust in vast vacant lots. Bike sharing remains very popular in China, and will likely continue to grow, just probably at a more sustainable rate. Meanwhile, we are left with these images of speculation gone wild—the piles of debris left behind after the bubble bursts.
How evangelicals, once culturally confident, became an anxious minority seeking political protection from the least traditionally religious president in living memory
One of the most extraordinary things about our current politics—really, one of the most extraordinary developments of recent political history—is the loyal adherence of religious conservatives to Donald Trump. The president won four-fifths of the votes of white evangelical Christians. This was a higher level of support than either Ronald Reagan or George W. Bush, an outspoken evangelical himself, ever received.
Trump’s background and beliefs could hardly be more incompatible with traditional Christian models of life and leadership. Trump’s past political stances (he once supported the right to partial-birth abortion), his character (he has bragged about sexually assaulting women), and even his language (he introduced the words pussy and shithole into presidential discourse) would more naturally lead religious conservatives toward exorcism than alliance. This is a man who has cruelly publicized his infidelities, made disturbing sexual comments about his elder daughter, and boasted about the size of his penis on the debate stage. His lawyer reportedly arranged a $130,000 payment to a porn star to dissuade her from disclosing an alleged affair. Yet religious conservatives who once blanched at PG-13 public standards now yawn at such NC-17 maneuvers. We are a long way from The Book of Virtues.
Two decades after Columbine, Americans remain split as to whether guns are dangerous or essential—and the school shootings continue.
LITTLETON, Colo.—Evan Todd, then a sophomore at Columbine High School, was in the library on the day 19 years ago when Eric Harris appeared in the doorway, wielding a shotgun. Harris fired in his direction. Debris, shrapnel, and buckshot hit Todd’s lower back; he fell to the ground and ducked behind a copy machine. Harris fired several more shots toward Todd’s head, splintering a desk and driving wood chips into Todd’s left eye.
Todd listened for several more minutes as Harris and Dylan Klebold murdered their classmates, taunting them as they screamed. Todd prayed silently: “God, let me live.”
Then Klebold pulled back a chair and found Todd hiding underneath a table.
He put a gun to Todd’s head. "Why shouldn't I kill you?" he asked.
One day in February 2009, a 13-year-old boy named Sasha Egger started thinking that people were coming to hurt his family. His mother, Helen, watched with mounting panic that evening as her previously healthy son forgot the rules to Uno, his favorite card game, while playing it. She began making frantic phone calls the next morning. By then, Sasha was shuffling aimlessly around the yard, shredding paper and stuffing it in his pockets. “He looked like an old person with dementia,” Helen later told me.
That afternoon, Sasha was admitted to the hospital, where he saw a series of specialists. One thought Sasha might have bipolar disorder and put him on antipsychotics, but the drugs didn’t help. Helen, a child psychiatrist at Duke University, knew that psychiatric conditions develop gradually. Sasha’s symptoms had appeared almost overnight, and some of them—including dilated pupils and slurred speech—suggested not mental illness but neurological dysfunction. When she and her husband, Daniel, raised these issues, though, one doctor seemed to think they were in denial.
His 2007 memoir lays out the incoming national-security adviser’s worldview.
For someone who has spent the better part of three decades in Washington, John Bolton remains remarkably unchanged since his days in the Reagan administration. He is as strident about much of the world and its intentions as he was in the 1980s. He still rails against multilateral institutions, global treaties, and diplomacy, which, in his view does not serve U.S. interests. It is these very qualities and views, which he shares regularly on Fox News, that made Bolton an obvious choice for the Trump administration. This week, despite advice against such a move from Republican foreign-policy experts, Trump named Bolton his third national-security adviser.
I read Bolton’s 2007 memoir, Surrender Is Not an Option: Defending America at the United Nations, which chronicles his time in government and his battles against what he views as unwieldy U.S. and global bureaucracies. Many of the issues he worked on in the first and second Bush administrations—especially North Korea, Russia, and Iran—are yet again dominating the news, and Trump’s foreign-policy agenda. In his book, Bolton consistently advocated for policies that he believed were in the best interests of the United States—and his opposition to positions staked out by U.S. allies such as Britain, the European Union, and South Korea, could presage some of the positions he could stake out as Trump’s national security adviser. Here is some of what Bolton said about these issues.
The first female speaker of the House has become the most effective congressional leader of modern times—and, not coincidentally, the most vilified.
Last May, TheWashington Post’s James Hohmann noted “an uncovered dynamic” that helped explain the GOP’s failure to repeal Obamacare. Three current Democratic House members had opposed the Affordable Care Act when it first passed. Twelve Democratic House members represent districts that Donald Trump won. Yet none voted for repeal. The “uncovered dynamic,” Hohmann suggested, was Nancy Pelosi’s skill at keeping her party in line.
She’s been keeping it in line for more than a decade. In 2005, George W. Bush launched his second presidential term with an aggressive push to partially privatize Social Security. For nine months, Republicans demanded that Democrats admit the retirement system was in crisis and offer their own program to change it. Pelosi refused. Democratic members of Congress hosted more than 1,000 town-hall meetings to rally opposition to privatization. That fall, Republicans backed down, and Bush’s second term never recovered.