What’s wrong with American medicine?

A provocative article in The New York Times (below) refers to a report in the Journal of the American Medical Association revealing that despite sophisticated diagnostic tools in modern medicine, the rate of misdiagnosis is about the same as it was in the 1930s!  Autopsy studies have shown that doctors seriously misdiagnose fatal illnesses about 20% of the time. This means that millions of patients are being treated for the wrong disease.

In part, this is because “there is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so.”

Indeed, if truth be told, the culture in contemporary medicine is self-serving:
“Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.”

“We just are not using the power of incentives to save lives.” Medicaid / Medicare czar, Dr. Mark McClellan acknowledged.

A diagnostic software program has been developed: Isabel allows doctors to type in a patient’s symptoms and, in response, spits out a list of possible causes, including rare conditions that most physicians would overlook.  It is accessible via the internet; access costs a hospital $80,000, or  individual subscribers can access it for $700.

In psychiatry the problem of diagnosis is far worse because psychiatry lacks any objective, verifiable diagnostic measure.

Psychiatry’s diagnostic “mood swings” are given to fashion:
Fads in psychiatry are a consequence of subjective methods of “diagnosing,” accomplished by use of suggestive catch-all questionnaires. The responses are interpreted by psychiatrists who have a vested interest in increasing the number of people who will qualify for insurance reimbursement.

Indeed, psychiatry’s ever inflated diagnostic manual, DSM-IV published by the American Psychiatric Association, has recently been shown to be fashioned by psychiatrists with financial conflicts of interest. The DSM-IV is tailored to provide psychiatrists diagnoses justifying their prescribing of the latest psychotropic drugs.

The latest diagnostic aberration in U.S. psychiatry is diagnosing young children manic-depression (bipolar disorder). Even as leading child psychiatrists admit, it is difficult to differentiate bipolar from ADHD, the gateway to pathologizing children as mentally diseased.

The Australian Broadcasting Corporation reports (below) about concerns raised by Dr. David Healy at an international conference earlier this month focusing on disease mongering. Dr. Healy talked about the medically unsupportable American trend of diagnosing young children with bipolar disorder.

Dr. Healy noted that the DSM-IV diagnostic guidelines specify that periods of highs and lows should last for weeks at a time at least.  But children’s moods normally fluctuate during the course of a day:  “Every kid’s mood goes up and down during the course of the day.”

Dr. Healy is concerned that those who advocate “diagnosing” children with bipolar, are lobbying to change the APA diagnostic guidelines: “The response from most of the rest of the world is that the Americans have gone hysterical.”

Dr. Healy’s concern is echoed in Australia by Dr Phill Brock, Chairperson of the Royal Australian & New Zealand College of Psychiatrists’ Faculty of Child and Adolescent Psychiatry: “We do not endorse that diagnosis in children.”

But in the U.S., Dr. Joan Luby, a leading academic child psychiatrist who supports the bipolar diagnosis in young children, while acknowledging that “Mania can be confused with ADHD.”

“During the manic phase of the illness children may experience exceedingly high self-esteem, an inflated sense of power or ability…They may act extremely happy, silly and giddy, but their moods can change rapidly.”

She cites the following as: “An extreme example that I’ve seen involved a manic preschooler who believed that she made the sun rise and set.”

Dr. Joan Luby heads the University’s TEAM (Treatment of Early Age Mania) whose focus, she defined:
“We hope that by comparing these drugs and drug combinations, we might be able to find better ways to control this severe illness in older, affected children, and as those results become available, we can look at whether these treatments also might help younger children.”

See: Washington University Medical News Press Release, and graph, Dec. 2005 at: http://mednews.wustl.edu/tips/page/normal/6244.html   or see: slide 36 and 37 at: http://www.ahrp.org/ahrpspeaks/TeenScreen/index.php

An investigative reporter might learn a great deal by asking the proponents of drugs for treating children’s behavior how much they have received from drug manufacturers within the last 10 years?

Contact: Vera Hassner Sharav
veracare@ahrp.org

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<a href="http://www.nytimes.com/2006/02/22/business/22leonhardt.html? ">http://www.nytimes.com/2006/02/22/business/22leonhardt.html? </a>
<strong>THE NEW YORK TIMES
February 22, 2006
Why Doctors So Often Get It Wrong
By DAVID LEONHARDT
</strong>
ATLANTA– ON a weekend day a few years ago, the parents of a 4-year-old boy from rural Georgia brought him to a children's hospital here in north Atlanta. The family had already been through a lot. Their son had been sick for months, with fevers that just would not go away.
The doctors on weekend duty ordered blood tests, which showed that the boy had leukemia. There were a few things about his condition that didn't add up, like the light brown spots on the skin, but the doctors still scheduled a strong course of chemotherapy to start on Monday afternoon. Time, after all, was their enemy.

John Bergsagel, a soft-spoken senior oncologist, remembers arriving at the hospital on Monday morning and having a pile of other cases to get through. He was also bothered by the skin spots, but he agreed that the blood test was clear enough. The boy had leukemia. "Once you start down one of these clinical pathways," Dr. Bergsagel said, "it's very hard to step off."

What the doctors didn't know was that the boy had a rare form of the disease that chemotherapy does not cure. It makes the symptoms go away for a month or so, but then they return. Worst of all, each round of chemotherapy would bring a serious risk of death, since he was already so weak.
With all the tools available to modern medicine — the blood tests and M.R.I.'s and endoscopes — you might think that misdiagnosis has become a rare thing. But you would be wrong. Studies of autopsies have shown that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. So millions of patients are being treated for the wrong disease.

As shocking as that is, the more astonishing fact may be that the rate has not really changed since the 1930's. "No improvement!" was how an article in the normally exclamation-free Journal of the American Medical Association summarized the situation.

This is the richest country in the world — one where one-seventh of the economy is devoted to health care — and yet misdiagnosis is killing thousands of Americans every year. How can this be happening? And how is it not a source of national outrage?

A BIG part of the answer is that all of the other medical progress we have made has distracted us from the misdiagnosis crisis. Any number of diseases that were death sentences just 50 years ago — like childhood leukemia — are often manageable today, thanks to good work done by people like Dr. Bergsagel. The brightly painted pediatric clinic where he practices is a pretty inspiring place on most days, because it's just a detour on the way toward a long, healthy life for four out of five leukemia patients who come here.

But we still could be doing a lot better. Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.
There is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so.

"You get what you pay for," Mark B. McClellan, who runs Medicare and Medicaid, told me. "And we ought to be paying for better quality."  There are some bits of good news here. Dr. McClellan has set up small pay-for-performance programs in Medicare, and a few insurers are also experimenting. But it isn't nearly a big enough push. We just are not using the power of incentives to save lives. For a politician looking to make the often-bloodless debate over health care come alive, this is a huge opportunity.

Joseph Britto, a former intensive-care doctor, likes to compare medicine's attitude toward mistakes with the airline industry's. At the insistence of pilots, who have the ultimate incentive not to mess up, airlines have studied their errors and nearly eliminated crashes.
"Unlike pilots," Dr. Britto said, "doctors don't go down with their planes."

Dr. Britto was working at a London hospital in 1999 when doctors diagnosed chicken pox in a little girl named Isabel Maude. Only when her organs began shutting down did her doctors realize that she had a potentially fatal flesh-eating virus. Isabel's father, Jason, was so shaken by the experience that he quit his finance job and founded a company — named after his daughter, who is a healthy 10-year-old today — to fight misdiagnosis.

The company sells software that allows doctors to type in a patient's symptoms and, in response, spits out a list of possible causes. It does not replace doctors, but makes sure they can consider some unobvious possibilities that they may not have seen since medical school. Dr. Britto is a top executive.

Not long after the founding of Isabel Healthcare, Dr. Bergsagel in Atlanta stumbled across an article about it and asked to be one of the beta testers. So on that Monday morning, when he couldn't get the inconsistencies in the boy's case out of his mind, he sat down at a computer in a little white room, behind a nurse's station, and entered the symptoms. Near the top of Isabel's list was a rare form of leukemia that Dr. Bergsagel had never seen before — and that often causes brown skin spots. "It was very much a Eureka moment," he said.

There is no happy ending to the story, because this leukemia has much longer odds than more common kinds. But the boy was spared the misery of pointless chemotherapy and was instead given the only chance he had, a bone marrow transplant. He lived another year and a half.
Today, Dr. Bergsagel uses Isabel a few times a month. The company continues to give him free access. But his colleagues at Children's Healthcare of Atlanta can't use it. The hospital has not bought the service, which costs $80,000 a year for a typical hospital (and $750 for an individual doctor).

Clearly, misdiagnosis costs far more than that. But in the current health care system, hospitals have no way to recoup money they spend on programs like Isabel. We patients, on the other hand, foot the bill for all those wasted procedures and pointless drugs. So we keep getting them. Does that make any sense?

E-mail: leonhardt@nytimes.com
Copyright 2006The New York Times Company
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Australian Broadcasting Corporation
News in Science
http://www.abc.net.au/science/news/health/HealthRepublish_1620249.htm
Toddlers diagnosed with bipolar
Anna Salleh
ABC Science Online
Friday, 21 April 2006

Young children are being medicated for an illness that some psychiatrists say doesn’t exist

Children as young as two years old are being inappropriately diagnosed and medicated for bipolar disorder, says a UK psychiatrist.  Professor David Healy of Cardiff University told the Inaugural Conference on Disease-Mongering recently in Newcastle, Australia, that increasing numbers of children are being treated for the condition with drugs that carry serious side-effects, without evidence the condition exists in that age group.

Healy says bipolar disorder is a condition in which someone’s mood swings between highs and lows and in its most serious form this can lead to acts of suicide.  He says until recently most people believed the illness only affects older teenagers or adults but the diagnosis is now being applied to young children, particularly in the US.

He says children as young as two who are “tricky to handle, overactive or difficult in some way” are being diagnosed with bipolar disorder.

And he says they are increasingly prescribed drugs known as mood stabilisers, which are used to treat the condition in adults and have serious side-effects.

He says American Psychiatric Association (APA) diagnostic guidelines specify that periods of highs and lows should last for weeks at a time at least.

But he says children being diagnosed as having bipolar disorder have moods that go up and down during the course of a day.  “Every kid’s mood goes up and down during the course of the day,” he says.

Healy says advocates of using the diagnosis on children say the APA guidelines should be changed.  “The response from most of the rest of the world is that the Americans have gone hysterical.”

Expanding treatment
Healy believes that the diagnosis of children with bipolar disorder is part of a general trend towards increasing the number of people treated with mood stabilisers, which he says have risks that are downplayed and benefits that are overplayed.

He says while a very small percentage of people have the serious form of bipolar disorder that might warrant medication, recently people with relatively mild mood swings have been treated, and this is now including children.

Healy says this spread of diagnosis is reflected in the increasing number of books on bipolar disorder aimed at clinicians, parents and children.

What he describes as a “watershed” book called The Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder sold 70,000 hardback copies in its first six months, indicating huge support for the diagnosis, he says.

“[And books for children] look for all the world like versions Little Red Riding Hood or Cinderella or whatever,” he says.

“They come in the same pastel colours, they show scenes of a kid who was getting into trouble and then being helped out by a kindly doctor who explains they’ve got a chemical imbalance and that medication will help.”

Healy is paid by the pharmaceutical company AstraZeneca to give talks on mental illness.

Australian psychiatrists also concerned
Chairperson of the Royal Australian and New Zealand College of Psychiatrists’ Faculty of Child and Adolescent Psychiatry, Dr Phill Brock, is also concerned about children being inappropriately diagnosed with bipolar.
“We do not endorse that diagnosis in children,” he says.

Brock runs the inpatient service of the Women’s and Children’s Hospital in Adelaide and says he is aware the diagnosis is being made, both by GPs and psychiatrists. “We would contend that because of the developmental context we’re not able to say categorically that this is an illness that can be applied to children.”

He says he is aware of advocates for diagnosing bipolar in children and found it alarming when a US organisation approached the faculty he represents 18 months ago to set up a support group for infants and children with bipolar disorder.

Healy says while a child might be hard to handle because they’ve moved house or school, because they’ve been bullied at day-care or because their parents aren’t getting on it is “easier to locate to the problem in the child”.

Brock is similarly concerned. “We know that children and teenagers frequently have changes in mood. That’s part of growing up,” he says.

For more information on bipolar disorder, including fact sheets and referrals, see beyondblue, Australia’s national depression initiative.

Related Stories
Psychiatry manual linked to drug money, News in Science 21 Apr 2006

© 2006 Australian Broadcasting Corporation

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