MMR doctor Andrew Wakefield fixed data on autism

Brian Deer

February 8, 2009

THE doctor who sparked the scare over the safety of the MMR vaccine for children changed and misreported results in his research, creating the appearance of a possible link with autism, a Sunday Times investigation has found.

Confidential medical documents and interviews with witnesses have established that Andrew Wakefield manipulated patients’ data, which triggered fears that the MMR triple vaccine to protect against measles, mumps and rubella was linked to the condition.

The research was published in February 1998 in an article in The Lancet medical journal. It claimed that the families of eight out of 12 children attending a routine clinic at the hospital had blamed MMR for their autism, and said that problems came on within days of the jab. The team also claimed to have discovered a new inflammatory bowel disease underlying the children’s conditions.

However, our investigation, confirmed by evidence presented to the General Medical Council (GMC), reveals that: In most of the 12 cases, the children’s ailments as described in The Lancet were different from their hospital and GP records. Although the research paper claimed that problems came on within days of the jab, in only one case did medical records suggest this was true, and in many of the cases medical concerns had been raised before the children were vaccinated. Hospital pathologists, looking for inflammatory bowel disease, reported in the majority of cases that the gut was normal. This was then reviewed and the Lancet paper showed them as abnormal.

Despite involving just a dozen children, the 1998 paper’s impact was extraordinary. After its publication, rates of inoculation fell from 92% to below 80%. Populations acquire “herd immunity” from measles when more than 95% of people have been vaccinated.

Last week official figures showed that 1,348 confirmed cases of measles in England and Wales were reported last year, compared with 56 in 1998. Two children have died of the disease.

With two professors, John Walker-Smith and Simon Murch, Wakefield is defending himself against allegations of serious professional misconduct brought by the GMC. The charges relate to ethical aspects of the project, not its findings. All three men deny any misconduct.

Through his lawyers, Wakefield this weekend denied the issues raised by our investigation, but declined to comment further 

Related Links

• Hidden records show MMR truth

• How the MMR scare led to return of measles

• MMR: Key dates in the crisis 

Keeping prevention in perspective: Has the value of screenings been oversold?

Prevention has become a catchword, prompting some experts to question whether physician and patient expectations are realistic.

By Victoria Stagg Elliott, AMNews staff. Posted Jan. 26, 2009.

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Alfred O. Berg, MD, MPH, believes prevention has been oversold. "As you start looking where the evidence is clear, start doing the math and asking what the actual benefit may be for an individual patient or clinician in practice, it does make you pause," said Dr. Berg, a former head of the U.S. Preventive Services Task Force and professor of family medicine at the University of Washington.

But he also thinks prevention has been undersold. Many interventions, such as vaccinations and smoking cessation, are not advocated enough.

Dr. Berg is part of a small and increasingly vocal group of doctors asking if every preventive medicine strategy -- from screening technology to lifestyle changes -- really can accomplish what physicians and patients hope for and if those that truly are effective get lost in the high volume of prevention messages.

"I don't think that the concept of prevention has been oversold, but there are certainly preventive interventions that have been oversold," said Barnett Kramer, MD, MPH, associate director for disease prevention at the National Institutes of Health.

Scientific evidence documenting a disconnect between what a preventive strategy can achieve versus what is expected is scarce. But many physicians experience the incongruence in daily practice. They also often see patients who have unrealistic perceptions about the degree to which specific health risks may affect them. The few studies that have been done on this subject have, for the most part, involved mammography.

A study in the May 17, 1995, Journal of the National Cancer Institute documented the results of a survey of 145 women 40 to 50 years old. Participants overestimated their risk of dying of breast cancer within the next decade by twentyfold. The relative risk reduction was overestimated sixfold, and the absolute risk by more than a hundredfold.

"We attributed this observation to marketing. The public marketing was so misleading," said William Black, MD, lead author and professor of radiology at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Expectation versus reality

Experts are concerned about such examples -- those in which expectations differ from reality -- because of the potential impact on the doctor-patient relationship. Are patients being scared unnecessarily? Will they take action that could endanger their health in response to test results? Are they being reassured falsely?

"If we promise what we cannot deliver, it's not fair to our patients and it's not fair to us as doctors," said David F. Ransohoff, MD, professor of cancer epidemiology, prevention and control at the University of North Carolina. He has written several papers on the value of colonoscopy.

87% of adults say routine cancer screening is always a good idea.

Concern is particularly high about screenings that can have risks that may not be fully appreciated or balanced by benefits.

"For patients who don't have any symptoms, the chances they have the disease are very low, and the risks become very important," said Dr. Nancy Baxter, associate professor of surgery at the University of Toronto.

Several recent publications support the concept that preventive modalities have significant and important limitations that need to be as well known as the positives.

"Most interventions are a close call and a personal decision. Most people would be surprised to learn that some trials don't show an increase in life expectancy," Dr. Kramer said. "The target population for most interventions are healthy people, and it's difficult to make healthy people better off than they already are. It's a high bar to clear."

For example, reviews of the impact of mammography estimate it reduces breast cancer mortality by about 15%. Some papers put that number as high as 25%, but a study in the Nov. 24, 2008, Archives of Internal Medicine found that women age 50 to 64 who were screened three times over a five-year period had a 22% higher incidence of invasive breast cancer than those screened only once. The authors suspect some of the cancers, had they not been detected with frequent screening, may never have become problematic and may have regressed on their own.

"We just need to be honest that it's a closer call than we have acknowledged," said H. Gilbert Welch, MD, MPH, one of the authors and professor of community and family medicine at Dartmouth Medical School in Hanover, N.H. He is also the author of Should I Be Tested for Cancer? Maybe Not and Here's Why.

Another study, in the Jan. 6 Annals of Internal Medicine, challenged the claim that colonoscopy can prevent as many as 90% of colon cancer deaths. Researchers did a population-based, case-control study in Ontario, Canada, and found that colonoscopy was associated with a 67% reduction in deaths from left-sided colorectal cancer, but only a 1% cut in mortality from the right-sided form.

"Ninety percent is a pretty tall order for any screening test. ... The study demonstrates that colonoscopy is an effective procedure for the prevention of death from colorectal cancer. It just may not be quite as effective as we've thought in the past," said Dr. Baxter, the paper's lead author.

With regard to lifestyle changes, most agree that moderate exercise and weight control are central to overall wellness. The question of the impact of weight loss on mortality rates has been more controversial -- studies result in an array of conflicting findings. Some eating styles also have been linked to a lower risk of various cancers and improved cardiovascular health, but these theories have not always been confirmed in randomized controlled trials.

"Things have been really mixed as to how exercise and diet relate to longevity," Dr. Welch said. "But most people feel better."

Finding a balanced view

Also, physician counseling on these subjects may not translate to improved health outcomes. The USPSTF endorses screening for tobacco use and subsequent counseling, but says evidence is insufficient to encourage primary care physicians to give advice about physical activity and nutrition.

"The question is: In the clinical setting, is it time well-spent for a clinician? The evidence is not strong," said Patrick Remington, MD, MPH, director of the Population Health Institute at the University of Wisconsin School of Medicine and Public Health.

Why expectations for prevention have become so great is not clear, although experts have several theories. Various preventive modalities are heavily promoted by patient organizations, medical societies and public health agencies. The limits of a preventive strategy may get lost as the benefits are emphasized and complex messages get oversimplified in awareness campaigns.

A zeitgeist also emerged in the last century that early detection and lifestyle changes always make a difference. "It just seems like it's the right thing to do," said Russell Harris, MD, MPH, a former USPSTF member and professor of medicine at the University of North Carolina.

In the early 20th century, inventor Thomas Edison predicted, "The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease." The phrase, "I will prevent disease whenever I can, for prevention is preferable to cure," is part of the modern version of the Hippocratic oath, written in 1964 by Louis Lasagna, MD. Bookshelves, magazine racks and the Internet are full of various publications purporting strategies to save lives. The American Medical Association has many books on the subject, including the American Medical Association Complete Guide to Prevention and Wellness, published in September 2008.

"Prevention should not be abandoned, but there should be a better balance to how we view [it]. There are going to be certain diseases where prevention is going to be better than treatment. The other side of the coin is there are going to be situations where treatment is better than prevention," Dr. Kramer said.

Some physicians say the process for deciding what preventive strategies to pursue is a good fit for shared decision-making to engage patients in understanding various strategies' potential harms and benefits. No one working in this area believes that any of these interventions are inherently bad or dangerous, but many hope to see them applied appropriately.

"When talking about prevention, it's important to put it into context," Dr. Black said. "We should be getting informed consent. ... The person has time to make a deliberate decision. They're not in pain, and there should not be pressure."

But many doctors want to balance the need to be honest about what something can do, with a fear of deterring patients from something that could protect their health.

"I'd hate to discourage women from having a mammogram. There are data that it does some good. It's not perfect, but it's the best we've got," said Carol Lee, MD, head of the American College of Radiology's breast cancer imaging commission.

And many physicians maintain prevention still hasn't been sold enough. After all, enthusiasm for it is high. A study in the Jan. 7, 2004, Journal of the American Medical Association found that 87% of adults felt that routine cancer screening was always a good idea. But that response still doesn't mean everyone is taking part.

"If we have oversold preventive services, smoking rates would not be at 20%. Colonoscopy rates wouldn't be at 40% to 50%, and mammography rates would approach 100%," said Martin Mahoney, MD, PhD, a family physician and director of the cancer prevention and detection center at the Roswell Park Cancer Institute in Buffalo, N.Y.

The print version of this content appeared in the Feb. 2, 2009 issue of American Medical News.

Birth of a Kidney! Doctors Remove Organ Through Woman’s Vagina

Jennifer Gilbert needed a kidney, and her aunt, Kimberly Johnson, had one. But instead of removing it through traditional surgery, doctors pulled it out through her vagina. The procedure was done in three hours, and is far less invasive: Johnson, who has three children, said it was easier than childbirth, and was home by the next day.

Instead of the typical five to six-inch abdominal incision, the process involves small pea-sized incisions (in this case, three) in the abdomen and navel, through which cameras are inserted. A bag attached to a hollow tube is then inserted through the vagina. The kidney is cut loose and, using the cameras, doctors guide it into the bag and pull it out through the vaginal opening.

Transvaginal kidney removal, as the procedure is known, has been used in the past on cancerous or nonfunctioning kidneys, and similar removals of gall bladders and appendixes have been done through the mouth and anus. But doctors believe this is the first time the procedure has been done on a healthy organ.

Johnson had already had a hysterectomy, and her lack of uterus made her a good candidate for the procedure—the doctors could benefit from fewer obstructions. Still, the medical community hopes that this new tactic will encourage more people (or, at least, more women) to donate.

Some doctors, however, have concerns about the procedure—specifically, the possibility of organs passing through contaminated areas of the body and getting infected. Not to mention the challenge of getting patients past the ick factor.

Related Content:
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Disco: Organ Transplants Gone Horribly Awry

FDA to study TV drug ads' influence on U.S. consumers

Controversial since they debuted in 1997, DTC ads are thought by many to require more oversight.

By Susan J. Landers, AMNews staff. Posted Feb. 2, 2009.

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Washington -- Are direct-to-consumer television ads the best way for consumers to absorb information? Maybe TV viewers don't even hear the laundry lists of potential side effects. Perhaps they are distracted by the accompanying scenes of happy people doing fun things or snoozing contentedly.

The Food and Drug Administration has outlined a novel study designed to measure participants' recall and comprehension of risk and benefit information in television ads.

The agency will produce ads for a fictitious blood pressure medication and recruit 2,400 participants to view them and report on the messages they take away. The study design was announced in the Dec. 30, 2008, Federal Register, and the agency is gathering comments until Jan. 29. The FDA's intention to conduct the study was first announced in 2007.

The action is expected to provide preliminary data on how the agency might set standards for DTC ads that conform to those called for by Congress, said Kathryn Aikin, PhD, social science analyst in the agency's Division of Drug Marketing, Advertising and Communications. "The data should help us plan whether additional research is needed to develop the standards called for in the FDA Amendments Act of 2007."

DTC advertisements have prompted debate among physicians and others ever since 1997, when they were first allowed on the airways and in print. Some find the ads raise legitimate issues about diseases and conditions. Many others, though, would like them to just go away for several reasons -- for instance, the time physicians and patients waste talking about unneeded medications during office visits.

A major objection to the ads centers on how information is presented. "Direct-to-consumer ads often portray drugs through rose-colored glasses by including more information about a drug's benefits than risks," AMA President Nancy H. Nielsen, MD, PhD, told a congressional oversight committee in May, 2008. "Imbalances in these ads can diminish patient understanding of certain drug risks and increase the need for an ongoing dialogue between patients and physicians about the benefits and risks of prescription drugs."

The American Medical Association developed a set of recommendations to ensure that ads provide a service to patients and physicians by providing objective benefit and risk information. The AMA also would like the FDA to review and preapprove the ads before they appear on TV and in magazines, and also would prefer that the ads not appear until physicians have been educated about the product.

A step toward improved regulations?

The AMA commended the FDA on its plan to conduct the study when the agency announced its 2007 proposal. "We agree with the agency that the results of this study should help improve how television advertisements present a drug's risks and benefits," wrote Michael D. Maves, MD, MBA, the Association's executive vice president and chief executive officer. "The AMA looks forward to the completion of this important study and, as necessary, the translation of its results into more effective DTC regulations."

Another big player in the TV ads debate is the Pharmaceutical Research and Manufacturers of America, which represents large drug and device manufacturers. A PhRMA spokesperson indicated that the proposal was still being considered for comment as of late January.

Consumer drug ads have been on the air and in print since 1997.

Several experts, however, wonder whether the study is worthwhile -- especially given the scarcity of funds in the federal budget.

The FDA is missing the fundamental question, said Steven Woloshin, MD, associate professor of medicine at the Dartmouth (N.H.) Institute for Health Policy and Clinical Practice. He described the issue this way: "Do patients understand how well the drugs work and do the ads help them have a better understanding?" He conducts research on enhancing the quality of medical communications.

"Given the scarce resources, is this the best way for [the agency] to be spending its money?" asked Peter Lurie, MD, MPH, deputy director of the Health Research Group at Public Citizen, a nonprofit consumer advocacy group in Washington, D.C.

"The questions are certainly interesting and the methodology thought-provoking, but ... in terms of enforcement, I'm not sure how much it will help," he said. Dr. Lurie has testified before Congress that the federal government should do more to stop misleading ads from reaching consumers.

Ending the Vicious Cycle: Virtual Mentor Feb No. 1

The guises in which abuse and violence present themselves to physicians (both in practice and in training) are as protean and plentiful as the choices these professionals make when so confronted. In this month's exploration of “Professional Responsibility in Preventing Violence and Abuse” we examine the context in which physicians' choices are made and the principles that underlie ethical decision making in these situations.

Two points deserve attention in the framing of our inquiry. First, is it pragmatically necessary to distinguish “abuse” from “violence” semantically? Many are inclined to treat these concepts as essentially interchangeable from a practical standpoint, while perhaps just as many would argue that “abuse” connotes a lesser degree of maltreatment in contrast to the visceral and physical connotations of “violence.” In this issue of Virtual Mentor, I advocate for compromise between these views, taking the perspective that both terms fall upon, and are descriptive of, a spectrum of pathological interactions that take place between two parties. Although one may be immediately tempted to replace “two parties” with recollections of quarreling spouses, lurid crimes reported in the media, or perhaps the uncomfortable notion of child abuse, it is instructive to note these “two parties” could just as well be physician and patient, physician-educator and student, or physician and staff.

Second, what is the appropriate scope for approaching this theme? Inasmuch as this is the first Virtual Mentor issue dedicated to this theme, there is plenty of unexplored territory in a particularly rich realm of exploration and discussion. The scope of violence and abuse is broad, potentially encompassing myriad aspects of abuse within the medical profession, family violence (child, domestic, partner, spousal, elder), youth violence (school bullying, school shootings, gang violence), broader forms of violence (war, violent crime), and even violence against the self (self-mutilation, suicide). I've decided to focus on the aspects of violence and abuse that clinicians are most likely to encounter in their professional careers, particularly those amenable to timely detection and intervention.

It is difficult to overstate the importance of preventing violence and abuse. The Centers for Disease Control and Prevention notes that "violence is a significant problem in the United States…from infants to the elderly, it affects people in all stages of life” [1], while the World Health Organization recognizes that “violence is a leading worldwide public health problem” [2]. Physicians in many specialties are qualified to intervene and ameliorate abuse and violence propagation, in both their clinical and public health roles. Despite being largely preventable with appropriate intervention, abuse and violence in their many forms often go undiagnosed and underreported. In 2006 alone, state and local child protective services substantiated more than 900,000 cases of child abuse or neglect [3]. That same year, more than 720,000 youths were treated in emergency rooms for injuries sustained due to violence [4]. Each year, there are nearly 8 million intimate-partner-related assaults suffered by men and women alike [5], thousands of which result in death [6]. The annual cost of lost productivity and medical expenses resulting from violence in the United States has been estimated at more than $70 billion [7].

Unchecked, violence and abuse propagate a vicious cycle, and the adage that “violence begets violence” is in fact empirically supported by numerous studies showing that those who are abused, neglected, and otherwise subjected to or exposed to violence early in life are statistically and significantly more likely to engage in a wide array of destructive behaviors and become perpetrators of violence themselves later in life [8].

Physicians have both a professional and ethical obligation to detect, prevent, and treat the results of abuse, but this obligation is not always clear-cut or easy to fulfill. On the topic of family violence, for example, the American Medical Association Code of Medical Ethics states that “due to the prevalence and medical consequences of family violence, physicians should routinely inquire about physical, sexual, and psychological abuse as part of the medical history” and furthermore that “physicians who are likely to have the opportunity to detect abuse in the course of their work have an obligation to familiarize themselves with protocols for diagnosing and treating abuse” [9].

At the same time, however, the code acknowledges that

laws that require the reporting of cases of suspected abuse…often create a difficult dilemma for the physician. The parties involved, both the suspected offenders and the victims, will often plead with the physician that the matter be kept confidential and not be disclosed or reported for investigation by public authorities [9].

Clearly, the physician's professional responsibilities in the context of violence and abuse prevention are often challenged by ethical conflict. It is the physician's duty to act in the best interest of the patient, but in many cases of violence and abuse what is truly best is in question. What professional obligations are applicable in these circumstances? And what should guide rational and ethical decision making when these obligations conflict? Virtual Mentor examines these concerns.

Although we must be cognizant of abuse and violence in clinical practice, simultaneously we should recognize that they are present within the medical profession as well. Many would argue that organized medicine is inherently hierarchical and that such intrinsic inequalities among status holders predispose the profession to abuse. Accordingly, Virtual Mentortackles abuse and violence prevention in medicine from both an intrinsic and extrinsic perspective. On the analogy of Russian nesting dolls, (or perhaps an onion, if you happen to be more gastronomically inclined), I argue that we can describe our exploration in terms of concentric realms of responsibility, critically analyzing violence and abuse prevention within the medical profession itself, within the integral and familiar patient-physician relationship, and finally within the broader context of society at large. This approach is reflected in the scope of this month's clinical cases.

In the first case, a medical student intent on pursuing a career in surgery grapples with the attending trauma surgeon's abuse. Commentators Dan Hunt, Barbara Barzansky, and Michael Migdal discuss the national prevalence of medical student mistreatment, the culture that enables continuation of these occurrences, and the options available to medical students who have experienced mistreatment.

Turning to the encounter between patient and physician, the second clinical case presents a sine qua non scenario for exploring the topic of violence and abuse prevention—a pediatrician who suspects child abuse ponders the appropriate clinical approach toward her patient and the patient's family. Commentator Karen St. Claire describes the scope of child abuse and neglect and explains the medical evaluation of and response to this threat to childhood well-being.

Moving outward to the question of physicians' obligations to society, the emergency physician in the third clinical case considers what steps to take when he evaluates a teenager who has been involved in violent gang activity. Commentators Lauren K. Whiteside and Rebecca M. Cunningham outline effective screening and prevention modalities for the critical public health problem of youth violence.

The remaining articles explore violence and abuse prevention from many perspectives, enhancing our holistic understanding of these issues. In the first of two medical education articles, Ana E. Nunez, Candace J. Robertson, and Jill A. Foster outline the significance of intimate partner violence (IPV) in clinical practice and recount the experiences and development of the Women's Health Education Program at Drexel University College of Medicine in educating students about IPV. In the second medical education article, Cindy Moskovic and colleagues make the case for upholding intimate-partner-violence education as a priority and describe the components, challenges, and successes of the IPV curriculum at the David Geffen School of Medicine at UCLA.

What should physicians do when confronted with knowledge or evidence of intimate partner violence? In “Mandatory Reporting of Domestic Violence: the Law, Friend or Foe?” published in the Mt. Sinai Journal of Medicine in 2005, Laura Iavicoli evaluated arguments for and against mandatory reporting by physicians. In this month's journal discussion, Isac Thomas reviews Iavicoli's arguments and concludes that “the unintended tragedy of mandatory reporting may be that, instead of facilitating intervention for victims of intimate partner violence, this policy might drive victims away from those who could help.” He believes that “reports of intimate partner violence to legal authorities should only be made with the victim's consent.”

Recall that the second clinical case examined the medical evaluation and approach to child abuse and neglect. How do we decide what constitutes child abuse and neglect in the first place, and what criteria should be considered when deciding whether or not to report it? In the clinical pearl, Jenelle R. Shanley, Deborah Shropshire, and Barbara L. Bonner review the clinical definitions of child abuse and neglect, explore the factors that influence physicians' decisions to report suspicious injuries and findings, and offer guidelines for making that difficult decision.

How do physicians maintain the balance between law and ethics? In the health law section, Kristin E. Schleiter discusses circumstances in which patient-physician confidentiality may conflict with the law. She poses the question, “When does public safety or preventing violence justify the erosion of the patient-physician relationship that occurs when physicians abandon the otherwise-sacred pledge of confidentiality?"

In the policy forum, Nancy Rappaport and James G. Barrett look at threat assessment in schools. The authors evaluate measures taken by certain schools in response to the threat of student violence. One Texas school district certifies teachers to carry weapons in the classroom and respond to threats with deadly force if necessary. Arguing that "arming teachers is a desperate school policy initiative,” the authors outline a rational framework in which medical professionals can more appropriately manage threats of school violence.

Two medicine and society pieces examine some of the underlying themes of violence and abuse that impact society. Janet Rose Osuch decries the legacy of abuse in medicine, homing in specifically upon the “culture of silence” that has often enshrouded medical error and the public humiliation sometimes employed in medical education. Jason Schnittker directs our attention to public reception of claims about the genetic causes of human behavior—mental illness and violent behavior, in particular—and addresses the consequences, positive and negative, of this enthusiastic acceptance.

The history of medicine article places our exploration of violence and abuse prevention in context. Linda L. Dahlberg and James A. Mercy summarize the history of violence as a public health problem, highlighting relevant public health developments of the past century, as well as steps taken by organizations such as the Centers for Disease Control and Prevention and the World Health Organization in response to these challenges.

Finally, in our op-ed section, Jorge C. Srabstein argues that “health professionals have the urgent public health responsibility to become informed and raise community awareness about the nature of bullying and its link to serious health risks.”

These articles and commentaries study abuse and violence from many different perspectives—clinical, ethical, professional, educational, historical, social, legal, and policy-based. It is my sincere hope that these discussions will drive home the integral role physicians have in preventing violence and abuse and will contribute to an ongoing process of education and reflection from which the medical profession, the patient-physician relationship, and society as a whole have much to gain.

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References

1. Centers for Disease Control and Prevention. Violence prevention at CDC. 2008. http://www.cdc.gov/ncipc/dvp/prevention_at_CDC.htm. Accessed January 6, 2009.
2. World Health Organization. World Report on Violence and Health. Geneva, Switzerland: World Health Organization; 2002.
3. US Department of Health & Human Services, Administration for Children & Families. Child Maltreatment 2006. Washington, DC: US Government Printing Office; 2006.
4. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). 2009. www.cdc.gov/ncipc/wisqars. Accessed January 15, 2009.
5. Tjaden P, Thoennes N. US Department of Justice. Extent, nature, and consequences of intimate partner violence: findings from the National Violence Against Women Survey, 2000. http://www.ncjrs.gov/pdffiles1/nij/181867.pdf. Accessed January 14, 2009.
6. US Department of Justice, Bureau of Justice Statistics. Homicide trends in the United States, 2007. www.ojp.usdoj.gov/bjs/homicide/intimates.htm. Accessed January 9, 2009.
7. Corso PS, Mercy JA, Simon TR, Finkelstein EA, Miller TR. Medical costs and productivity losses due to interpersonal and self-directed violence in the United States. Am J Prev Med. 32(6):474-482.
8. Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008.
9. American Medical Association. Opinion 2.02 Abuse of spouses, children, elderly persons, and others at risk. Code of Medical Ethics. Chicago, IL: American Medical Association. 2006. http://www.ama-assn.org/ama1/pub/upload/mm/Code_of_Med_Eth /opinion/opinion202.html. Accessed January 13, 2009.

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Justin P. Lee, MS-IIIKeck School of MedicineUniversity of Southern CaliforniaLos Angeles, California

Medicare pay must be fixed, says HHS pick Daschle

Reforming Medicare's SGR formula is one of the main concerns for the Health and Human Services secretary nominee.

By Doug Trapp, AMNews staff. Posted Jan. 19, 2009.

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Washington -- Former Sen. Tom Daschle, appearing at his first confirmation hearing to be Health and Human Services secretary, pledged to replace Medicare's sustainable growth rate formula with a system that bundles payments in an attempt to reward good patient outcomes.

Daschle also promised to examine inefficiencies in private Medicare plans, discourage tobacco use, support the training of primary care physicians and work with lawmakers in a bipartisan manner.

Daschle elaborated on his positions at a Jan. 8 hearing for the Senate Health, Education, Labor and Pensions Committee. The Senate Finance Committee, which has primary jurisdiction over the HHS nomination, had not scheduled a hearing as of press time. A full Senate vote will determine if Daschle's appointment is confirmed. President-elect Barack Obama also has named Daschle to direct the White House Office of Health Reform.

Daschle, a former Senate majority leader, said Medicare's SGR formula "just isn't working right." The latest in a series of temporary payment patches expires at the end of 2009. If Congress doesn't act before Jan. 1, 2010, doctors will undergo an estimated 21% Medicare pay cut. He said a new formula should focus on bundling payments based on episodes of care instead of paying per procedure.

"I'm not one who supports the so-called performance-based approach, but I do believe that there are episodic ways with which to look at reimbursement that give us a lot more latitude" to reward better outcomes, he said. He added that this would lower costs and lessen hassles for physicians, though he did not elaborate further.

Medicare Advantage plans will be paid 114% of traditional Medicare rates in 2009.

Daschle also said he wants to provide more scholarships and student loan payment help to medical students who agree to enter primary care.

Sen. Mike Enzi (Wyo.), the ranking Republican on the HELP committee, asked Daschle if he favored lawmakers using budget reconciliation to adopt health reform legislation. Reconciliation is a partisan process used to limit debate and amendments on bills that change tax law or address mandatory federal spending. The procedure also permits adoption with a simple majority vote instead of the 60 votes usually needed to cut off debate and move to a final vote.

Daschle said his goal is to see health legislation adopted through the normal order of business with 70-vote or higher majorities. "I really want to work in a collaborative way. It's the only way we're going to get this done."

Sen. Richard Burr (R, N.C.) asked Daschle about funding private Medicare plans. Medicare Advantage plans will be paid an average of 114% of traditional Medicare rates in 2009, says a Dec. 2008 Medicare Payment Advisory Commission report. The American Medical Association and other physician groups support equalizing private Medicare plan pay with fee-for-service pay, and the money saved could go toward boosting physician rates.

Daschle responded that Medicare Advantage has improved health care access for people in rural areas but that the plans have become expensive. "We have to look at whether or not we're getting our money's worth," he said. Obama wants "to look at the inefficiencies and the problems associated with spending in Medicare Advantage and address them."

Daschle pledged to have HHS agencies work together to address complicated problems such as childhood obesity.

4,000 people sent ideas on health issues to the Obama transition team.

He said the National Institutes of Health, the Food and Drug Administration, the Centers for Disease Control and Prevention, and the Centers for Medicare & Medicaid Services don't communicate enough.

Enzi also asked if Daschle supported directing the FDA to regulate tobacco. Enzi is concerned that such measures would give tobacco legitimacy when the product offers only health risks. The nominee didn't say he opposed regulating tobacco but that he would try to use FDA authority to discourage tobacco use.

Committee Chair Edward Kennedy (D, Mass.) asked Daschle for an update on a nationwide series of community meetings on health reform. The Obama transition team asked Americans to hold forums to discuss views and concerns about health care, then to report the results by Dec. 31, 2008. Daschle said more than 8,500 people have held discussions, and more than 4,000 people sent feedback to the transition team.

"We are currently compiling their reports to share with each of you and the president-elect and everyone else. But one thing was crystal clear: America cannot afford more of the same when it comes to health care in this country," he said.

Daschle attended a discussion in Durbin, Ind., on Dec. 29. The conversation focused on rural health care access and health costs, he said.

The World’s Smallest Motor Could Propel a Medical “Microbot” Through Arteries

Within a few decades, a surgeon may be able to make a tiny incision in a patient’s artery and insert a miniature robot that would scoot along through the blood vessel to the area of concern. The microbot could remove blockages, scrape plaque off of artery walls, remove a few cells from an organ to test for cancer, or could even, eventually, carry a tiny camera to show doctors exactly what’s going on inside the body. In a major step towards that science fiction-tinged surgical scenario, researchers have built and demonstrated a motor about twice the width of a human hair that could power such a microbot.

Researcher James Friend says that miniature mechanics have been a long time coming. “If you pick up an electronics catalogue, you’ll find all sorts of sensors, LEDs, memory chips etc that represent the latest in technology and miniaturisation,” he says. “Take a look however at the motors, and there are few changes from the motors available in the 1950s” [BBC News].

Doctors already snake catheters through blood vessels in many procedures to reduce the impact of surgery, but some blood vessels, like the labyrinthine network in the brain, are too narrow and delicate to reach with current technology. But a microbot might be able to reach even these most sensitive areas, and could one day be used to remove clots from stroke patients’ brains in the emergency room. The researchers have tested their motor in human blood and artificial arteries and later this year it will begin experiments in pigs, whose arteries and brains are similar to humans, before proceeding to full-scale human trials [Telegraph].

The new motor, which is described in the Journal of Micromechanics and Microengineering, is powered by a piezoelectric material, which vibrates in response to an applied electric field. A spiral rod absorbs those vibrations and translates them into rotational forces that spin a tiny stainless-steel ball. That motion could be put to work to rotate a whip-like tail over a thousand times a second, say the team, in a similar style to the beating flagellum of a sperm cell [New Scientist].

If the idea of a microbot speeding through blood vessels on an urgent mission sounds familiar, you must be a movie buff: The idea was first floated in 1966’s Fantastic Voyage, starring Raquel Welch, in which a similar machine was placed inside a diplomat to perform life-saving surgery. The researchers … have paid homage to that film by naming their device, Proteus, after the capsule in the film [Telegraph]. In 1987, Inner Space sent a similar micro-craft on another lifesaving mission.

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