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Friday, March 30, 2012

Public health for nincompoops

Consistency, it is said, is the mark of a true champion. Utter lack of consistency, therefore, must indicate something else entirely. I'll be kind and call it: nincompoopery.

Not my Hat! by cogdoggblog via Flickr and a Creative Commons licenseWhen it comes to public health policy, we are a pack of utter nincompoops. Sorry, but it is what it is.

The timing of this rant is inspired by recent events related to women and matters of family planning. We'll come back to that. For now, let's try this on:

Should medical marijuana be legal everywhere, or not?

You likely had a knee-jerk reaction to the marijuana question. You may feel strongly that marijuana should absolutely be available for medical use. You may feel just as strongly that the idea is outrageous. It's an illegal drug, after all. Or you may feel you don't know enough about medical marijuana to decide.

But I think the best response to the question is another question, a deeper question, a question that gets at the principles--the first principles--that most reasonable people would agree should decide the matter: On what basis is ANY substance approved or disapproved for medical use?

Let's at least agree that trying to answer this about a drug, and never bothering to answer it about all drugs, is inordinately inefficient. It means starting the same debate from scratch every time. Truly silly at best, a formula for inconsistent idiocy at worst. Nincompoopery.

So, on what basis SHOULD any drug be approved or disapproved?

We might think a drug should be disapproved if it's dangerous. But that's clearly not so; drugs far more dangerous than marijuana are used in medicine all the time. A few that spring immediately to mind include nitroprusside, Ketamine, Coumadin and haloperidol.

Perhaps a drug should be disapproved if it's addictive? That's clearly not the case either, since vastly more addictive drugs than marijuana are in routine use, among them the benzodiazepine class of sedatives, home to Valium, that are among the very few habit-forming drugs from which withdrawal can actually be lethal. But then again, alcohol is also potentially habit-forming, and withdrawal can be lethal, and not only is it approved for use, but no prescription is required. And while on the topic, plain old tobacco is more addictive than cannabis.

Well, all right. Perhaps a drug should be disapproved if it's already disapproved! Perhaps we should simply hold the line against medical use of substances that are already illegal. That would be enough to dispatch marijuana.

But it would also be enough to dispatch cocaine and heroin, and here I've got bad news. Cocaine is an approved drug, on hand in virtually every emergency department in the country. It is used, among other things, to control epistaxis, the medial term for severe nosebleeds. During my years as an ER doc, I treated patients with it on a number of occasions. We would soak cotton in a cocaine solution, and into the patient's nose it would go.

As for heroin, it's not legal per se, but Dilaudid is. This is a synthetic opiate painkiller that is, in essence, heroin on steroids. It is many times more potent than heroin or morphine in its narcotic effects.

We could, I think, come up with sound criteria to guide decisions regarding all drugs. They would include such things as: a clear need, clear results of testing, a favorable benefit/risk ratio when used as intended and so on. For what it's worth, medical marijuana almost certainly passes through any such filter, but that's a topic for another time.

What about medically-assisted dying? This is another emotive, provocative topic prone to evoke reflexive answers, but not a lot of reflection. If the goal of medical treatment is to extend life at all costs, the topic is clearly taboo. But then the right question is: What is the goal of medical treatment?

Personally, I think medical treatment is about the patient. I think it serves the patient of sound mind, and the family of sound heart. Admittedly, soundness of mind and heart can at times be hard to judge, but more often than not we can make the call. But this, too, is a debate for another day. My point now is simply that judgments about medically-assisted dying in the absence of judgments about the fundamental objectives of medical care are cart before horse, and tail wagging the dog.

Not to mention (come to think of it, yes to mention) the fact that those elements in our society most opposed to assisted dying seem often to be OK with capital punishment. So sanctity-of-life arguments don't seem to put the issue to bed.

Perhaps we want to oppose all societal actions that aid and abet misguided or objectionable behavior? That is the customary opposition to so-called "harm reduction" strategies, such as needle exchange programs for IV drug users. Such programs have been shown, decisively, to reduce HIV transmission without increasing drug use, but there is a prevailing objection on principle.

But is it a "first" principle, applied consistently? I dare say not! Seat belts and air bags prevent injuries and deaths from car crashes that overwhelmingly would not occur in the first place if people didn't drive while impaired, drive while distracted, drive while texting or exceed the speed limit. So don't seat belts and air bags "aid and abet" speeding, driving under the influence and so on? I leave you to chew on it.

I take a lot of abuse from the "Stop telling us what to do, Katz!" crowd. It doesn't cost me any sleep; it's all part of the gig. But I note it as a fact.

But here's the thing: Those who call me names, many nasty and some profane, for suggesting that we at times need public health policies to protect us--that, at times, the best defense of the human body resides with the body politic--do so on the grounds of defending autonomy. They do so arguing that self-sufficient, self-reliant, reasonably intelligent adults don't need the likes of me, or a big government, telling them what to do.

I might just take this on the chin and live with it (although a counter-argument is not hard to make), were it even remotely consistent. But it's not.

As best I can tell, it's the same "Butt out and let autonomous adults run their own lives" crowd who feels that they/the government absolutely SHOULD tell women when they can and can't get contraceptives, and when they must have ultrasound probes rubbed over them, and perhaps even inserted into them.

In other words, somewhere out there is a pack of hypocritical, occasionally foul-mouthed nincompoops who do NOT object to autonomous adults being bossed around. They simply want to be the ones to do the bossing!

For what it's worth, I think there is a middle path best defined by first principles. I think we could sensibly decide when drugs should be legal or illegal, available by prescription or over the counter. I think we could sensibly decide when regulations are required, and when informing people is enough because knowledge is power. I think we could, but for the most part, we don't.

We hide behind ideology while ignoring epidemiology, and let tales of sound and fury signifying nothing consistent or even sensible wag the dogma.

What we wind up with is public health policy for nincompoops. And if this morass of sloppy thinking and hypocrisy is the best we can do, that's about what we deserve.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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