Sunday, May 28, 2006

Politics and the New England Journal of Medicine

In case you missed the most recent issue of the New England Journal of MEDICINE's (the capital font is for emphasis) publishing of Hillary Clinton and Barack Obama's 2008 presidential bid perspective piece entitled "Making Patient Safety the Centerpiece of Medical Liability Reform" on their proposal for medical liability reform, it can be found, available for free and to all (unlike most of the other peer-reviewed research studies and reviews published by physicians in the Journal) here. Interesting that this piece was displayed so prominently in the medical press but has failed to be picked up by the political press. As you read this piece ask yourself, why does this piece appear where it does?

When you combine politics and medicine as in this piece's title, you get on-the-Hill "position speak" which coins such terms as "patient safety" and creates the unspoken bind that any alternative position is "against patient safety." This is typical political Hill strategy but now it inserts itself into a health-care community not seasoned to this type of manipulation.

Now don't get me wrong, medical liability reform is needed. Certainly there are points made by senators Clinton and Obama that warrant careful consideration. But manipulation of physicians with such patient-centric titles (who doesn't want patient safety?) and legislation not yet "peer reviewed" in the halls of Congress (especially when no retort is published) in one of the most influencial and cited medical journals screams of bias and limits the objective credibility desired by its readers.

Does the publication of this work (which reiterates the legislation now moved to committee in the Senate and published previously) violate the Journal's own Ingelfinger rule? The NEJM boasts: "Just 8% of manuscripts submitted are accepted for publication and none are reported in any other medium prior to publication in NEJM." It now seems legislative opinion pieces are permitted a double standard - after all, this piece was presented before in the U.S. Senate on 28 Sept 2005 as Senate Bill 1784.

None of us are ignorant to the political overtones of this debate. Some have even suggested this legislation might consitute a bribe of physicians. Certainly more balanced opinions exist regarding this legislation and even more opinions exist on the validity of the data regarding medical liability and medical errors. But I ask: where are the senatorial perspective pieces in the Journal on the other medical liability reform legislation (like S. 22 or S. 23) recently fillibustered and defeated by Democratic interests on the Hill?

Or does this perspective piece fall under the guise of a Journal advertorial? If so, it was not properly labeled.

Perspectives are just that: perspectives. Certainly the influential nature of the authors of this piece bear notice. But their political position should not be permitted to manipulate the medical community in a medical journal until acceptably vetted on the floor of the Senate.



Anonymous said...

My ideal for malpractice reform?

No malpractice suit could be filed unless precleared by a review panel to which ANYONE could refer the case. This would go a long way towards punishing gross malpractice against the poor and ignorant. Example: patient of mine died secondary to bladder rupture because the nurses failed to unclamp her foley catheter (her bladder was being irrigated) and ignored her complaints of pain. No malpractice suit was filed because her family failed to understand what had happened.

TM Lutas said...

If anyone can refer, the lawyers will always refer, just to see what gets stirred up. There's a reason why you normally have to have standing to file a case. Justice would grind to a halt under the weight of paperwork filed by computer and judged by human beings.

Real Cheap Travel Team said...

Editorial malpractice!

DrWes said...

Anony 08:05:

Like the commander of a ship, unfortunately you'd be dragged into the litigation regarding your patient as well, even though that error was no fault of your own. Where's the incentive for you to disclose that error just so it can be tied to your Medicare reimbursement (as Pay-for-Performance initiative that CMS has implemented will do) and spend the $90K or more (on average) just to defend even the most frivolous claims?


Dan Collins said...

Oh, crap. When SciAm started employing Alan Alda as the voiceover guy on their specials, I declined to resubscribe. Wasn't the NEJM where the speculative calculations of Iraqi civilians dead due to the war were printed? Do the same people who defend the bizarre methodology of that article hold out the same form of charity towards Bjorn Lomborg? Is Hillary holding out for inexpensive, high-quality legal counsel for every American?

M. Simon said...

The biggest politicization of medicine is the war on self medicators.

Addiction or Self Medication?

There is a lot of PTSD in America that is seriously undertreated. What is the answer to this from the medical cartel?

A War On Unpatented Drugs.

A lot of this stems from child abuse. What do we do about it? Persecute the abused:


It would be really nice if we had a truly free market in medicine. In Mexico most drugs are available over the counter. In America we REQUIRE a physician's permission. Tagamet and other similar drugs before they went off pattent are another case in point. A $40 dollar doctor visit was required for a drug that was eventually determined safe enough to sell over the counter. And when did they become over the counter drugs (selling at a much lower cost than when you needed a Drs. prescriptiion)? Why after they went off patent.

Medicines alliance with government has corrupted it.

Anonymous said...

The current system rewards the whiners and mostly does not compensate the overwhelming majority of victims of malpractice. Any honest physician would have to acknowledge that horrific fact. No fix worthy of the name that does not correct the problem is not a solution at all in my estimation.

Anon 8:05

Anonymous said...

Some of these comments really show how doctors and nurses have become the bad guys due to our society's penchant for litigation and perfect outcomes. There's a reason we're taught to chart "like there's a lawyer sitting on your shoulder." Most of us enter the profession because of a desire to help others and we're rewarded with suspicion and lawsuits. Sigh...

The governing bodies and journals in medicine and nursing have been political animals for a long time. I have never joined my state's nursing association because of its political nature. This obvious political gesture by the NEJM doesn't surprise me at all.

A referral system where all comers could refer cases would be an absolute disaster. Not only does it actively encourage abuse by lawyers but it would allow those completely ignorant of medicine to claim malpractice. For example, my mother-in-law, a medical expert because she went to radiology school in the 50s even though she never worked a day after she graduated, is convinced that a baby she lost in the early 60s was because the cord was wrapped around the baby's neck during delivery. She oftens talks about how she wishes she had sued the doctor. Anyone who has spent any time in a Labor & Delivery unit knows that a nuchal cord is relatively common and usually easily reduced. Under an open referral system, her poor Ob would have spent his $90K educating this woman on the mechanics of delivery.

About Mexican medicine - You still need an Rx to get meds in Mexico, just like here. The main difference is which meds require a scrip and which don't. Anyway, touting the Mexican system as something to emulate can only come from someone who has never been sick there.

Anonymous said...

I stopped reading (and trusting) NEJM in the 1980s when it jumped on the gun-control bandwagon with the thoroughly-debunked Kellerman study.

Anonymous said...

The NEJM is a socialist rag and I stopped subscribing to it years ago due to its blatant leftist agenda.

Anonymous said...

Vermontaigne wrote (8:53am):

Wasn't the NEJM where the speculative calculations of Iraqi civilians dead due to the war were printed?

No, that was The Lancet.

M. Simon said...

I have been sick in Mexico.

I was impressed that the medicines I needed were available over the counter.

"Unless we put medical freedom into the Constitution, the time will come when medicine will organize an undercover dictatorship. To restrict the art of healing to one class of men, and deny equal privilege to others, will be to constitute the Bastille of medical science. All such laws are un-American and despotic, and have no place in a Republic. The Constitution of this Republic should make special privilege for medical freedom as well as religious freedom." abridged quote --Benjamin Rush, M.D., a signer of the Declaration of Independence

Clark Goble said...

I believe it was the Lancet not the NEJM that did the Iraqi calculations. Although I think they were far less controversial than they ought to have been. The authors were using the standard methods of calculation that the US has itself appealed to in other conflicts, especially African ones. It's not ideal but it seems somewhat hypocritical to say it applies to every war but Iraq. And I say that as someone who was in favor of the war. (Although clearly not the way Rumsfeld conducted it)

With regards to the medical dispute I can see both sides. Clearly doctors ought be wary of becoming political. Yet if there are basic values that doctors feel is an essential part of medicine it behooves them to make their point. The alternative is to suggest that doctors have no voice in the debate which seems very, very problematic.

Nancy Reyes said...

The NEJM has long been a promoter of "progressive" causes.
Back in the late 1980's, they published at least eight articles on euthanasia, all of which claimed the Netherlands had allowed this under tight regulation.
I wrote back time and again that the large range in "estimates" (from 500 to 20 000 cases a year) made it unlikely that there was any regulation, since regulation required reporting, collecting data, and in normal data collection the numbers would be more accurate.
Finally,the Lancet published an article that obscured in the text but showed in the tables that indeed the data was not being documented. When I confronted the editors, Relman sent a letter back saying that the articles were "opinion pieces" and therefore did not need to verify the statements. Needless to say, there was no official retraction either.

Anonymous said...

I thought the article was also worthy of comment, in a similar vein. I found it interesting that the program Sens. Clinton and Obama highlighted, in Michigan, took place in a state that also has caps. It is most certainly not a "pure sample."

DrWes said...

T.M. -
Your insights were excellent. Perhaps the most disturbing piece of the Barack/Hillary legislation is that there remains no cap on potential litigation - no doubt why lawyers likely support their bill - and the Michigan perspective certainly makes the point that there's still value to the MAJORITY of patients for liability caps.