Pharmaceutical companies previously did all their own research and testing and submitted the results to the Food and Drug Administration for approval to put a medication on the market.

Since the 1990s or so, Big Pharma has farmed out more and more of that testing to companies like Quintiles Transnational Corp., which grew quickly to meet the demand.

Now Quintiles is branching out…

Now Durham, N.C.-based Quintiles is the world’s biggest contract research organization, and more than ever, it’s using its deep pockets to entwine itself with the pharmaceutical companies, fronting them cash and services for a piece of the profits once a drug is approved.

Quintiles, which was created in 1982, upped the ante last month, saying it wants to invest even more in potential drugs as pharmaceutical companies grapple with the down economy. Quintiles is hoping its new investments will produce enormous payoffs in the future,….

Quintiles’ decision to become more aggressive in taking investment risks comes at a time it′s betting drug makers can use the resources it can offer, both cash and services.

‘They’re both currency for managing risk and having skin in the game,’ said Ron Wooten, a Quintiles executive vice president who heads the company’s capital investment group.

Controversy over creating the drug investment unit in 2000 was key in pushing Quintiles founder Dennis Gilling and several private-equity firms to buy out shareholders for $1.75 billion and take the company private again in 2003. Wall Street analysts complained they couldn’t estimate what the drug investments were worth, prompting Gilling and others to decide the company’s stock was undervalued.

The private company no longer publishes its profits. It claims revenues of about $3 billion a year. That’s also about what Quintiles has invested in other drug companies.

Furthermore,

Quintiles appears to be uniquely positioned to both invest in and test potential medications. None of the half-dozen major shareholder-owned contract research organizations will have a drug-investment division after Wilmington, N.C.-based Pharmaceutical Product Development Inc. spins off its unit in a few months, Coldwell said.

The payoffs for the risk of developing a drug can be huge.

In 2002, Quintiles took a chance on Eli Lilly and Co.’s antidepressant Cymbalta. Quintiles said it invested $125 million in cash, then spent another $400 million on a sales force of more than 550 after the product launch. Cymbalta is now Lilly′s second-biggest drug. Quintiles said it’s brought in more than $700 million so far for a stream of royalties lasting to 2012.

Japan’s Eisai Co. is hoping Quintiles′ money and experience helps it double the number of potential treatments it can put through testing simultaneously

The article raised a concern that “the buffer between drug makers and testers are again blurred.”

But not to worry…. Here is the response from Quintiles,

Wooten, the Quintiles executive, doesn’t see his company’s increased interest in bringing drugs to the market affecting its testing objectivity. Instead Quintiles is the outsider turning a hard eye on which pharmaceuticals will become profitable.

‘It allows you to really get to the essence of the data that you’re looking at instead of what you hope it says,’ he said. There isn’t ‘the natural bias that you would have with your own babies.’

Furthermore, the AP reporter got reassurances from a noted academic expert in the area,

The FDA preserves the integrity of testing in a landscape already pockmarked with potential conflicts of interest that include company-sponsored academic research and investigators testing drugs while owning shares in companies that own the drug, said Kenneth Getz, a senior fellow at Tufts University’s Center for the Study of Drug Development.

The FDA’s view is that any company with a financial stake in a potential drug will face similar scrutiny from the agency.

‘It’s assumed,’ FDA spokeswoman Karen Riley wrote in an e-mail, ‘that drug/device/biologic companies who sponsor trials of pending products have a conflict because they will gain if the product is approved.’

Besides, pharmaceutical companies have navigated the tricky territory that comes with testing, Getz said. So have the companies like Quintiles that have taken on the outsourced work, he said.

‘These potential conflicts of interest are ever-present, and the real question is how do companies manage these potential conflicts effectively,’ he said. ‘These are massive, massive companies that have thousands of staff that are not generally aware of a conflict of interest at a corporate level. They are paid to do a quality job that meets internal and regulatory guidelines or they are not going to keep their jobs.’

Here on Health Care Renewal, we have discussed how the conflicts of interest that are now pervasive in health care can adversely affect clinical care, teaching, and research.  We have looked at how clinical research sponsors, who have a vested interest in having the results favor the products and services they sell, may manipulate the design, implementation, analysis, and dissemination of research, and when all else fails, suppress unfavorable results.&nbsp We have also looked at problems with the ethics and quality of research done by contract research organizations, who are, after all, paid by companies again with vested interests in selling particular products or services.

Given all that, one may argue that having contract research organizations invest in particular drugs or devices which they are also evaluating through clinical research&nbspmay not make things much worse.&nbsp However, at the least, it seems to me that it further obfuscates conflicts of interest that may lead to biased research results, dishonoring the patients who volunteered for the trials, and biasing the information on which patients and physicians make decisions.

Finally, I should note how Quintiles new investments in specific drugs was defended in the article.  The article quoted Quintiles executive vice president Ron Wooten suggesting that Quintiles might be able to be objective in making the original decision to invest in a drug. He conveniently did not address what might happen after the investment was made, when Quintiles was performing, analyzing, and reporting clinical research on a drug or device in which it had invested.

The article also quoted Kenneth Getz, the Senior Fellow at Tufts, who seemed unconcerned about the issue.  What the article did not mention is that the Tufts Center for the Study of Drug Development, at which Mr Getz is based,

receives unrestricted grants from pharmaceutical and biotechnology firms, as well as companies that provide related services to the research-based industry (e.g., contract research, consulting, and technology firms). These grants represent approximately 40% of Tufts CSDD’s operating expenses.

per the Center’s web-site. Another page on the web-site lists Mr Getz’s qualifications,

Kenneth A. Getz is a senior research fellow at the Tufts CSDD. Considered an expert on the investigative site and CRO markets, R&amp D management, ECT solutions adoption and clinical research volunteerism,….

Mr. Getz is the founder and chairman of CISCRP ….

He holds an MBA from the J.L. Kellogg Graduate School of Management at Northwestern University and a bachelor’s degree, Phi Beta Kappa, from Brandeis University. Mr. Getz worked for over seven years in management consulting, where he assisted biopharmaceutical companies in planning and implementing drug development strategies. He is also the founder and former CEO of CenterWatch.

Note that Mr Getz seems to have no training in biomedical science, medicine, or health care.  Furthermore, CISCRP (the Center for Information and Study on Clinical Research Participation), has an advisory board (see their web-site here)&nbspthat includes representatives of pharmaceutical companies (Vertex Pharmaceuticals, Biogen Idec, and Roche), and contract research organizations, (PPD Inc, and particularly, in this case, Quintiles). The vast list of the Center’s “supporters” include a catalog of drug and biotechnology companies (including Abbott Vascular, Amgen, AstraZeneca, Biogen Idec, Daiichi Sankyo Pharmaceutical Development, Eli Lilly, Forest Laboratories, Genentech, Genzyme, GlaxoSmithKline, Janssen, Johnson and Johnson, Merck, Novo Nordisk, Novartis, Ortho-McNeil, Pfizer, Roche, Sankyo, Sanofi-Aventis, Serono, Shire, Takeda, and Wyeth), and contract research organizations, (including Covance, Parexel, PPDI, and notably again, Quintiles.)

So the other lesson from this bit of news is how the information the public, health care professionals, and policy makers  receive about health care policy is frequently shaped by people with horses in the race, but that such influences are rarely disclosed.  This article included an interview with a single apparently academic expert who provided reassurance that the conflicts of interest discussed in the article were not really so worrisome.  This expert, however, failed to disclose his own extensive, albeit somewhat indirect ties to a variety of corporations that might benefit from the conflicts discussed as the main topic of the article, including corporations that were directly involved in them (Quintiles and Eli Lilly).  Maybe because the reporter thought that the expert was unbiased, there was no attempt to find a contrasting opinion.

So I say again, again, again, health care professionals, policy  makers, and people in general need to be extremely skeptical of most of the apparently unbiased pronouncements made about medical and health care policy issues in the media.  It would be a small step toward a more transparent discussion if those who expressed opinions would also fully disclose in detail their relevant conflicts of interest.

Bruce G. Charlton. Medical Hypotheses. 2008; 71: 625-628

Summary

Perhaps the earliest authoritative measurement of a social class gradient in IQ, with a stratification of occupations among the parents of children with different IQs, is seen in two fascinating papers published in 1923 and 1929 in the British Journal of Psychology. The authors were GH Thomson and JF Duff (both of whom were later knighted) and the papers’ main findings were confirmed by later researchers. Results of an intelligence test administered to 13419 children aged 11–12 were analyzed according to parent’s occupation. The average children’s IQ at extremes of social class among their parents included clergymen-121, teachers-116 and bankers and managers-112 at the upper end; while at the lower end there were ‘cripples and invalids’-94, cattlemen-93, hawkers and chimneysweeps-91, and the ‘insane, criminal’-88. More than 100 specific categories of parental occupations were then combined into 13 social classes, with their children’s average IQ as follows: Professional-112; Managers-110; Higher Commercial-109; Army, Navy, Police, Postmen-106; Shopkeeping-105; Engineers [ie. apprenticed craftsmen, such as mining engineers]-103; Foremen-103; Building trades-102; Metal workers, shipbuilders-101; Miscellaneous industrial workers-101; Miners and quarrymen-98; Agriculture-98; Labourers-96. A follow-up study compared an ‘intelligent’ group (IQ 136 plus) with a matched IQ 95–105 ‘control’ group. IQ testing at age 11–12 was predictive of teacher’s reports of higher levels of intelligence and health at age 16; and better performance in official examinations. The occupations of fathers, grandfathers and uncles were consistent with occupation being indicative of ‘an inherited quality’ (i.e. IQ) and there was regression from parents to grandparents and uncles among the ’intelligent’ but not among controls. Other findings included a wider variance in intelligence among boys than girls, and descriptions of the predictive value of IQ in estimating future education, examinations and health. Although the distribution, heredity and predictive value of childhood IQ measurements was once quite widely understood, for the last few decades IQ research has been regarded as morally-suspect and IQ scientists subjected to vilification, persecution and sanctions. Ignorance and misunderstanding of IQ is the norm among intellectual elites in schools, universities, the media, politics and public administration. Consequently IQ research is actively-shunned, and has near-zero influence on public policies. Since this area of science has been so comprehensively ‘disappeared’ from public consciousness as a result of socio-political pressure; it seems probable that other similarly solid and vital domains of scientific knowledge may also be ‘hidden in plain sight’.

***

Perhaps the earliest authoritative measurement of a social class gradient among the parents of children with different IQs is seen in two fascinating papers published in 1923 [1] and 1929 [2] in the British Journal of Psychology.

The authors were Godfrey H Thomson and James Fitzjames Duff – both of whom were later knighted. The research was done from Armstrong College of Durham University in the city of Newcastle upon Tyne, England – Armstrong College later became a part of King’s College which then became the independent University of Newcastle [3]. Thomson was Professor of Education in Newcastle, then later moved to the Chair of Education in Edinburgh from where he provided ‘Eleven plus’ examinations for much of Britain [4] and [5]. Duff moved to Manchester University and ultimately returned to Durham to become Warden (equivalent to Vice Chancellor – the senior administrative position in UK universities) of the collegiate Durham division of the university [3] and [6]. Duff is credited with initiating Durham’s ascent from a tiny theological and teaching college to become one of the premier UK universities [3].

As well as the intrinsic fascination of these trail-blazing researches, the two papers provoke reflection on the effect on science of changes in the national socio-political ethos. The fate of Sir Godfrey and Sir James’s papers provides an example of how once widely-accepted knowledge, generated by very senior and prestigious establishment figures, can later become generally disregarded or even denied, despite abundant scientific confirmation and elaboration by later researchers.

It seems that even in modern times, and in a liberal democratic society such as the UK where information is freely and easily accessible, scientific knowledge can apparently be ‘disappeared’ when it comes into conflict with the dominant socio-political agenda: can become, as it were, ‘hidden in plain sight’.

The social distribution of intelligence in Northumberland

The 1923 Duff and Thomson study began when an intelligence test was administered on February 24 1922, to all children aged 11 and 12 at state elementary schools in Northumberland excluding Newcastle and Tynemouth; yielding an enormous sample of 13419 children (6930 boys; 6695 girls). Further information on parental occupation was provided by teachers. The children’s IQ was then tabulated according to their parent’s (implicitly father’s) occupation.

Average IQ was 99.6, 877 children had an IQ of 120 plus and 1337 had an IQ less than 80. Boys exhibited a slightly larger apparent standard deviation than girls (no specific numbers were given by the authors), with a greater proportion of the most intelligent children being boys (IQ 130-9 – 80 boys, 49 girls; IQ above 140 – 12 boys, 4 girls) and also a greater proportion of the least intelligent being boys (IQ below 80 – 715 boys, 622 girls).

Although private schools were not sampled, and consequently there were no children with parents of the very highest social classes, nonetheless the parents social classes ranged widely from clergymen, lawyers, teachers, chemists, bankers and managers at the top; to farm labourers, brewery and mineral-water workers, ‘cripples and invalids’, cattlemen, ‘hawkers and chimneysweeps’ and the ‘insane, criminal’ at the bottom.

The average IQ (rounded to the nearest integer) of the children of some well-represented extremes of social class among the parents was clergymen-121, teachers-116 and bankers and managers-112 at the upper end while at the lower end there were farm labourers-94; brewery workers-94; ‘cripples and invalids’-94, cattlemen-93, hawkers and chimneysweeps-91, and the ‘insane, criminal’-88. In between, by far the largest number of parents was the 5659 coal miners (average IQ of children-98).

One surprising statistic is that the children of n = 16 ‘Doctors, dentists, vets’ [i.e. veterinarians] had a reported average IQ of only 102 – the same as builders and below plumbers! My guess is that (in this particular time and place) most rural or semi-rural resident ’doctors, dentists, vets’ who sent their children to state schools were not college-educated, but had instead been trained by apprenticeship: more like craftsmen than professionals.

More than 100 specific categories of parental occupations were then combined into 13 social classes, with their children’s average IQ as follows: Professional-112; Managers-110; Higher Commercial-109; Army, Navy, Police, Postmen-106; Shopkeeping-105; Engineers [ie. apprenticed craftsmen, such as mining engineers]-103; Foremen-103; Building trades-102; Metal workers, shipbuilders-101; Miscellaneous industrial workers-101; Miners and quarrymen-98; Agriculture-98; Low grade occupations, labourers-96.

Finally the parents occupations were divided into two simple divisions of ‘brain work’ having an average IQ of 107 versus ‘hand work’ having an average of IQ 99.

Duff and Thomson also comment that although there are striking stepwise average differences in IQ by parental social class, the parental occupation according to the 13 social classes only predicted child’s IQ with a Pearson correlation of 0.28. In other words, each social class contained a range of IQs, with considerable overlapping between classes.

Following-up the children of highest intelligence

The 1929 Duff paper was a follow-up of the highest-IQ children (IQ 136 plus) which were termed the ‘intelligent’ group with an IQ 95-105 ‘control’ group matched from the same schools. Parents and teachers were asked for information, but the replies were incomplete; and data was obtained on only 64 ‘intelligent’ and 28 ‘control’ subjects.

It was found that IQ testing at age 11–12 was predictive of teacher’s reports of higher levels of intelligence and health at age 16; higher career aspirations; and also better performance in the Durham School Certificate examinations, especially the highest levels of examination results.

Occupations of fathers, grandfathers and uncles were surveyed in terms of their social class. The most striking analysis was in terms of the percentage of fathers that were at the level of skilled labourer or higher: there were 64% of fathers in the intelligent group at this level and 28% of fathers in the control group. By comparison among the intelligent group 49% of grandfathers and 52% of uncles were at this level; while in the control group 33% of grandfathers and 40% of uncles.

Duff commented that this pattern was consistent with occupation being indicative of ‘an inherited quality’ with a regression from parents to grandparents and uncles among the intelligent – but no consistent regression among the average control group when the data as a whole is analyzed. He concludes: “Intelligence is not the sole factor that determines occupation; but that it is an important factor cannot be doubted.”

Science then and now

Reading the articles after eighty years there are striking differences when compared with modern practice. Most surprisingly there is no Reference section and only five footnotes (in the earliest paper). My impression is that this paucity is partly due to embryonic nature of the field – with very little prior relevant published research; and partly due to the fact that the authors were writing for a small, familiar audience of scientific peers, who did not need to have spelled-out precisely how this piece of research fitted into the development of the subject. In those days background assumptions were often simply taken for granted, rather than referenced. The methodology was, by modern standards, skimpy – supplemented with an offer to supply extra detail to ‘anyone interested’. The general tone of these papers is therefore somewhat like a letter addressed to other members of an exclusive club.

At this early stage in the science, researchers were almost simultaneously devising methods and applying them to gather data. The social class categories used were generated specifically for this paper, and apparently on ‘commonsense’ grounds – since no detail is given about the principles underlying the classification.

Yet, for all the apparent arbitrariness and subjectivism of style (as is seems to us nowadays), and the incompleteness of the follow-up study, these two papers seem to have been both prescient and essentially correct (as judged by subsequent knowledge) and their main findings have been substantially replicated or expanded:

1. It has been confirmed that men have a wider variance in intelligence than women – with a greater proportion of both high-scorers and low-scorers [7].

2. Although Duff and Thomson’s studies did not directly measure parental IQ, the authors’ assumption was that occupations reflected IQ. Many later studies have confirmed that there is a significant social class/occupational gradient in average IQ – the size of this gradient depending upon the degree of specificity with which social class is defined e.g. [8], [9], [10] and [11].

3. Thomson and Duff’s 1923 analysis demonstrated what later epidemiologists of the 1990s re-discovered for health and social class [12] – that socio-economic differences are not absolute or fixed in size; rather the gradient is much greater when socio-economic position is analyzed precisely than when measured imprecisely. Here there was a gradient of 33 IQ points from 121 down to 88 when 100-plus specific occupations are used; a gradient of 16 IQ points from 112 down to 96 when specific occupations are collapsed into 13 groups; and a gradient of only 8 IQ points from 107 down to 99 for the dual categories of head-work versus hand-work.

4. Childhood IQ has been confirmed to be predictive of future educational (and also occupational) attainments e.g. [13], [14], [15] and [16].

5. It has been confirmed that childhood measurements of IQ are predictive of subsequent health e.g. [9], [17] and [18].

6. IQ is confirmed to be substantially heritable, and exhibits regression to the mean consistent with the degree of heritability e.g. [13], [14] and [15].

The contemporary invisibility of IQ research
Duff and Thomson were both knighted, ending their careers as highly respected and influential figures in the UK educational establishment. The main findings of these papers from the 1920s have been amply replicated in the modern consensus on IQ [e.g. [20] and see above]. And the basic understanding of the distribution, heredity and predictive value of childhood IQ measurements which they pioneered was widely appreciated.

However, for the last few decades IQ research has generally been regarded as a morally-suspect activity and the candid discussion of IQ is taboo among the intellectual elites in schools, universities, the media, politics and public administration. IQ scientists have been – and still are – subjected to vilification, persecution and sanctions [15], [19], [21], [22] and [23]. This 80 year old knowledge is typically regarded by mainstream public discourse as surprising, shocking and controversial – or the facts may even be denied outright.

Consequently, despite its remarkable prescience and importance, this pioneering work on IQ, plus three generations of supporting scientific literature, is ignored or actively-shunned – and has near-zero influence on modern public policies.

Since this area of science has so been comprehensively ‘disappeared’ from public consciousness in the face of socio-political pressure, it seems probable that other similarly solid and vital domains of scientific knowledge may also be hidden in plain sight.

References

[1] J.F. Duff and G.H. Thomson, The social and geographical distribution of intelligence in Northumberland, Brit J Psychol 14 (1923), pp. 193–198.

[2] J.F. Duff, Children of high intelligence: a following-up enquiry, Brit J Psychol 29 (1929), pp. 413–438.

[3] E.M. Bettenson, The University of Newcastle upon Tyne: a historical introduction, 1834–1971, University of Newcastle upon Tyne, Newcastle upon Tyne, UK (1971).

[4] G.H. Thomson, Education of an Englishman, Moray House, University of Edinburgh, Edinburgh (1968).

[5] Wikipedia. Godfrey Thomson. http://en.wikipedia.org/wiki/Godfrey_Thomson; 2008 [accessed 10.07.2008].

[6] Sir James Fitzjames Duff. thePeerage.com: A genealogical survey of the peerage of Britain as well as the royal families of Europe. http://thepeerage.com/p18060.htm 2008 [accessed 10.07.2008].

[7] L.V. Hedges and A. Nowell, Sex differences in mental test scores, variability, and numbers of high-scoring individuals, Science 269 (1995), pp. 41–45.

[8] M. Argyle, The psychology of social class, Routledge, London (1994).

[9] C.L. Hart, I.J. Deary, M.D. Taylor, P.L. MacKinnon, G. Davey Smith and L.J. Whalley et al., Scottish mental health survey 1932 linked to the Midspan Studies: a prospective investigation of childhood intelligence and future health, Public Health 117 (2003), pp. 187–195.

[10] D. Nettle, Intelligence and class mobility in the British population, Brit J Psychol 94 (2003), pp. 551–561.

[11] R. Lynn and T. Vanhanen, IQ and global inequality, Washington Summit, Augusta, Georgia, USA (2006).

[12] G.D. Smith, M.J. Shipley and G. Rose, Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall Study, J Epidemiol Commun Health 44 (1990), pp. 265–270.

[13] L.M. Terman and L.H. Oden, The gifted child grows up: Volume 4 (Twenty five years follow up of a superior group), Stanford University Press, Stanford, CA, USA (1959).

[14] A.R. Jensen, The g factor Praeger: the science of mental ability, Westport, CT, USA (1998) p. 15.

[15] R.J. Herrnstein and C. Murray, The bell curve, Forbes, New York (1994).

[16] G. Park, D. Lubinski and C.P. Benbow, Contrasting intellectual patterns predict creativity in the arts and sciences, Psychol Sci 18 (2007), pp. 948–952.

[17] G.D. Batty, I.J. Deary and G.S. Gottfredson, Premorbid (early life) IQ and later mortality risk: systematic review, Annals Epidemiol 17 (2007), pp. 278–288.

[18] L.S. Gottfredson, Intelligence: is it the epidemiologists elusive ‘fundamental cause’ of social class inequalities in health?, J Personality Social Psychol 86 (2004), pp. 174–199.

[19] H.J. Eysenck, Rebel with a cause: autobiography of Hans Eysenck, W.H. Allen, London (1990).

[20] U. Neisser et al., Intelligence: knowns and unknowns, Amer Psychol 51 (1996), pp. 77–101.

[21] I.J. Deary, Intelligence: a very short introduction, Oxford University Press, Oxford (2001).

[22] L.S. Gottfredson, Applying double-standards to ‘divisive’ ideas, Perspect Psychol Sci 2 (2007), pp. 216–220.

[23] J. Malloy, James Watson tells the inconvenient truth: faces the consequences, Med Hypotheses 70 (2008), pp. 1081–1091.

This promises to be an engaging two days, and I encourage even late arrivals to head over to hear the speakers and shmooze with other Leaners.

We’ll start, though, with a humorous, light touch.  GBMP’s Bruce Hamilton (seen here) is famous for a short video, entitled Toast, in which he demonstrates the basic principles of Lean process improvement.  How fitting, then that the bagel toasting process at the convention center is anything but Lean!  A batch process, with poorly designed flows, leaves people waiting in line, unsure of what to do next.  Even the toaster itself is in an unstable setting, almost falling off the table!

Some of you may recall my “oatmeal chronicles,” from last year’s IHI Annual Forum, where the convention center in Florida likewise inadvertently provided a wonderful display of a poor service process.  Perhaps this kind of thing is intended at these kind of conferences, to offer real-time examples of how not to do things, so the attendees can think more clearly about how to do them right.

Bottom image adapted from Fig. 2 of Schumann et al. (2010). Neuroanatomy of the human amygdala postmortem. Nissl-stained section of amygdala nuclei.

The amygdala is a subcortical structure located within the medial temporal lobes. It consists of a number of different nuclei, or collections of neurons delineated by commonalities in morphology and connectivity. The amygdala is best known for major roles in fear conditioning (Paré et al., 2004) and responding to emotional stimuli more generally (Phelps & LeDoux, 2005), but its functions extend beyond that.

A new study by Bickart and colleagues (2010) examined the relationship between the overall size of the amygdala in a group of 58 volunteers and the number of people in each person’s social network. The authors observed a direct correlation between the two: the larger the amygdala, the larger the social network. Why did they expect such a finding? The “social brain hypothesis” (Dunbar, 1998) is cited as providing general evidence in favor of increased brain size in more social animals. However, the major references that motivated the specific hypothesis about the amygdala are book chapters, which seemed rather weak and unscholarly to me.

Predictably, a number of silly headlines appeared in the popular press…

How to Win Friends: Have a Big Amygdala?

Got a big social network? Then you probably have a large amygdala, according to a new study that found a connection between the size of this brain region and the number of social relationships a person has. The complexity of those relationships — as measured by the number of people who occupied multiple roles in a social network such as being simultaneously a friend and a co-worker — was also linked with amygdala size.

…and in blogs:

The Twitter Spot in Your Brain

Heavy Facebook users may have weighty amygdalas

But the worst headline of all (because it is patently false) is…

Study: More Friends on Facebook Equals A Bigger Amygdala In Your Brain

The number of Facebook friends you have is correlated to the size of your amygdala, the center used to process the memory of your emotional reactions in your brain, according to a new study published in Nature Neuroscience. The volume of your amydala has been connected to the size of the circle of those you come in contact with even with nonhuman primate species before, so Kevin Bickart and his coauthors took the idea and tested it out on people who interact with people on Facebook.

Does the Amygdala Have a Social Network?

First of all, the size of the amygdala has absolutely nothing to do with Facebook or any other contemporary social networking site. The scale for quantifying social network size and complexity was taken from a 1997 paper on Social Ties and Susceptibility to the Common Cold (Cohen et al., 1997), which in turn cited a book chapter from 1991. There was no such thing as Facebook or Myspace in 1997, only Geocities (1994) and Tripod.com (1995). As for the history of online communities, The WELL was launched in 1985 as a bulletin board system and could be considered as a proto-social networking site.

So who was included in Cohen et al.’s (1997) definition of a social network? One requirement was that the participant spoke to the individual in person or on the phone at least once every two weeks:

The Social Network Index assesses participation in 12 types of social relationships. These include relationships with a spouse, parents, parents-in-law, children, other close family members, close neighbors, friends, workmates, schoolmates, fellow volunteers (eg, charity or community work), members of groups without religious affiliations (eg, social, recreational, or professional), and members of religious groups. One point is assigned for each type of relationship (possible score of 12)¹ for which respondents indicate that they speak (in person or on the phone) to someone in that relationship at least once every 2 weeks. The total number of persons with whom they speak at least once every 2 weeks (number of network members) was also assessed.

Results for the amygdalar correlations with social network size and complexity were nearly identical, so the authors focused on the former in the paper. Importantly, amygdala volume did not correlate with life satisfaction or the perceived quality of the relationships. Basically, you could have a large social network that is not of your own choosing. One participant could have a large family, many co-workers, intrusive neighbors, and few real friends, while another is gregarious and parties with different groups of friends every night of the week. This particular study does not distinguish between the two.

Were any other parts of the brain correlated with social network size? No! [which I find hard to believe]. For the entire group of 58 participants, no significant results were observed in other subcortical regions (i.e., hippocampus [which served as a control region], brainstem, nucleus accumbens, ventral diencephalon, thalamus, caudate, putamen, and globus pallidus). An exploratory whole-brain analysis of cortical thickness did not reveal any correlations at conventional levels of significance.

Are we supposed to believe that only one area of the brain is involved in maintaining social networks? I think not. Even within the article, subgroups of participants (i.e., males, all older subjects)² showed correlations between hippocampal volume and social network characteristics. This makes intuitive sense, as a better memory might be helpful in keeping track of large numbers of people.

What about cortical regions containing spindle neurons (Nimchinsky et al., 1999), a cell type unique to humans, great apes, humpback whales, elephants and dolphins? Spindle neurons (aka von Economo neurons) are found in the anterior cingulate cortex and frontoinsular cortex. Or how about orbitofrontal cortex, with a volume that correlates with social cognitive competence (Powell et al., 2010)? None of these regions were related to network size.

What happens to people born without amygdalae due to Urbach-Wiethe disease, a rare genetic disorder? Does “the woman without fear” (and without amygdalae) have a tiny social network? How about other patients with amygdala damage? Anecdotal evidence suggests they can have close ties with their families and can even become more social after their brain injuries.³ Furthermore, Amaral et al. (2003) suggest that

…the effects of amygdala lesions in the adult and infant macaque monkey do not support a fundamental role for the amygdala in social behavior.

So small or absent amygdalae may not be a complete disaster.

But Is Bigger Better?

Findings from our study provoke the question, “Is a bigger amygdala better?” To answer this question, we must consider what “bigger” means and what a bigger amygdala might be “better” for. Striedter suggests that bigger means better connected, so that a brain region with more volume (in cross-species or within species comparisons) has an enhanced ability to modulate processing in its target regions. From cross-species comparisons in nonhuman primates, researchers propose that a bigger amygdala might provide processing advantages for visual signals from conspecifics…

…Yet it is far from clear that the cross-species comparisons can be generalized to infer that a bigger amygdala is better in humans, particularly when it comes to social functioning.

When Bigger Is NOT Better

One prominent example is the finding of larger amygdalae in children (and adults) with autism (Howard et al., 2000; Mosconi et al., 2009). However, the literature on this issue is variable (and voluminous), so I won’t discuss it further here. More consistent are observations of increased amygdala volumes in generalized anxiety disorder (Etkin et al., 2009; Schienle et al., 2010). In rats, chronic stress causes hypertrophy (enhanced dendritic arborization) of pyramidal and stellate neurons in the basolateral nucleus of the amygdala (Vyas et al., 2002).

A further interpretive conundrum is presented by the variety of conditions that are associated with increased amygdala volume: first-episode patients with nonschizophrenic psychoses, women high in harm avoidance, learning disabled adolescents at high risk of schizophrenia, adopted Romanian adolescents who experienced severe early institutional deprivation, and political conservatism.⁴ As explained by Tebartz van Elst et al. (2007):

Like often in psychiatric research, these findings seem to be contradictory and thus frustrating at first glance. However, if a dimensional rather than a categorical approach is chosen, all these findings might be integrated based on the assumption that the amygdala volume status might reflect the dominant mode of emotional information processing. Psychopathological features such as depressed mood, anhedonia, lack of drive, phobic anxiety, and rumination might characterize a mode of emotional information processing that is associated with enlarged amygdala volumes, whereas symptoms like emotional instability, dysphoria, irritability, aggression, and psychotic anxiety might go along with reduced amygdala volumes.

Correlation does not equal causation. If the findings are replicable, we don’t know if having a large social network increases the size of the amygdala [perhaps due to the stress and anxiety such social pressures entail?], or if having a hefty amygdala causes one to form a large social network.

Broken Social Scene – Fire Eye’d Boy (WATCH on YouTube)

Footnotes

¹ The notion that any one person could fulfill all 12 social roles is absurd. How can anyone simultaneously be a spouse, parent, parent-in-law, child, other close family member, close neighbor, friend, workmate, schoolmate, fellow volunteer, member of a group without religious affiliations, AND member of a religious group?? Obviously, some of these are mutually exclusive.

² The 58 participants were a diverse group ranging in age from 19-83 yrs (mean = 52.6), which I found strange for such an exploratory study. The demographics were quite unbalanced as well: males (n=36) vs. females (n=22); young (n=19) vs. old (n=35) [which does not add up to 58].

³ Anecdotal evidence from Sophie Scott:

@sophiescott: it’s odd, isn’t it. I worked with DR, who had bilateral amygdala damage. Hard to assess her network but she was very close…

@sophiescott: …with her extended family. Another amygdala patient, SE, had become very social since his head injury.

@sophiescott: there were clear effects of their brain damage on their actual social interactions, but they still had them.

⁴ This study was published in a newspaper, not in a peer reviewed journal (see Left Wing vs. Right Wing Brains).

References

Amaral DG, Bauman MD, Schumann CM. (2003). The amygdala and autism: implications from non-human primate studies. Genes Brain Behav. 2:295-302.

Bickart, K., Wright, C., Dautoff, R., Dickerson, B., & Barrett, L. (2010). Amygdala volume and social network size in humans. Nature Neuroscience DOI: 10.1038/nn.2724

Cohen S, Doyle WJ, Skoner DP, Rabin BS, Gwaltney JM Jr. (1997). Social ties and susceptibility to the common cold. JAMA 277:1940-4.

Dunbar RIM. (1998). The social brain hypothesis. Evol. Anthropol. 6:178–190.

Etkin A, Prater KE, Schatzberg AF, Menon V, Greicius MD. (2009). Disrupted amygdalar subregion functional connectivity and evidence of a compensatory network in generalized anxiety disorder. Arch Gen Psychiatry 66:1361-72.

Howard MA, Cowell PE, Boucher J, Broks P, Mayes A, Farrant A, Roberts N. (2000). Convergent neuroanatomical and behavioural evidence of an amygdala hypothesis of autism. Neuroreport 11:2931-5.

Mosconi MW, Cody-Hazlett H, Poe MD, Gerig G, Gimpel-Smith R, Piven J. (2009). Longitudinal study of amygdala volume and joint attention in 2- to 4-year-old children with autism. Arch Gen Psychiatry 66:509-16.

Nimchinsky EA, Gilissen E, Allman JM, Perl DP, Erwin JM, Hof PR. (1999). A neuronal morphologic type unique to humans and great apes. Proc Natl Acad Sci 96:5268-73.

Paré D, Quirk GJ, Ledoux JE. (2004). New vistas on amygdala networks in conditioned fear. J Neurophysiol. 92:1-9.

Phelps EA, LeDoux JE. (2005). Contributions of the amygdala to emotion processing: from animal models to human behavior. Neuron 48:175-87.

Powell JL, Lewis PA, Dunbar RI, García-Fiñana M, Roberts N. (2010). Orbital prefrontal cortex volume correlates with social cognitive competence. Neuropsychologia 48:3554-62.

Schienle A, Ebner F, Schäfer A. (2010). Localized gray matter volume abnormalities in generalized anxiety disorder. Eur Arch Psychiatry Clin Neurosci. Sep 5. [Epub ahead of print].

Schumann CM, Bauman MD, Amaral DG. (2010). Abnormal structure or function of the amygdala is a common component of neurodevelopmental disorders. Neuropsychologia Oct 13. [Epub ahead of print].

Tebartz van Elst L, Ebert D, Hesslinger B. (2007). Amygdala volume status might reflect dominant mode of emotional information processing. Arch Gen Psychiatry 64:251-2

Vyas A, Mitra R, Shankaranarayana Rao BS, Chattarji S. (2002). Chronic stress induces contrasting patterns of dendritic remodeling in hippocampal and amygdaloid neurons. J Neurosci. 22:6810-8.

Summary

Robert Emlyn Havard (1901–1985; general practitioner and sometimes medical scientist) was the only non-literary member of the Inklings – a1930s and 1940s Oxford University club which included Lewis and Tolkien. Despite spending most of his time in family medicine, Havard was a productive medical scientist. While still a student at Cambridge University, Havard co-authored an influential study published in the Journal of Physiology of 1926 entitled ‘The influence of exercise on the inorganic phosphates in the blood and urine’. The style and structure of this paper provides a charming window into the elite medical science of the 1920s.
Article Outline

Havard: The medical Inkling

The Inklings was a group of friends and colleagues who gathered around Lewis in Oxford University during the 1930s and 1940s [1]. The group would meet weekly after dinner in the evening at Lewis’s rooms in Magdalen College to read works-in-progress, and more informally to converse in the Eagle and Child (‘Bird and Baby’) pub in St Giles.

Lewis is now world famous as author of the Narnia fairy stories, and was probably the greatest lay Christian writer of the 20th century. The other world famous Inkling was Tolkien, author of The Hobbit and The Lord of the Rings. Charles Williams the novelist, poet and theologian was a later member. Other well-known Inklings included the philosopher Owen Barfield, Nevill Coghill – who became known as a Shakespearian director and published the best known modern English version of Chaucer’s Canterbury Tales, the ‘angry young man’ novelist and literary scholar John Wain, and the biographer Lord David Cecil. Lewis’s brother Warren (‘Warnie’) was usually in attendance: he was a popular historian of the France of Louis XIV. Tolkien’s youngest son Christopher later joined, and is now the only surviving Inkling – Christopher Tolkien is the most important scholar of his father’s work.

In a recent book on the Inklings, The company they kept [2], Diana Pavlac Glyer notes that almost all of the regular members of the group were active authors – producing academic books, essays, novels, stories, plays and poems. The Inklings essentially functioned as a writers’ group that provided mutual encouragement, criticism and editorial assistance. Superficially at least, the odd-man-out was Robert Emlyn Havard (1901–1985), who was a general practitioner and sometimes medical scientist and the family physician for both Lewis and Tolkien.

Havard appears in fictional form as the somnolent but shrewd character ‘Dolbear’ in Tolkien’s posthumously published story The Notion Club papers [3]; and Lewis’s Prince Caspian is dedicated to Havard’s daughter [4]. He had various nicknames bestowed on him by the group including ‘Humphrey’, ‘the Red Admiral’ (due to a beard grown while in the navy) and UQ – which stood for the ‘Useless Quack’. Indeed, in his sneering and pervasively unreliable biography of Lewis, Havard is depicted by AN Wilson as something of a buffoon [5].

This was far from the case, as can be seen from Havard’s early career as a medical scientist. The most complete account of Havard’s life so-far is by Walter Hooper in his Lewis: a companion and guide [6]. Havard began by taking a first class degree in chemistry at Keble College, Oxford then studying medicine at Gonville and Caius College, Cambridge and Guy’s Hospital in London to graduate with the Oxford medical degree of BM BCh in 1927. He took an Oxford DM (Doctor of Medicine) in 1934 while working at Leeds University in the Biochemistry Department, and in the same year returned to Oxford as a research fellow in The Queen’s College, and around this time became a general practitioner.

Despite spending most of his time in general medical practice, Havard was a productive medical scientist with his name on more than two dozen papers published in first rank journals such as Nature, the Lancet, Biochemical Journal and the Journal of Physiology. He had three spells of research and publication – the first mainly to do with human biochemistry during the mid 1920s while he was still a medical student; a second studying more clinical aspects of biochemistry from the early 1930s as a medical graduate doing a doctorate in Leeds and Oxford, and the third from the early 1940s when working on anti-malarial drugs while an above-conscription-age volunteer for military service during world war two [2].

Exercise, phosphates and fun

During his days as a medical undergraduate in Cambridge, Havard co-authored (with George Adam Reay) an influential study published in the Journal of Physiology of 1926 entitled ’The influence of exercise on the inorganic phosphates in the blood and urine’. It was this amiable paper, with its depictions of a time when doing science was akin to an undergraduate ‘jape’, that provoked the following reflections.

This paper was certainly not earth-shattering, nonetheless seems to have been one of the most cited of that year’s volume of J. Physiol. There are currently 13 references to be found on the Google Scholar database (http://scholar.google.co.uk) (quite a lot for such an old paper) with the most recent reference in 1971.

The style and structure provides a charming window onto the very different science of the early 1920s; with its un-translated ‘varsity’ slang, ‘clubby’ style of referencing which lists only authors surnames without initials (in 1926 the membership of the Physiological Society was less than 400 [7]) and delightful vignettes concerning the conduct of experiments.

One striking feature is that the experimental methodology reported in the paper is described as having changed significantly throughout the period of the experiment, and results are given both for before and after these trial-and-error modifications. A modern scientific paper would surely omit the earlier failed attempts. Indeed, the style of this article is less like a modern paper than a slice of laboratory life. The impression is that these scientific pioneers wanted to share not just their results, but the nuts and bolts of how results were generated.

Havard and Reay describe how ‘the exercise took the form of the subject running up and down the laboratory stairs, 40 ft in height, until he was exhausted’ during and after which many one cubic centimetre blood samples were taken from the subject’s finger in order to measure the phosphate etc. – which seems likely to have been a painful procedure. However, one of the main subjects listed was ‘R.E.H.’ himself, so he could not be accused of inflicting on others something he avoided himself.

Indeed, all the experimental subjects are listed by their initials, and presumably therefore identifiable by those ‘in the know’ (so, none of our present-day worries about ‘confidentiality’ are in evidence). In one of the tables we are told that that subjects include G.B. described as ‘A rowing man’, W.E.T. a ‘Rugby “Blue”’ (a ‘Blue’ was awarded to Oxford undergraduates for competing at the highest level of university sport), H.K.B.O. a ‘Running “Blue”’, E.H.F a ‘Sprinter’; and again Havard himself who is, by contrast to these athletes, only ‘Partly trained’.

Collecting urine samples was a problem – we are informed that H.K.B.O. (despite – or maybe because? – of being a Running Blue) was unable to produce a urine sample for 7 min after his exercise. In another experiment R.H.B (‘Running’) was ‘as exhausted and distressed as any of the untrained subjects’ – which must have been rather humiliating for him. But then R.H.B seems not to have been a Blue.

Three women were included as subjects. Miss (I assume it was a Miss) M.M. did exercise which was rather disdainfully dismissed as ‘not very vigorous’; Miss B.E.H. managed ‘more vigorous’ exercise while the Amazonian Miss C.E.L. was able to perform ‘very vigorous’ exercise – unfortunately however after these exertions she was depicted as ‘very exhausted’. Havard noted, with obvious regret, that the women produced ‘anomalous results’ which were ‘difficult to account for’.

In conclusion the authors reported that phosphate goes up a little then markedly down on exercise, and that trained men show less of these exercise-induced changes in their blood inorganic phosphate.

A snapshot from a lost era

My interest in this paper was stimulated because it presents in microcosm a snapshot of science from an all-but lost era of the ‘invisible college’ of collaborating and competing researchers who knew each other well-enough to dispense with formalities, and whose world was essentially private despite publication in widely circulated journals [8]. To the hard-nosed professional modern scientist, such early 20th century papers look eccentric and idiosyncratic. The paper is indeed ‘amateur’, but mostly in a desirable sense of describing science as an avocation done for intrinsic reasons and the esteem of peers, rather than a vocation rewarded by a secure income and managerial power.

But much more important and striking is the total absence of exaggeration, hype, or spin: the paper’s openness, candour – in a word honesty. This marks the biggest and most dismaying contrast between publications of the science of 80 years ago and of modern science. There has indeed been a loss of innocence, collegiality and fun; but a loss of unvarnished truthfulness is the most serious change against current practice [9].

I have said that Havard was not himself a writer, but on the evidence of this early article, Havard was an unusually vivid scientific author from his mid-twenties. Indeed he wrote essays and journalistic reviews dating back to his student days and continuing through into the 1950s. Furthermore, Havard contributed posthumous memoirs of both Lewis [10] and Tolkien [11].

All of which helps explain why, despite not being a literary man, ‘Humphrey’s’ presence at the Inklings meetings was so highly valued.

Acknowledgements

I am grateful to Robert Havard’s eldest son John, who kindly gave me a list of some of his father’s publications, and provided fascinating background information by means of e-mail and telephone conversations. John Havard’s brother Mark (i.e. RE Havard’s second son) also corresponded, and reminded me that the doctor in CS Lewis’s 1943 novel Perelandra was named ‘Humphrey’.
References

[1] H. Carpenter, The inklings, George Allen and Unwin, London (1981).

[2] D.P. Glyer, The company they keep: CS Lewis and JRR Tolkien and writers in community, Kent State University Press, Kent, Ohio (2007).

[3] J.R.R. Tolkien, The Notion Club papers, Morgoth’s ring: history of middle earth volume IX, HarperCollins, London (1992).

[4] C.S. Lewis, Prince Caspian, Geoffrey Bles, London (1951).

[5] A.N. Wilson, CS Lewis: A biography, Collins, London (1990).

[6] R.E. Havard and G.A. Reay, The influence of exercise on the inorganic phosphates of the blood and urine, J Physiol 61 (1926), pp. 35–48.

[7] W.F. Bynum, A short history of the physiological society 1926–1976, J Physiol 263 (1976), pp. 23–72. View Record in Scopus | Cited By in Scopus (0)

[8] T. Kealey, Sex, science and profits: how people evolved to make money, William Heinemann, London (2008).

[9] B.G. Charlton, The vital role of transcendental truth in science, Med Hypotheses 72 (2009), pp. 373–376.

[10] R.E. Havard, Philia: Jack at ease. In: T. James and C.S. Como, Editors, Lewis at the breakfast table and other reminiscences, Harvest/HBJ Book, New York (1979), pp. 215–228.

[11] R.E. Havard and J.R.R. Professor, Tolkien: a personal memoir, Mythlore 17 (1990), pp. 61–62.

The American Cancer Society prints yearly statistics on recommended tests and preventative measures that all Americans should observe to reduce their chances of getting cancer.

But what happens if you go and get the tests, but the doctor(s) don’t pick up on the cancer?

What happens if you go to your primary care physician for months and he or she fails to order the proper tests?

What if you miss the opportunity to fight your cancer head on because it is diagnosed too late?

We often receive calls from families concerned that a physician failed to diagnose their loved one’s cancer – and sometimes, that failure to diagnose becomes a lawsuit.

Other times however, a doctor′s failure to diagnose does not rise to the level of Medical Malpractice under Virginia law.

How could that be, you may wonder? A doctor fails to diagnose cancer and you can’t file a lawsuit?
The answer is complicated.

• If a doctor has failed to diagnose cancer; and
• The physician should have diagnosed it (meaning – signs and symptoms or tests revealed cancer); and
• The delay in diagnosis caused the cancer to advance so far it could not be treated

THEN and only then

You may have a lawsuit.

Failure to diagnose cancer for 1 month, 2 months – may not be a case.

Failure to diagnose cancer for a year, giving the cancer time to grow from treatable form to an invasive cancer - that′s a different story.

My Mother is a cancer survivor, twice. and the second time her oncologist didn’t believe the growth was cancer so he did nothing for few months. He was wrong, but thankfully, his failure to diagnose it did not cause her any additional harm. She was able to treat the cancer.

If you are unsure whether you or your loved one has a potential claim, call our office today. We are happy to walk you through this process.

Monarchs and their heirs are not always noted for their rational medical advice. But James VI of Scotland, who became James I of England in 1603, was different.

Published anonymously in 1604 but immediately credited to the king, A Counterblaste to Tobacco flew in the face of prevailing medical opinion by outlining some of the chief health risks of smoking more than three centuries before scientists made the connection.

Possibly the first official antismoking campaign, the royal pamphlet highlighted cost and passive smoking as two of the most powerful arguments against tobacco, while it lamented that addiction, peer pressure, and fashion were among the most difficult obstacles to overcome.

Gastroenterologist’s view of the stomach

Recently, while covering for one of my partners on a weekend, I was consulted by a physician to do a procedure. The doctor wanted his patient to undergo an EGD, which is a scope test that examines the esophagus, stomach and first portion of the small intestine called the duodenum. We gastroenterologists do this test routinely to search for an explanation for a patient’s symptoms, or to determine if these organs might be harboring a lesion that is silently bleeding.

Gastroenterologists are obligated to perform procedures for sound medical reasons. I have already confessed publicly on this blog why physicians like me have performed medical tests for the wrong reasons. The medical universe is not ideal, and neither are its players. Nevertheless, we want our care to make sense and not to waste dollars. For example, if a patient is suffering an acute headache, it would be hard to justify ordering a CAT scan of the abdomen, which would be unlikely to explain the symptom. One reason that wrong tests are done is because physicians ask colleagues for a specific procedure, and not for their cognitive advice.

For example, when we order a radiology examination, such as routine x-rays, CAT scans, MRIs, etc., we are not requesting the radiologist’s opinion on the medical issue, only that the test be performed. For ordinary readers who are on the sidelines of the medical arena, here’s how it works.

• A doctor like me decides that a patient needs a CAT scan.
• I order it.
• The radiologist does it.

Personally, I think this is a serious failing in medical practice. Radiologists have the deepest expertise in the procedures they do, yet they are not routinely consulted in advance. If they had knowledge of the particular patient, they could advise us if our intended test is the best option. Perhaps, a different radiology test would clarify the clinical issue better. Or, perhaps, we ordered the proper test, but it should be performed using special technique. In general, radiologists are not treated as true consultants, but as technicians. By doing so, clinicians like me who take care of patients are squandering an opportunity to practice better medicine. 

Of course, there are many times that physicians and radiologists do confer to optimize the diagnostic approach. But, in my experience, these important conversations are exceptional. Physicians who order imaging studies on their patients likely feel that they have enough knowledge to choose the right exam. Some do, and some don’t.

I have never liked serving as a technician gastroenterologist, but I am often asked to do so. Like every other gastroenterologist, I have performed requested procedures that were reasonable, but that I would not have personally recommended if my advice had been sought. The patient referenced at the top of this post was in a different category. This was not a ‘gray area’ issue.

This particular patient was having some minor rectal bleeding. He had already had the pleasure of a full colonoscopy this past November, when hemorrhoids were discovered. No additional testing was necessary for the current minor bleeding, as hemorrhoids were the likely culprit. The request for an EGD was nonsensical. The ordering physician had no economic conflict of interest in ordering the test; only the gastroenterologist would benefit financially. An EGD here was like ordering a foot x-ray on a patient with a sore throat.

I will now risk outrage from my medical colleagues by sharing a dark secret with the public. I will divulge two pieces of confidential medical code, and trust you all to protect me from vengeful physicians who will accuse me of breaking sacred medical omerta. In other words, what you read on Whistleblower, must remain here.

At the very bottom of my consultation report, I wrote: ‘will discuss with you’. This is standard medical code for, your request is nuts and I won’t put in writing what I really think. When a doctor uses this phrase, it means that a private conversation between the consulting and referring physician will soon follow. Ask your own doctor what the phrase ‘will discuss with you’ means, but be prepared for garbled gobbledygook seasoned with a dash of doublespeak.

Later that day, my partner continued the discussion with the physician and gently asked for his rationale for requesting the EGD. Here comes secret code #2. The referring physician wanted the EGD ‘for completeness’. When a doctor uses this phrase, as we all have done, it means, the test makes no sense and is totally unnecessary.

So, what happened? Monday morning, the gastroenterologist who was originally consulted assumed care of the case. The EGD was done.

Fear of litigation results in overutilization of medical care. I know this personally. But, there are other reasons why we physicians pull the procedure trigger. This vignette illustrates that our profession has its own healing to do.  Tort reform can’t cure it all.

While I didn’t perform the EGD, am I an accomplice by not standing up to the referring physician initially?  Can I rightfully still consider myself to be an ethical practitioner?  Radiologists don’t refuse to do CAT scans that make no clinical sense. Should the standard be different for other medical procedures, which have very low risks of complications? What would you have done here? Would you have refused the physician′s request, which would likely result in the loss of this physician’s future referrals? Would you rationalize the unnecessary test knowing that if you didn’t do the EGD, that someone else would? Do private pracitioners view this scenario differently than employed physicians? Should they?

Do you have similar vignettes from your own practice or experience that you can share?

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dOWNLOAd .

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“Sometimes we forget just how short and precious our time on this planet really is. It’s for this reason that John Lewis′s new television ad seems to have struck an uncharacteristic chord.

You won’t find many people admitting to crying over the usual flood of formulaic adverts on our screens – yet this ‘moving’ ad has got Britain talking – and sobbing into their breakfast bowls.

At 91 seconds long, and costing £6 million, the ad shows the the life cycle of a woman from birth to old-age – infancy, a girl′s birthday party, a clumsy kiss in a university corridor, marriage, pregnancy, parenthood and the path into old age.”