1 Boring Old Man

After being stationed together in the UK, five couples have been vacationing together for a week every summer all over North America. We got to be sort of a family back in those days, and that continues, honorary aunts and uncles, nieces and nephews – now over 40 years. Back then we were two internists, a flight surgeon, a primary care guy, and an anesthesiologist. We became a gastroenterologist, psychiatrist, two ophtalmologists, and a hospital administrator. We’ve been to all the weddings and funerals, and our kids travel together too. There are a number of replaced joints and other infirmities, so our activities are more muted. All but one are retired. While we never talk politics or religion, there’s a forty year narrative about medicine and life – which is where I’m headed.

The other internist [gastroenterologist] was the the best clinician I’ve ever known – and the others were top of the line. That’s part of the bond. We learned together and set a good standard for each other back in those post-training days. In the catch-up talk this year, they wanted to know about the Study 329 article I was an author on in the intervening year. It was kind of surprising. They didn’t know about ghostwriting, or guest authoring, or Dollars for Docs, or the Sunshine Act, or the academic-industrial complex, or outcome switching, or all the rest of it. Only the gastroenterologist picked up on what I was talking about. But first, he talked about pharmacology and the changes in his specialty [which he labeled as "miraculous"]. He mentioned antibiotics for ulcer disease [Helicobacter pylori] and the amazing endoscopes they have now. But what he was really talking about were the drugs for turning off stomach acid – H₂ blockers and proton-pump inhibitors.

He reminded me of those long nights with GI bleeders in my day, and how, not infrequently, we couldn’t get it stopped and had to call the surgeons. It was a regular on-call event for any internist. "That’s a thing of the past," he said. "With the new drugs, we saw a lot fewer bleeds, and when we did – we could stop them with the scopes." "Chronic ulcer disease? Rare to never." "Surgery required? I can’t recall the last case." Parenthetically, throughout the week, the ophthalmologists talked about the advances over their careers – Lasik, cataract lenses, microscopic surgery, etc. – as did the anesthesiologist – both drugs and equipment. But the gastroenterologist did say, "When the acid switch drugs first came out, they performed as advertised. But later, I thought the newer ones were overblown in the journals. I stopped reading and mostly learned about them at meetings, from colleagues." And then came the punch line. "But you know, you don’t have to read the whole article. You can just read that little thing at the top."

He was referring to the abstract at the beginning of journal articles. I’ve thought about that along the way myself. Back in those days, that’s what I did too – read the abstracts. I got four or five journals a month, reprints left at the office, more in the mail, and I worked 10 hour days. I couldn’t possibly have done more than that. I’d look at the graphs and scan the tables sometimes, but I rarely read the whole articles – certainly not drug studies. To read them like I’ve read them on this blog takes a day or two. Then, I expected the abstract to be just that – an accurate abstract. I might deeply study an article for the odd journal club, but not routinely. I would expect that what I did was the norm, or if anything, I was on the conscientious end of the spectrum.

All I had on last week’s trip was a tablet computer [new and more unfamiliar than I’d planned], but I could get my blog, so I thumbed back through articles I had looked at over the years – just reading the abstracts. Thinking back, in my naiveté, there was a time when I might have even thought that the abstracts were something the journal editorial staff wrote. Whatever I thought, my index of suspicion was woefully low. Nowadays, the abstracts are carefully crafted by ghosts. And looking at them as a group, the abstracts are usually inflated over and above the distortions already in the articles. I concluded that the pharmaceutical marketing departments must know that’s what doctors do, read/scan the abstracts – that little thing at the top.

Recently, Dr. Carroll proposed that the FDA extend its oversight to the published studies [CORRUPTION OF CLINICAL TRIALS REPORTS: A PROPOSAL], which makes perfect sense to me. They are the only ones who have direct access to the Protocol and the the Raw Data from these Clinical Trials needed to insure accuracy. And the FDA is built around statistical and analytic prowess. On one of the list-serves, there was a critique of his proposal, arguing that it was unnecessary because all the information is on the FDA approved package insert for doctors to read [also reprinted in the Physician’s Desk Reference]. The argument was that to do the same thing with journal publications would be redundant. I guess the implication was that doctors are too lazy to read the inserts, aren’t keeping up.