Citation Impact

Share The US scientific community as ranked by the number of citations for our scientific articles falls behind Italy for 1012.

Our global ranking in the burden of disease studies(GBD) -- ranking us near the bottom -- may be only the tip of the iceberg. As for widely cited scientific papers, we were once far ahead of all other countries, but Switzerland surpassed us in the relative citation impact sometime prior to 2002. The UK followed suit in 2006 and now Italy in 2012. SciVal Analytics of Elsevier did the calculations. We do, however, remain ahead in the share in the top 1% of publications according to a notation in Nature News[1]

Can you doubt that our academic standing has slipped as a result of the exorbitant cost of higher education, or is there something more? Has medical education slipped as well; do physician extenders now practicing on their own, or does alternative medicine have an impact? Osteopathic schools are a growth industry. Hopkins advises medical student applicants seeking family practice to apply to schools of osteopathy. Many schools are back to a curriculum before Flexner paying for community preceptors and in a new wrinkle, standardized patients and semi robotic manikins.

Absent the academic rigorous of scientific education and of the ethical discipline of professional societies, entropy prevails. Has science given way to humanity, or has it given way to expedience?

 [1] |Nature 12 Dec 2013, 504, p192

Protocol-Based Treatment of Hypertension

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Protocol-Based Treatment of Hypertension: A Critical Step on the Pathway to Progress 
Thomas R. Frieden, MD, MPH, Sallyann M. Coleman King, MD, MSc, Janet S. Wright, MD.
JAMA. 2014;311(1):21 doi:10.1001/jama.2013.282615

The undiagnosed and untreated incidence of Diabetes in this country far exceeds that of the rest of the modern World. If the article is to be believed half of us are walking around with BP in excess of 140/90. Are treatment protocols the solution to correcting this burden?

I think not. The problem is not treatment protocols or any treatment, but diagnosis of the hypertension in the first place. Judging by my experience with students, hospitals clinics and offices, the BP cuff is the most neglected and misused instrument in the clinic. The best you can hope for is a very expensive automated BP machine that may or may not be reliable, never mind calibrated. The operator of the auto BP machine likely has minimal training in its use and little or none in the anatomy, physiology and principal of BP readings.

The only reliable BPs readings come from the physician him or herself, the least likely person to waste time on such a mundane thing as vital signs, and even then a cavalier attitude can negate abnormal findings. A good RN will get you good BPs if you give her a good cuff and a mercury manometer, but there too, administrators do not want to waste RN time taking vital signs when it can be done at the lowest cost denominator by an assistant. If a number gets duly recorded. that satisfies the administrator and any auditor that might review the chart.

Can you say why, for instance, you might want to take the BP in both arms or at least in the right arm? Was the patient standing, sitting or recumbent when the reading was taken? Was the cuff the right size; was the stethoscope turned the right way, or was one earpiece of the stethoscope behind the ear of the assistant, or did she bother to take the patient's sweater off?

If any of us, psychiatrists included, profess to practice by the Hippocratic method -- by that I mean total focus on the patient observing every detail -- then the physician must surely examine the pulse, the appearance and the blood pressure. I submit that if half of us are running around with undiagnosed hypertension or pre-hypertension, then half or more of the BP recordings in the patient record are wrong. How long does it take to take a BP and note the patient's pulse? How often do you suppose the assistant fails to note an arrhythmia? There are BP machines outside almost every pharmacy. I have yet to try one that I found believable. The point is that diagnosis of HT will emerge as epidemic if we bother to sit down with our patient, look them in the eye -- not the computer -- and take the pulse and BP ourselves. (Left arm BP may be normal in Coarctation while the Right arm and cerebral circulation reaches high levels.) Protocols are worthless in the absence of the right diagnosis.|

Informed debate over free-market ideas for health reform.

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Academicians and planners often miss the simple fact that health care by any measure is not a free market. Arguably, there is room for debate. There are no winners or losers in this debate except the American people. They are losing. The Global Burden of Disease shows the US some 26^th out of 33 industrialized countries, close to the bottom in nearly every category.

The concept of competition has merit, but a blank check from insurance companies promotes only competition for the dollar return and not for patient care. The intentions are great, but the planners do not see the forest for the trees. Nearly everything they have done has made matters worse. There is no competition between insurance companies, either now or back before the ACA. There is no competition between providers or between institutions either. With insurance company blank checks each provider and each institution is free to charge whatever they like promoting the most profitable services as would any corporate business. There is no incentive for insurance companies to restrict charges because increased charges result in approved increases in policy pricing and thus revenue. All of these players in health care: insurance, institutions, providers and drug companies are, in effect, monopolies. I submit that efforts to enlist the magic of free enterprise merely codify the monopoly and greed from all players including patients.

Competition with cooperation between states is good. There are vast regional differences in health risk and disease. Competition with cooperation between universities is good; it leads to academic excellence and progress. Open competition with cooperation between providers is good because medicine is a science and diversity of effort, inductive reasoning and sharing of data are the scientific method.

Competition for the dollar in a vital public infrastructure is not helpful. Public health is practically dead on the vine in the US due to the favoring of personal liberties over the intrinsic mandate for the public good – health.

The best competition of all would be between the private sector and traditional insurance company medicine. Competing public systems, run state by state, would increase the diversity, the science and the advancement of medicine -- with patient outcome the reward. Medical schools and city or county hospitals once fulfilled some of that role but not now given the Siren call of pre paid insurance and deregulation. These two competing systems are vastly different. Let free enterprise work for the two systems and let the market determine which system dominates. Let both sides give it their best.

This dichotomy is the real debate in Washington. Let the debate play out in the real world as a competition between belief systems with cooperation between both.

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Medical Education

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In reading The Law, it sounds like a formula for today, a Flexner Report[1] from 25 centuries ago, and it would not hurt to reread the Flexner Report either.

          1. Medicine is of all the arts the most noble; but, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgment of them, medicine is at present far behind all the other arts. Their mistake appears to arise principally from this, that in the cities, there is no punishment connected with the mal practice of medicine except disgrace, and that does not hurt those who are familiar with disgrace. Such persons are like the figures in tragedies, for as they have the shape, and dress, and personal appearance of an actor, they are only stage dressing, so also physicians are many in title but very few in reality. [They wear the stethoscope around their neck and pretend to the knowledge]
          2. Whoever is to acquire a competent knowledge of medicine, ought to be possessed of the following advantages: a natural disposition; excellent instruction; a favorable position for the study; early tuition; love of labor and leisure. First, a natural talent is required; for, when Nature leads the way to what is most excellent, instruction in the art takes place, which the student must try to appropriate to himself by reflection, becoming an early pupil in a place well adapted for instruction. He must also bring to the task a love of labor and perseverance, so that the instruction, taking root, may bring forth proper and abundant fruit.
           3. Instruction in medicine is like the cultivation of the products of the earth. For our natural disposition is, as it were, the soil. The tenets of our teacher are, as it were, the seed. Instruction in youth is like the planting of the seed in the ground at the proper season. The place where the instruction is communicated is like the air imparted to vegetables by the atmosphere. Diligent study is like the cultivation of the fields. It is time, which imparts strength to all things and brings them to maturity.
           4.  Having brought all these requisites to the study of medicine, and having acquired a true knowledge of the art, we shall thus, in travelling through the cities, be esteemed physicians not only in name but in reality. However, inexperience is a bad treasure, and an empty purse to those who possess it. Whether in opinion or reality, being devoid of self-reliance and competence, fosters both timidity and audacity. For timidity betrays a want of powers, and audacity a lack of skill. There are, indeed, two things, knowledge and opinion, of which the one makes its possessor truly to know, the other to be ignorant.
           5. Those things, which are sacred, we must impart only to sacred persons, and thus it is not lawful to impart them to the profane until they have been initiated in the mysteries of the science.

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[1] Flexner Report is a book-length study of medical education in the United States and Canada. , written by the educator Abraham Flexner and published in 1910, sponsored by the Carnegie Foundation. Flexner lived 1866-1959. Flexner reformed medical education in the United States; he also helped found the Institute for Advanced Study in Princeton. Many aspects of the present-day American medical profession and educational system stem from the Flexner Report.