Selling Sickness [book reviews]

    I just read a review of Selling Sickness  (published in the July/August issue of the ACP Journal Club) and thought you might be interested to read this and other reviews of this book.  [Link to more reviews at the end of this post.] 

See also A Collection of Articles on Disease Mongering;  Ethics and the Pharmaceutical Industry; Pharma fears and “Sicko” [on Michael Moore’s new film, from Sue Pelletier’s Capsules]

Moynihan R, Cassels A. Selling Sickness: How the world’s biggest pharmaceutical companies are turning us all into patients. Vancouver: Greystone Books, 2005.

An excerpt from the review:
Thirty years ago, Henry Gadsden, chief executive of Merck, told Fortune magazine he wanted Merck “to be more like chewing gum maker Wrigley’s.”
Gadsden said it had long been his dream to make drugs for healthy people, because then Merck would be able to “sell to everyone.” This is the starting point and central thesis of Moynihan and Cassels’ book, Selling Sickness—that pharmaceutical companies are working to turn us all into patients, and in the process generate ever-bigger profits for themselves (and ever-greater health care costs for health care systems). They make a compelling case that big pharma has deliberately used its influence to broaden disease definitions to expand its markets. For example, they report that GlaxoSmithKline (formerly SmithKline Beecham) has claimed that social anxiety disorder (SAD) affects 1 in 8 Americans. Other definitions put the prevalence variously at < 1% or, in some studies, up to 4%. By more broadly defining the criteria for SAD, the pharmaceutical company created a greatly expanded market for its drug Paxil, the first drug approved for the treatment of SAD.

The reviewer concludes:
Most of the examples and the citations are American. The
United States has < 5% of the world’s population but 50% of the global market in prescription drugs. Cassels is Canadian, and Moynihan is Australian. Both of these countries are protected against the full force of big pharma by having publicly funded health systems and evidence-based agencies that make decisions about provision of prescription medicines. Furthermore, unlike the
United States, these countries have limited direct-to-consumer advertising. Nevertheless, this book is informative and alarming reading regardless of where you live. The authors claim, and I agree with them, that along with regulatory and advertising controls, a major antidote to selling sickness is skepticism—of drug industry claims and drug company–funded research. Evidence-based medicine has a big role to play in maintaining balance between the important benefits of appropriately used prescription drugs and the risks for unsubstantiated claims and promotions by the industry.

Journal Record [subscription required]  Search inside the book at Amazon
BMJ Review     CMAJ Review

The James Lind Library: Why fair tests of treatments in health care are needed

     I was just reading the latest issue of the ACP Journal Club and I came across an interesting editorial by Dr. Iain Chalmers, founder of the Cochrane Collaboration and editor of the James Lind Library.

The James Lind Library was created to help people understand fair tests of treatments in health care by illustrating how fair tests have developed over the centuries.  This is a fascinating Web site and well worth a perusal by those interested in the history of fair testing of health care treatments.

James Lind was the Scottish naval surgeon who conducted a controlled trial for treatment of scurvy, and published his A Treatise of the Scurvy in 1753. This must be one of the first systematic reviews published …Together with a Critical and Chronological View of what has been published on the subject …

Chalmers I. Why fair tests are needed: a brief history [editorial]. ACP J Club 2006; 145(1):A8-A9. [subscription required]

Excerpt: Fair tests of treatments are those that take steps to obtain reliable information about treatment effects by reducing the misleading influences of biases and the play of chance. Why do we need such tests in health care? Have not doctors, for centuries, “done their best” for their patients? Sadly, health professionals in most if not all spheres of health care have harmed their patients inadvertently, sometimes on a very wide scale, because treatment decisions were not informed by what we now consider to be reliable evidence about the effects of treatments. Indeed, patients themselves sometimes harm other patients when, on the basis of untested theories and limited personal experiences, they encourage the use of treatments that turn out to be harmful.  

The question is not whom we can blame but whether we can reduce the harmful effects of inadequately tested treatments. And it seems we can-to a great extent-first, by avoiding applying untested theories about the effects of treatment in practice, and second, by wider use of fair tests of treatments.
PubMed Record       PubMed Related Articles      Journal Record

Effectiveness of an evidence-based chiropractic continuing education workshop on participant knowledge of evidence-based health care

   Just published in Chiropractic & Osteopathy:

Feise RJ, Grod JP, Taylor-Vaisey A. Effectiveness of an evidence-based chiropractic continuing education workshop on participant knowledge of evidence-based health care. Chiropr & Osteopat 2006; (electronic)

BACKGROUND: Chiropractors must continue to learn, develop themselves professionally throughout their careers, and become self-directed and lifelong learners. Using an evidence-based approach increases the probability of optimal patient outcomes. But most chiropractors lack knowledge and interest in evidence-based approaches. The purpose of this study was to develop and measure the effectiveness of evidence-based training for chiropractic practitioners in a continuing education setting.
METHODS: We developed and evaluated a continuing education workshop on evidence-based principles and methods for chiropractic practitioners. Forty-seven chiropractors participated in the training and testing. The course consisted of 12.5 hours of training in which practitioners learned to develop focused questions, search electronic data bases, critically review articles and apply information from the literature to specific clinical questions. Following the workshop, we assessed the program performance through the use of knowledge testing and anonymous presentation quality surveys.
RESULTS: Eighty-five percent of the participants completed all of the test, survey and data collection items. Pretest knowledge scores (15-item test) were low (47%). Post intervention scores (15-item test) improved with an effect size of 2.0. A 59-item knowledge posttest yielded very good results (mean score 88%). The quality of presentation was rated very good, and most participants (90%) would definitely recommend or recommend the workshop to a colleague.
CONCLUSIONS: The results of the study suggest that the continuing education course was effective in enhancing knowledge in the evidence-based approach and that the presentation was well accepted.
PubMed Record    Free Full Text 

Friday Fun: Birth dates explained and non-existent last names

  If imitation is the sincerest form of flattery, then Sue of face2face should feel very flattered right now. I just read one of her blog entries and found a couple of amusing sites for a Friday Fun post. Thanks, Sue.

Birthday Calculator

You can plug your birth date into this calculator and discover all kinds of interesting things about the day you were born. The site is somewhat limited, however. For example, nowhere in my entry does it say that my mother was watching the Santa Claus parade in Toronto when she went into labour with me, or that one of my feet was born in a taxi. But still, now I know why I love the crescent moon.

How common is your surname in America?

You can find out by plugging your name into this database. Well, my full last name isn’t in the database, but the first part of my last name is number 12. That’s out of 55.000 names! This even beats Moore, which is number 13. Number 1? Smith. I guessed at and found numbers 4 and 6, but I can’t figure out numbers 2, 3 and 5.

Mazmanian is not in the database because it’s not in the top 55,000. So this site is also somewhat limited, apparently.

Here’s an extra, a list I just found of Ten things you should never do on a Friday afternoon. It doesn’t include blog writing.

Deconstructing the evidence-based discourse in health sciences: truth, power and fascism

  The following article was published by some Canadian researchers in the September 2006 issue of the International Journal of Evidence-Based Healthcare. I just read about it on Sue Pelletier’s blog Capsules. Have a look and see what you think …

Holmes, Dave, Murray, Stuart J, Perron, Amélie & Rail, Geneviève. Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. International Journal of Evidence-Based Healthcare 2006; 4 (3), 180-186.

Background Drawing on the work of the late French philosophers Deleuze and Guattari, the objective of this paper is to demonstrate that the evidence-based movement in the health sciences is outrageously exclusionary and dangerously normative with regards to scientific knowledge. As such, we assert that the evidence-based movement in health sciences constitutes a good example of microfascism at play in the contemporary scientific arena. 

Objective The philosophical work of Deleuze and Guattari proves to be useful in showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm – that of post-positivism – but also and foremost in showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure. 

Conclusion The Cochrane Group, among others, has created a hierarchy that has been endorsed by many academic institutions, and that serves to (re)produce the exclusion of certain forms of research. Because ‘regimes of truth’ such as the evidence-based movement currently enjoy a privileged status, scholars have not only a scientific duty, but also an ethical obligation to deconstruct these regimes of power.

Journal Record      DOI Link     Full Text     A Rant

Inappropriate use of the title chiropractor and term chiropractic manipulation in the peer-reviewed biomedical literature

  Here’s another article that was just published online in Chiropractic & Osteopathy: [free full text]

Wenban AB. Inappropriate use of the title chiropractor and term chiropractic manipulation in the peer-reviewed biomedical literature. Chiropr Osteopat 2006; 14(1):16.

BACKGROUND: The misuse of the title chiropractor and term chiropractic manipulation, in relation to injury associated with cervical spine manipulation, have previously been reported in the peer-reviewed literature. The objectives of this study were to –
1) Prospectively monitor the peer-reviewed literature for papers reporting an association between chiropractic, or chiropractic manipulation, and injury;
 2) Contact lead authors of papers that report such an association in order to determine the basis upon which the title chiropractor and/or term chiropractic manipulation was used;
3) Document the outcome of submission of letters to the editors of journals wherein the title chiropractor, and/or term chiropractic manipulation, had been misused and resulted in the over-reporting of chiropractic induced injury.
METHODS: One electronic database (PubMed) was monitored prospectively, via monthly PubMed searches, during a 12 month period (June 2003 to May 2004). Once relevant papers were located, they were reviewed. If the qualifications and/or profession of the care provider/s were not apparent, an attempt was made to confirm them via direct e-mail communication with the principal researcher of each respective paper. A letter was then sent to the editor of each involved journal.
RESULTS: A total of twenty four different cases, spread across six separate publications, were located via the monthly PubMed searches. All twenty four cases took place in one of two European countries. The six publications consisted of four case reports, each containing one patient, one case series, involving twenty relevant cases, and a secondary report that pertained to one of the four case reports. In each of the six publications the authors suggest the care provider was a chiropractor and that each patient received chiropractic manipulation of the cervical spine prior to developing symptoms suggestive of traumatic injury. Regarding two of the four case reports contact with the principal researcher revealed that the care provider was not a chiropractor, as defined by the World Federation of Chiropractic. The authors of the other two case reports did not respond to my communications. Regarding the case series, which involved twenty relevant cases, the principal researcher conceded that the term chiropractor had been inappropriately used and that his case series did not relate to chiropractors who had undergone appropriate formal training. The author of the secondary report, a British Medical Journal editor, conceded that he had misused the title chiropractor. Letters to editors were accepted and published by all four journals to which they were sent. To date one of the four journals has published a correction.
CONCLUSIONS: The results of this year-long prospective review suggests that the words chiropractor and chiropractic manipulation are often used inappropriately by European biomedical researchers when reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury. Furthermore, in those cases reported here, the spurious use of terminology seems to have passed through the peer-review process without correction. Additionally, these findings provide further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of the title chiropractor and term chiropractic manipulation may be a significant source of over-reporting of the link between the care provided by chiropractors and injury. Finally, editors of peer-reviewed journals were amenable to publishing letters to editors, and to a lesser extent corrections, when authors had inappropriately used the title chiropractor and/or term chiropractic manipulation.
PubMed Record       BioMed Central     DOI Link

How far can complementary and alternative medicine go? The case of chiropractic and homeopathy

   This study was just published online in Social Science & Medicine: [subscription required]

Kelner M, Wellman B, Welsh S, Boon H. How far can complementary and alternative medicine go? The case of chiropractic and homeopathy. Soc Sci Med 2006; .Abstract: This paper examines the efforts of two complementary and alternative occupations, chiropractors and homeopaths, to move from the margins to the mainstream in health care in the province of Ontario. We use a variety of theoretical perspectives to understand how health occupations professionalize: the trait functionalist framework, social closure, the system of professions, and the concept of countervailing powers. The research traces the strategies that the leaders of the two groups are employing, as well as the resources they are able to marshal. These are analyzed within the context of the larger institutional and cultural environment. The data are derived from in-person interviews with 16 leaders (10 chiropractic and 6 homeopathic) identified through professional associations, teaching institutions and informants from the groups. The responses were analyzed with qualitative content analysis. We also used archival materials to document what the leaders were telling us.
The data revealed four main strategies:
(1) improving the quality of educational programs,
(2) elevating standards of practice,
(3) developing more peer reviewed research, and
(4) increasing group cohesion.
Although both groups identified similar strategies, the chiropractors were bolstered by more resources as well as state sanctioned regulation. The efforts of the homeopaths were constrained by scarce resources and the absence of self-regulation. In both cases the lack of strong structural support from government and the established health professions played an important role in limiting what was possible. In the future, it may be to the state’s advantage to modify the overall shape of health care to include alternative paradigms of healing along with conventional medical care. Such a shift would put complementary and alternative medicine occupations in a better position to advance professionally and become formal elements of the established health care system.
PubMed Record   PMID: 16926065

Chiropractic manipulation in adolescent idiopathic scoliosis: A pilot study

  Here is a new study just published in Chiropractic & Osteopathy. Free full text is available. 

Rowe DE, Feise RJ, Crowther ER, Menke JM, Souza TA, Goldsmith CH, Stoline MR, Schaller TM, Grod JP. Chiropractic manipulation in adolescent idiopathic scoliosis: A pilot study. Chiropr Osteopat 2006; 14(1):15.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) remains the most common deforming orthopedic condition in children. Increasingly, both adults and children are seeking complementary and alternative therapy, including chiropractic treatment, for a wide variety of health concerns. The scientific evidence supporting the use chiropractic intervention is inadequate. The purpose of this study was to conduct a pilot study and explore issues of safety, patient recruitment and compliance, treatment standardization, sham treatment refinement, inter-professional cooperation, quality assurance, and outcome measure selection.

METHODS: Six patients participated in this 6-month study, 5 of whom were female. One female was braced. The mean age of these patients was 14 years, and the mean Cobb angle was 22.2 degrees. The study design was a randomized controlled clinical trial with two independent and blinded observers. Three patients were treated by standard medical care (observation or brace treatment), two were treated with standard medical care plus chiropractic manipulation, and one was treated with standard medical care plus sham manipulation. The primary outcome measure was Cobb, and the psychosocial measure was Scoliosis Quality of Life Index.

RESULTS: Orthopedic surgeons and chiropractors were easily recruited and worked cooperatively throughout the trial. Patient recruitment and compliance was good. Chiropractic treatments were safely employed, and research protocols were successful.

CONCLUSIONS: Overall, our pilot study showed the viability for a larger randomized trial. This pilot confirms the strength of existing protocols with amendments for use in a full randomized controlled trial.

Trial Registration: This trial has been assigned an international standard randomized controlled trial number: ISRCTN41221647  by Current Controlled Trials, Ltd.

PubMed Record      Free Full Text  

Lifelong learning, faculty development and conflict of interest

 
From the September 2006 issue of the Journal of General Internal Medicine: [subscription required for last two years; 1997-2004, and January 2006 Supplement available free online]

Hojat M, Veloski J, Nasca TJ, Erdmann JB, Gonnella JS. Assessing physicians’ orientation toward lifelong learning. J Gen Intern Med 2006; 21(9):931-936.

Abstract: Despite the importance of lifelong learning as an element of professionalism, no psychometrically sound instrument is available for its assessment among physicians. To assess the validity and reliability of an instrument developed to measure physicians’ orientation toward lifelong learning. Mail survey. Seven hundred and twenty-one physicians, of whom 444 (62%) responded. The Jefferson Scale of Physician Lifelong Learning (JSPLL), which includes 19 items answered on a 4-point Likert scale, was used with additional questions about respondents’ professional activities related to continuous learning. Factor analysis of the JSPLL yielded 4 subscales entitled: “professional learning beliefs and motivation,””scholarly activities,””attention to learning opportunities,” and “technical skills in seeking information,” which are consistent with widely recognized features of lifelong learning. The validity of the scale and its subscales was supported by significant correlations with a set of criterion measures that presumably require continuous learning. The internal consistency reliability (coefficient alpha) of the JSPLL was 0.89, and the test-retest reliability was 0.91. Empirical evidence supports the validity and reliability of the JSPLL.
PubMed Record    Earlier Study by the same authors [full text] 

Sullivan AM, Lakoma MD, Billings JA, Peters AS, Block SD. Creating enduring change: demonstrating the long-term impact of a faculty development program in palliative care. J Gen Intern Med 2006; 21(9):907-914.

Abstract: Improved educational and evaluation methods are needed in continuing professional development programs. To evaluate the long-term impact of a faculty development program in palliative care education and practice. Longitudinal self-report surveys administered from April 2000 to April 2005. Physician and nurse educators from North America and Europe. All program graduates (n=156) were invited to participate. Two-week program offered annually (2000 to 2003) with 2 on-site sessions and 6-month distance-learning period. Learner-centered training addressed teaching methods, clinical skill development, and organizational and professional development. Self-administered survey items assessing behaviors and attitudes related to palliative care teaching, clinical care, and organizational and professional development at pre-, postprogram, and long-term (6, 12, or 18 months) follow-up. Response rates: 96% (n=149) preprogram, 73% (n=114) follow-up. Participants reported increases in: time spent in palliative care practice (38% preprogram, 47% follow-up, P<.01); use of learner-centered teaching approaches (sum of 8 approaches used “a lot”: preprogram 0.7+/-1.1, follow-up 3.1+/-2.0, P<.0001); and palliative care topics taught (sum of 11 topics taught “a lot”: preprogram 1.6+/-2.0, follow-up 4.9+/-2.9, P<.0001). Reported clinical practices in psychosocial dimensions of care improved (e.g., assessed psychosocial needs of patient who most recently died: 68% preprogram, 85% follow-up, P=.01). Nearly all (90%) reported launching palliative care initiatives, and attributed their success to program participation. Respondents reported major improvements in confidence, commitment to palliative care, and enthusiasm for teaching. Eighty-two percent reported the experience as “transformative.” This evidence of enduring change provides support for the potential of this educational model to have measurable impact on practices and professional development of physician and nurse educators.
PubMed Record 

Weinfurt KP, Friedman JY, Allsbrook JS, Dinan MA, Hall MA, Sugarman J. Views of potential research participants on financial conflicts of interest: barriers and opportunities for effective disclosure. J Gen Intern Med 2006; 21(9):901-906.

Abstract: There is little guidance regarding how to disclose researchers’ financial interests to potential research participants. To determine what potential research participants want to know about financial interests, their capacity to understand disclosed information and its implications, and the reactions of potential research participants to a proposed disclosure statement. Sixteen focus groups in 3 cities, including 6 groups of healthy adults, 6 groups of adults with mild chronic illness, 1 group of parents of healthy children, 1 group of parents of children with leukemia or brain tumor, 1 group of adults with heart failure, and 1 group of adults with cancer. Focus group discussions covered a range of topics including financial relationships in clinical research, whether people should be told about them, and how they should be told. Audio-recordings of focus groups were transcribed, verified, and coded for analysis. Participants wanted to know about financial interests, whether or not those interests would affect their participation. However, they varied in their desire and ability to understand the nature and implications of financial interests. Whether disclosure was deemed important depended upon the risk of the research. Trust in clinicians was also related to views regarding disclosure. If given the opportunity to ask questions during the consent process, some participants would not have known what to ask; however, after the focus group sessions, participants could identify information they would want to know. Financial interests are important to potential research participants, but obstacles to effective disclosure exist.
PubMed Record 

Journal of General Internal Medicine    

Open access: implications for scholarly publishing and medical libraries

  From the July 2006 issue of the Journal of the Medical Libary Association:

Albert KM. Open access: implications for scholarly publishing and medical libraries. J Med Libr Assoc 2006; 94(3):253-262.

Purpose: The paper reviews and analyzes the evolution of the open access (OA) publishing movement and its impact on the traditional scholarly publishing model.

Procedures: A literature survey and analysis of definitions of OA, problems with the current publishing model, historical developments, funding agency responses, stakeholder viewpoints, and implications for scientific libraries and publishing are performed.

Findings: The Internet’s transformation of information access has fueled interest in reshaping what many see as a dysfunctional, high-cost system of scholarly publishing. For years, librarians alone advocated for change, until relatively recently when interest in OA and related initiatives spread to the scientific community, governmental groups, funding agencies, publishers, and the general public.

Conclusions: Most stakeholders acknowledge that change in the publishing landscape is inevitable, but heated debate continues over what form this transformation will take. The most frequently discussed remedies for the troubled current system are the “green” road (self-archiving articles published in non-OA journals) and the “gold” road (publishing in OA journals). Both movements will likely intensify, with a multiplicity of models and initiatives coexisting for some time.
PubMed Record     Free Full Text    July 2006 Issue