Canadian Medicine

Our post on "" has been selected as the top medical blog post of last week, by , the host of .

Here's a sampling of some of the other posts included in Grand Rounds:

• Dr Judy Paley, of Denver doc online, has a on marijuana withdrawal and the absence of any proven drug therapy to help patients with either the withdrawal itself or its symptoms. She theorizes that ronabinol, a synthetic version of the active ingredient in marijuana THC, or rimonabant, which blocks the brain's endocannibinoid receptors, might be effective. (Or not. Nobody's tested those for marijuana withdrawal.)
• If hospitals were run by nurses instead of doctors or bureaucrats, patient care would be immeasurably better, .
• on the importance of physicians' cultural competence in managing patients' diabetes.
• Maybe the dearth of primary care physicians isn't such a bad thing; it encourages the development of more high-quality, efficient walk-in clinics, , writing about the situation in the US.
• writes about prescriptions for heart disease, like beta blockers and ACE inhibitors -- for gorillas.
  

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Being a doctor is hard work. But being a doctor to refugees? That’s quite possibly one of the most difficult medical assignments imaginable.

In yesterday’s Calgary Herald, Terence Leung who work with the Calgary Refugee Health Program: Lanice Jones, Lorraine Croft and program director Carolyn Pim.

CALGARIAN AID
“It's just a reminder of what we take for granted. For example, $6 million in Canadian health care is spent in about 17 minutes, whereas that kind of funding in a place like Laos will go to 2010,” Dr Jones told the Herald.

“By chance you're born in Canada where we're not starving, freezing or anything. We feel obligated to give something back. For myself, you spend the first half of your medical career with your trade, whereas the second half goes to more humanitarian pursuits,” Dr Croft said.

Dr Pim, who’s worked in Laos and Uganda, said emergency facilities in those countries have been lacking, “But what I've been impressed and amazed by is that the doctors and system there has so few resources and they're able to do so much with so little.”

THE REALITIES OF REFUGEE CARE
The Herald’s article takes a rather different approach than I did in December 2006.

My article began:

Tied to the roof, she was forced to watch as her husband was tortured to death beside her. Her two children were nowhere to be seen. Finished with her husband, the attackers moved on, joining the growing mob spreading violence and terror across the countryside. It was 2002; the Ivory Coast civil war had begun.

That woman was one of Dr Lavanya Narasiah's first patients.

The recurring theme of the interviews I conducted -- which doesn’t appear at all in the Calgary Herald’s piece -- was the lack of support for physicians who work in what is now being called Migration Medicine and Health. That lack of support, according to Dr Narasiah in Montreal and Dr Kevin Pottie of the University of Ottawa, manifests itself in insufficient provincial funding for physicians, which has made the number of immigrant-health doctors scarce.

In a field of medicine where the work is particularly emotionally draining and requires a great deal of specialized knowledge and a special skill set, shouldn't practitioners at least get the financial and human-resources support they need?


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Journalists consistently incite panic over small -- but novel and frightening-sounding -- health risks like SARS and bioterrorism, and all but ignore major ones like lack of exercise and smoking, according to new research. “The intensity of media coverage inversely correlated with the actual number of deaths,” report researchers Larisa J Bomlitz and Mayer Brezis in a new study on the deleterious effect on public health of the American mass media, last Friday.

Just check out the study’s findings in the diagram to the right -- the greater the risk, the less reporters seem to care.

What’s behind this pattern? The best way to explain it is not the desire to sell more newspapers, as you might expect. Rather, the answer lies in an economics analysis of cognitive bias called “prospect theory.”

Bomlitz and Brezis offer a convincing explanation in their discussion of their results (the data they used is from 2003, hence the number of SARS stories):

“[The inversely correlated health reporting trend is] consistent with psychological theory on cognitive biases, whereby a small change is perceived as more notable than a stable information signal, even if the latter may convey a more significant message - as described by the prospect theory. Perceptual systems are designed to enhance the accessibility of changes and differences: cold water feels colder if our other hand is immersed in warm water because perception is deter mined by comparison. The magnitude of a stimulus and its perceived significance derive from the contrast between that stimulus and other prior and simultaneous stimuli. The prospect theory extends the principle underlying these perceptual illusions to the explanation of cognitive biases in financial or health-related decisions.”

The study cites as its source Daniel Kahneman, a Princeton psychologist, who described prospect theory in his 2002 Nobel Prize lecture, which is online (PDF).

In his lecture, Dr Kahneman explained that people react differently to health risks depending on whether they’re framed as survival rates or mortality rates. Dr Kahneman mentioned a few neat demonstrations of this cognitive bias. One is “The Asian Disease” problem:

Imagine that the United States is preparing for the outbreak of an unusual Asian disease, which is expected to kill 600 people. Two alternative programs to combat the disease have been proposed. Assume that the exact scientific estimates of the consequences of the programs are as follows:

If Program A is adopted, 200 people will be saved

If Program B is adopted, there is a one-third probability that 600 people will be saved and a two-thirds probability that no people will be saved
Which of the two programs would you favor?

In this version of the problem, a substantial majority of respondents favor program A, indicating risk aversion. Other respondents, selected at random, receive a question in which the same cover story is followed by a different description of the options:

If Program A’ is adopted, 400 people will die

If Program B’ is adopted, there is a one-third probability that nobody will die and a two-thirds probability that 600 people will die

A clear majority of respondents now favor program B’, the risk-seeking option. Although there is no substantive difference between the versions, they evidently evoke different associations and evaluations. This is easiest to see in the certain option, because outcomes that are certain are over-weighted relative to outcomes of high or intermediate probability (Kahneman & Tversky, 1979). Thus, the certainty of saving people is disproportionately attractive, and the certainty of deaths is disproportionately aversive.

So SARS and bioterrorism are frightening because of their rarity and their high mortality rates, even though the absolute number of deaths is very low; the opposite is true of lack of exercise and smoking.

And that’s the explanation for that seemingly inviolable law of journalism: “If it bleeds, it leads.”

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University of Minnesota journalism professor Gary Schwitzer is one of the most astute and intelligent critics of misleading, erroneous and fear-mongering health reporting. He’s the publisher of US health-news monitoring site and he’s associated with its Canadian sister site, .

Professor Schwitzer also has a great . Just last week he wrote about an in The New York Times’s coverage of websites that offer information on breast cancer.

uses a headline, "Most Breast Cancer Sites Get It Right" over a story that begins:

The Internet is filled with unreliable health information and bogus claims. But sites dedicated to breast cancer information appear to have a high level of accuracy, a new study shows.

Texas researchers recently analyzed 343 Web pages, retrieved using search engines that consumers are likely to use when seeking information about breast cancer. The study, published online today in the medical journal Cancer, turned up 41 inaccurate statements on 18 of the Web sites, or an error rate of just 5.2 percent.

But that "just 5.2 percent" is the focus of the headline and the lead in a on the same study, but headlined, "Some breast cancer websites inaccurate." The story begins:

Five percent of breast cancer Web sites have mistakes, with those involving alternative or complementary medicine the most likely to be misleading, U.S. researchers reported on Monday.

So is an error rate of "only" 5% good - and worthy of headlines? Or is an error rate of 5% "bad" and worthy of the headline?

Here’s a , if you want to decide for yourself.


IMAGE: "," Bomlitz and Brezis, Hebrew University, Journal of Public Health advanced access, February 15, 2008

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A growing wave of violent kidnappings are targeting high-earning Afghans, many of whom are physicians. But the country's police are looking the other way, says a .

The Afghan attorney general's office says that in the past 10 months, they have investigated 130 Afghan kidnappings for ransom — 23 of them in Kabul. Those are believed to be a fraction of the actual number.

NPR spoke with the father of one doctor who was snatched off the street last month, and another who was shot in the arm, blindfolded, beaten and held captive chained to a wall in a windowless basement for 19 days until his brothers put up the ransom money.

Afghan docs are some of the country's top earners, raking in $15-a-month salaries, marking them as prime ransom targets for kidnappers. (To put things in perspective, Afghanistan's nurses make 3000 rupees, or $7.50 CAD, and janitors 2000 rupees, .)

According to the NPR article, some of the Afghan doctors who still practise in the country have armed themselves.

Even from the beginning of the war in 2001, the state of southern Afghanistan's hospitals has deteriorated quickly, as The Guardian (UK) . These latest attacks threaten to drive the few remaining physicians from the country, raising questions about how effective NATO forces -- and its large Canadian contingent -- have been at shoring up security in Afghanistan.


Photo: . An Afghan doctor examines a patient in a ward of the Jamhuriat Hospital (Republic Hospital) in Kabul, Afghanistan, March 30, 2006.

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The latest edition of Medicine 2.0, a collection of blog entries on the role of the internet and interactivity in medicine, is at med student Bertalan Meskó's blog.

Our entry, "Quebec man's pancreas up for grabs in online auction," is featured, alongside many other interesting posts, including:

• Digital Pathology Blog on ,

• from Tomography on 20 different Web 2.0 tools for diagnostic imaging professionals,

• a from The Efficient MD,

• and a (with ratings) organized by the profession of the authors -- physician, nurse, journalist, etc -- at Medblog.nl.

Image:

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