Saturday, August 12, 2017

I am opening a private internal medicine practice in Ellsworth, Maine

I hope to see patients with challenging disorders, those who wish to reduce their medications and/or use diet and lifestyle changes to improve health (especially diabetes and hypertension), and those with illnesses occurring after tick bites, or related to military service or anthrax vaccine.  I will also treat the range of illnesses seen in primary care internal medicine, and I love to work with patients to achieve optimal wellness.

Throughout my career, I have had patients referred to me who were not helped by standard western medicine. While I cannot help everyone, I often take a unique look at the illness, and have a broader palette of measures to use than most doctors.

I believe everyone deserves great healthcare, so have made my charges considerably lower than standard rates. I also offer sliding scale fees for low income patients.  However, in order to make this practice work, I cannot accept any insurance plans, and patients must pay for my services when services are rendered.

Appointments may be made at (207) 522-5229.

Sunday, July 23, 2017

WHO DREAMS UP US FOREIGN POLICY? In Syria, there is no answer that makes sense. Has our foreign policy been privatized?

from  What the demise of the CIA’s anti-Assad program means

Washington Post Opinion by David Ignatius
July 20, 2017


"What did the CIA’s covert assistance program for Syrian rebels accomplish? Bizarrely, the biggest consequence may be that it helped trigger the Russian military intervention in 2015 that rescued President Bashar al-Assad — achieving the opposite of what the program intended. 
Syria adds another chapter to the star-crossed history of CIA paramilitary action. These efforts begin with the worthy objective of giving presidents policy options short of all-out war. But they often end with an untidy mess, in which rebels feel they have been “seduced and abandoned” by the promise of U.S. support that disappears when the political winds change..." x
... Run from secret operations centers in Turkey and Jordan, the program pumped many hundreds of millions of dollars to many dozens of militia groups. One knowledgeable official estimates that the CIA-backed fighters may have killed or wounded 100,000 Syrian soldiers and their allies over the past four years.  
"... The United States didn’t have a political strategy to match the CIA’s covert campaign. “There was no ‘there’ there, in terms of a clearly articulated national security objective and an accompanying strategy,” said Fred Hof, a former State Department official who has followed the Syria story closely."
... Contrast the sad demise of the CIA’s anti-Assad program in western Syria with the rampaging campaign against the Islamic State in the east. What’s the difference? In the east, motivated, well-organized Syrian fighters are backed by U.S. warriors on the ground and planes in the sky. In this game, halfway is not the place to be. 

Thursday, June 22, 2017

Evidence based medicine manifesto for better healthcare/ BMJ

Here is a very good start at diagnosing inherent problems in the medical research enterprise, and suggestions for correcting them.--Meryl

BMJ 2017357 doi: https://doi.org/10.1136/bmj.j2973 (Published 20 June 2017)
  • Carl Heneghan, director1,
  • Kamal R Mahtani, deputy director1,
  • Ben Goldacre, director EBM DataLab1,
  • Fiona Godlee, editor in chief2,
  • Helen Macdonald, head of education2,
  • Duncan Jarvies, multimedia editor2
    1. A response to systematic bias, wastage, error, and fraud in research underpinning patient care
      Informed decision making requires clinicians and patients to identify and integrate relevant evidence. But with the questionable integrity of much of today’s evidence, the lack of research answering questions that matter to patients, and the lack of evidence to inform shared decision how are they expected to do this?
      Too many research studies are poorly designed or executed. Too much of the resulting research evidence is withheld or disseminated piecemeal.1 As the volume of clinical research activity has grown2 the quality of evidence has often worsened,3 which has compromised the ability of all health professionals to provide affordable, effective, high value care for patients.”
      The BMJ and the University of Oxford’s Centre for Evidence Based Medicine have collaborated on Evidence Live, a yearly conference designed to “develop, disseminate, and implement better evidence for better healthcare.” Through this work and other projects, we know of substantial problems but also progress and solutions spanning the breadth of the evidence ecosystem, from basic research to implementation in clinical practice.
      The EBM manifesto offered here grew from that awareness. It is an open invitation for others to contribute to and join a movement towards better evidence by providing a roadmap for how to achieve the listed priorities and to share the lessons from achievements already made. Its aim is to complement and unite existing efforts as well as create new ones.

      Why can’t we trust the evidence?

      Serious systematic bias, error, and waste of medical research are also well documented (box 1).4 Most published research is misleading to at least some degree, impairing the implementation and uptake of research findings into practice. Lack of uptake into practice is compounded by poorly managed commercial and academic vested interests15; bias in the research agenda (often because of the failure to take account of the patient perspective in research questions and outcomes)1617; poorly designed trials with a lack of transparency and independent scrutiny that fail to follow their protocol18 or stop early19; ghost authorship20; publication and reporting biases5721; and results that are overinterpreted or misused,22 contain uncorrected errors,14 or hide undetected fraud.923

      Box 1: Problems with current evidence

      • A landmark review suggested that results from half of all trials are never published, and that positive trials are twice as likely to be published as results from negative trials5
      • The cost of clinical drug trials rose fivefold in one decade and is hindering the development of new medicines6
      • 85% of research spending currently goes to waste 4
      • In a study of systematic reviews, 86% of 92 Cochrane reviews did not include data from the main harm outcome 7
      • A systematic review of 39 studies found no robust studies evaluating shared decision making strategies8
      • From 2009 to 2014 the drug industry received fines totalling $13bn (£10bn; €12bn) for criminal behaviour and civil infringements—few systematic changes have occurred to prevent such problems occurring again9
      • “Despite repeated calls to prohibit or limit conflicts of interests among authors and sponsors of clinical guidelines, the problem persists”10
      • One third (34%) of scientists report questionable research practices, including data mining for statistically significant effects, selective reporting of outcomes, switching outcomes, publication bias, protocol deviations, and concealing conflicts of interest11
      • A 2012 survey of 9036 BMJ authors and reviewers found that of the 2782 (31%) who replied, 13% had witnessed or had firsthand knowledge of UK based scientists or doctors inappropriately adjusting, altering, or fabricating data during their research for the purpose of publication12
      • 8% of authors from 630 articles admitted they had lied in their authorship statements13
      Poor evidence leads to poor clinical decisions. A host of organisations has sprung up to help clinicians interpret published evidence and offer advice on how they should act. These too are beset with problems such as production of untrustworthy guidelines,10 regulatory failings,23 and delays in the withdrawal of harmful drugs.24 Collectively these failings contribute to escalating costs of treatment,25 medical excess (including the related concepts of medicalisation, overdiagnosis, and overtreatment)26 and avoidable harm.24

      Developing more trustworthy evidence: the EBM manifesto

      The steps required to develop trustworthy evidence (box 2) have been refined through a series of activities with stakeholders, including seminars, round table discussions, online consultations, and direct feedback. Tackling the problems will take time, resources, and effort. The evidence based medicine community should take responsibility for this. However, it is a vast project that is being led, and will be led, by disparate groups around the world. We hope to focus attention on the tools and strategies most effective at delivering change, so that we can all work together to improve healthcare using better quality evidence. The manifesto document and priorities are a living document and will evolve over time to advocate for trusted evidence for better healthcare. If you want to have your say and join the discussion then visit (http://evidencelive.org/manifesto/).

      Box 2: EBM manifesto for better health

      • Expand the role of patients, health professionals, and policy makers in research
      • Increase the systematic use of existing evidence
      • Make research evidence relevant, replicable, and accessible to end users
      • Reduce questionable research practices, bias, and conflicts of interests
      • Ensure drug and device regulation is robust, transparent, and independent
      • Produce better usable clinical guidelines
      • Support innovation, quality improvement, and safety through the better use of real world data
      • Educate professionals, policy makers, and the public in evidence based healthcare to make an informed choice
      • Encourage the next generation of leaders in evidence based medicine

      Tuesday, May 30, 2017

      Zimbabwe's historic anthrax epizootic: new analysis

      A paper has been published here and, while in draft form, discussed at length here, which reanalyzes the features of Zimbabwe's anthrax epizootic, which began in 1978 and slowly tailed off after 1980.

      The authors include an MD and geography specialists from the University of Nevada, Reno.  The first author, James M. Wilson, MD, has founded a center to investigate and forecast epidemics.  From his bio:
      Director, Nevada State Infectious Disease Forecast Station @ the University of Nevada-Reno.This is the first operational infectious disease forecast station in the United States that operates at the state level. 
      The group has done a great job collecting information about weather (temperature, rainfall), soils, outbreak locations, possible means of spread, and number of animals and humans affected, as well as the movement of the epidemic over time.  The group has pulled together the detail needed to create maps and tables that convey how the epidemic evolved chronologically.

      The authors have [as I believe I did in 1992] put to rest a number of unsupported theories as to the nature of the epidemic, and confirmed that the geographic "hops" anthrax made are not explained by natural occurrences.  The authors confirm that anthrax cases extended to the borders of Zimbabwe, but remained confined within Zimbabwe's boundaries. Adjoining countries experienced no similar epizootic.

      The authors agree that the vast majority of human cases were associated with exposure to anthrax-contaminated animals, hides or meat.

      Of interest, a number of anonymous commenters were extremely critical of Wilson's paper as it was in progress.  Their arguments were mostly specious, and I would be able to knock each down if it was useful to do so; I did knock down a few, then stopped sparring with anonymous critics.  If the critics were serious, presumably they would have used their names.  What was interesting was the concerted attack on Wilson, some 38 years since the onset of the epizootic, to deny the event could have been due to biological warfare.  Yet there is no other explanation, consistent with the facts, that has ever been put forward.

      Wilson's paper also makes clear that the 2015 report on this epizootic, by Stephan P. Velsko from Lawrence Livermore National Laboratory (LLNL), self-published by LLNL, is not worth the paper it is printed on. Velsko ditched the facts and built a house of cards based on his own inferences about the epidemic, providing an example of the extreme lengths a so-called scientific exercise can be taken to turn the scientific method on its head. I criticized his work here.

      Wilson reported that I had been living in Zimbabwe at the time of the epizootic.  Actually, I was living in the US.  I travelled to Zimbabwe to study the epizootic in 1992, and did a poster presentation on the epizootic in Nairobi at the International Society for Infectious Diseases in July 1992, making the argument that the many unique features of this epizootic could only be explained as an act of biological warfare.  Margarete Isaakson, a South African infectious disease scientist with likely connections to Project Coast, and an interest in Ebola, screamed at me in Nairobi for daring to present such rubbish. I believe this was because I came too close to her area of expertise.

      Nothing has changed since Zimbabwe's tragic epizootic.  Biowarfare is a horrible mode of warfare that has not been eradicated, identifying it is controversial, and developing the scientific tools that allow one to definitively identify when an act of offensive biowarefare has been used, shifts the balance of power from the perpetrators to the investigators and to those who were attacked.  That seems a very fair power shift, but it isn't to everyone's liking. (What makes biological warfare especially attractive is the ability to hide that it actually occurred, and who caused it.) Scientific studies that remove this advantage are, unsurprisingly, being attacked.

      The attacks, mostly spurious, that Wilson has received for his paper tell us there are still many people who would keep the whole subject under wraps.

      Finally, despite a 2010 paper by Fasanella et al. that flies can transmit anthrax spores in the lab (and several similar earlier papers going back decades have found the same thing), the problem is the flies' failure to transmit enough spores or viable vegetative forms to cause illness in livestock, because on the order of one million spores is required to achieve an infectious dose. It is much more likely that flies could transmit anthrax to rodents, for whom several orders of magnitude fewer organisms are required.  But in nature, they do not seem to do this, either.  So much for the fly theory.

      While I am pleased this subject is getting the careful attention it deserves, I wonder why it is getting it now?

      Wednesday, May 24, 2017

      COMMENTARY Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records/ WBUR

      By 
      It happens every day, in exam rooms across the country, something that would have been unthinkable 20 years ago: Doctors and nurses turn away from their patients and focus their attention elsewhere — on their computer screens.
      By the time the doctor can finally turn back to her patient, she will have spent close to half of the appointment serving not the needs of her patient, but of the electronic medical record.
      Electronic medical records, or EMRs, were supposed to improve the quality, safety and efficiency of health care, and provide instant access to vital patient information.
      Instead, EMRs have become the bane of doctors and nurses everywhere. They are the medical equivalent of texting while driving, sucking the soul out of the practice of medicine while failing to improve care.
      To fix them, hospital administrators and clinicians need to work together to demand better products from EMR manufacturers and to urge government to relax several provisions of the HITECH Act, the 2009 law that spawned many of the problems with EMRs.
      How did technology that has increased efficiency in every other industry become such a drag on health care? For starters, people who take care of patients did not design or choose these systems. They were foisted upon us.
      Doctors and nurses know that good diagnosis and treatment requires listening attentively to their patients. They spend years learning to parse the clues that patients offer, both the physiological and personal, in order to provide the right care.
      To do this well takes time and undivided attention.
      Making sense of a patient’s blood panel means knowing the patient’s work and eating habits, and where he or she may have traveled. We need to know if the patient is experiencing a traumatic life event, like the death of a parent or domestic abuse, in order to interpret an elevated blood pressure.
      Instead of making this easier, most EMRs create extra work. A lot of extra work, thanks to endless prompts with multiple choice answers that hardly ever fit the facts and that demand click after click to get anything done.
      Want to order a simple test? That requires getting through multiple prompts. Need to write a prescription -- an exercise that used to take less than 15 seconds? Another set of clicks.
      Typing, filing, mailing results and placing referrals all used to be done by assistants. Now, EMRs put that burden on clinicians, and we must do it during office visits, or “encounters,” as EMRs call them. And when the wrong button is clicked, the wrong test or drug is ordered, or it does not go through at all, delaying medical care.
      It’s death by a thousand clicks, and it happens every day.
      We are frustrated by EMRs because they pull us away from our patients. We are driven mad by the fact that EMRs in different locations do not talk to each other. And we think it’s just wrong that much of the EMR’s busywork is about optimizing billing for the hospital.
      Who is to blame? Start with EMR manufacturers, who lobbied Congress to require every hospital and doctor’s office to install an EMR system; hospital administrators who bought technology that conveniently pushed billing duties onto doctors and nurses; and federal regulators, who imposed on EMRs numerous quality metric requirements that do nothing to improve care.
      We do not want to go backward. We believe that computing is essential to the future of medicine. We simply want all EMRs to live up to their promise of improving care and making patient information readily available.
      Thousands of doctors in Boston and across the country are expressing the same frustration, through gritted teeth, between exasperated sighs, and in resignation letters. EMRs are driving too many health care providers to hang up their scrubs and white coats in search of work that is less infuriating and more fulfilling.
      As we continue to debate how our country will finance an equitable health care system for all, we need a long-term strategy to address this crisis in health care delivery.
      The public and private institutions of this city have long and illustrious histories of leadership in health care. Now is the time to embrace that tradition and do something about EMRs. We plan to hold town hall meetings to give providers, patients and community members a chance to discuss how to address the problems of EMRs. We invite executives and administrators from all our hospital systems to participate.
      The sound of medicine is not the click of a mouse. It is the human voice. Let’s bring it back, for the sake of our patients’ health and our own sanity.

      Friday, May 5, 2017

      How the federal government helps make healthcare unaffordable/ Medscape

      One big contributor to ridiculously high administrative costs of medicine in the US is the federal government.

      Constantly changing federal rules seem to aim for complexity.  Compliance is nearly impossible for small medical practices, because Medicare changes its rules every few months. Doctors have to play by its rules, but it is very difficult to keep up with them.  Medicare feels no need to issue its rules on time, even after it announces their schedule for release.

      Here is an example from today's Medscape.  Just remember that YOU are paying for this nonsense, and it is one reason that healthcare has basically become unaffordable in the US:
      "The Centers for Medicare & Medicaid Services (CMS) has announced that by the end of May, it will notify all clinicians who are eligible for payment under the new Merit-Based Incentive Payment System (MIPS). One of two payment tracks in CMS' Quality Payment Program, MIPS was launched January 1. Physicians who are subject to MIPS will have their performance on quality, electronic health record (EHR) use, and practice improvement measured this year to determine positive or negative payment adjustments in 2019.
      Physicians and other clinicians are subject to MIPS if they bill more than $30,000 a year in Medicare Part B allowed charges a year and provide care for more than 100 Part B–enrolled Medicare beneficiaries annually. They are exempt from MIPS, however, if they receive a specified percentage of income from one of several care delivery models that are known as advanced alternative payment models.
      CMS originally said it would notify clinicians who must participate in MIPS by last December, before the 2017 performance measurement period began. But CMS failed to do that, leaving many physicians and group practices in limbo... 
      CMS recently released a list of "qualified registries" clinicians can use to report their quality data, he said. But the agency has not issued a list of approved "qualified clinical data registries." The qualified registries are mainly offered by EHR vendors, which can charge hefty fees for the service. In contrast, the more reasonably priced qualified clinical data registries are operated by specialty societies and quality improvement collaboratives.
      Gilberg views this omission as a challenge for some practices that want to report more data to CMS this year to qualify for a bonus in 2019... 
      CMS' requirement that all MIPS participants use 2015 Edition EHRs presents practices with another quandary. So far, only two major EHR vendors, Epic and Allscripts, have had their 2015 Edition EHRs certified by the government. There is serious concern in the industry that the bulk of eligible clinicians will not have 2015 EHRs by the start of the 2018 reporting period....

      Thursday, May 4, 2017

      US Medicine is a Racket: 10 Examples by Elisabeth Rosenthal, MD

      Former NY Times journalist and non-practicing physician Elisabeth Rosenthal's new book, An American Sickness, lists 10 economic "rules" of US medicine that are guaranteed to make money, but not to improve outcomes:
      1. More treatment is always better. Default to the most expensive option.
      2. A lifetime of treatment is better than a cure.
      3. Amenities and marketing matter more than good care.
      4. As technologies age, prices can rise rather than fall.
      5. There is no free choice. Patients are stuck. And they're stuck buying American.
      6. More competitors vying for business doesn't mean better prices; it can drive prices up, not down.
      7. Economies of scale don't translate to lower prices. With their market power, big providers can simply demand more.
      8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
      9. There are no standards for billing. There's money to be made in billing for anything and everything.
      10. Prices will rise to whatever the market will bear.
      Here is a review of her book.  I am thrilled this book is getting the attention it deserves: for without understanding what our health care system has become, there is no way to make the changes needed for it to work for the People, and their medical providers.

      NSA collected Americans' phone records despite law change: report/ Reuters

      The Office of the Director of National Intelligence (ODNI) just issued a report that said the NSA had FISA court permission to spy on less than 100 people (terrorism suspects) in 2016, but it collected information on 150 million phone calls instead.

      You might ask how NSA whittled down the billions of phone calls made in the US last year to 150 million.  Or you might remember that a former top NSA official, Bill Binney, told us in 2014 that NSA collects not only the metadata, but the entire conversation, of most phone calls:
      At least 80% of all audio calls, not just metadata, are recorded and stored in the US. The NSA lies about what it stores.”
      And then you might call the ODNI report a "limited hangout"--designed to make us think we are getting the "real truth" at last, when in fact this new "admission" barely scratches the surface of what is truly happening.

      Today I was sent a short guide on achieving internet privacy, designed for journalists.  I have my doubts that true privacy is possible, especially for journalists handling issues related to "national security," but there do exist methods to make it harder for the snoops. This free guide, by Michael Dagan, may be worth a look if you need to beef up your security.

      Below is from the Reuters story on the ODNI admission:


      The U.S. National Security Agency collected more than 151 million records of Americans' phone calls last year, even after Congress limited its ability to collect bulk phone records, according to an annual report issued on Tuesday by the top U.S. intelligence officer.
      The report from the office of Director of National Intelligence Dan Coats was the first measure of the effects of the 2015 USA Freedom Act, which limited the NSA to collecting phone records and contacts of people U.S. and allied intelligence agencies suspect may have ties to terrorism.
      It found that the NSA collected the 151 million records even though it had warrants from the secret Foreign Intelligence Surveillance court to spy on only 42 terrorism suspects in 2016, in addition to a handful identified the previous year.
      The NSA has been gathering a vast quantity of telephone "metadata," records of callers' and recipients' phone numbers and the times and durations of the calls - but not their content - since the September 11, 2001, attacks...

      Thursday, April 27, 2017

      French intelligence service piles on with more anti-Assad nonsense--here's why it is BS

      According to the LA Times and echoed by many other outlets, 
      "France’s foreign ministry says deadly sarin gas used in a chemical attack in Syria this month that killed 87 people “bears the signature” of President Bashar Assad’s government.
      A six-page report by French intelligence services claims the nerve agent came from hidden stockpiles of chemical weapons that Damascus was supposed to have destroyed under an U.S.- and Russian-brokered deal in 2013."
      Here is what you should be aware of as you sift this latest news:

      1.  Assad gave up 1300 tons (2,600,000 pounds) of his chemical weapons in 2013-14.  They were moved out of Syria, loaded on ships, and destroyed by portable shipboard factories far offshore.  This complicated, non-transparent process, which was completed far from prying eyes in the middle of the ocean, lent itself to transferring stocks of Assad's sarin and mustard gas to unknown third parties.


      Damascus was not given the option of destroying its own weapons, nor was it even considered safe to do so in a war zone.  The chemical weapons had to be handed over to the West.


      Who might now have some of the [allegedly destroyed] sarin and mustard gas that Assad offered up for destruction?


      2.  Since chemical and biological weapons may leave a chemical or genetic signature, and since a major advantage of such weapons is the difficulty of identifying a perpetrator, the smart players do their best to create chem/bio weapons that leave the signature of someone else. 


      3.  If you know the chemical signature of a chemical or biological weapon, even if you cannot obtain someone else's material, you may be able to reverse engineer a specific signature and impute an attack to your enemy.


      4.  Seymour Hersh and others have noted that weapons from Gaddafi's stockpile were sent from Libya through Turkey to Syria to be given to anti-Assad rebel forces, in a complicated maneuver engineered by the CIA.  Sarin was alleged to have been found by police, who arrested al-Nusra rebels in Turkey with 2 kg. of sarin.  Using Gaddifi's arms gave the CIA plausible deniability of involvement.


      Anyone giving sarin to Syrian 'rebels' would expect its use to be attributed to Assad.


      It should not be lost on the reader that, according to Hersh, the US has established a track record of transferring someone else's sarin to Syrian rebels, so its use would be imputed to Assad.  In other words, there has already been CIA connivance in a complex operation to create false flag chemical attacks in Syria, in 2013.

      5.  The UN report on chemical weapons attacks in Syria in 2013 did not blame Assad for them, and a commissioner of the 
      Independent International Commission of Inquiry on Syria, Carla del Ponte, described evidence favoring the rebels as the perpetrators.


      6.  Since no Syrian sarin attacks have ever been demonstrated conclusively to be due to Assad or to anyone else (rumors and claims abound, but definite proof has been elusive), France's claim that the recent sarin is from Assad because it matched sarin from an earlier attack is utter nonsense, since we don't know the source of the earlier sarin signature.


      7.  The French intelligence service authored this report.  And the US intelligence services authored the 2003 report of Iraq's WMD, and claimed the 2013 sarin attacks were due to Assad (without proof, read the report here).  US and UK intelligence services had something to do with the Trump "golden showers" dossier of trash.


      These intelligence services were all carrying out their missions, which sadly have become propaganda, not intelligence. 


      8.  There was no motive for Assad to use chemical weapons in 2013, and no motive today.  Each time sarin was allegedly used, was after his army had made recent impressive gains. Instead, strategically, Assad had much to lose from employing sarin.  


      Read what a former State Department insider had to say about the unlikelihood Assad used chemical weapons in 2013, in an article in the Atlantic.


      9.   When you consider the background to the claims about Syria's chemical weapons, the series of stories blaming Assad for attacking his people with sarin this month make less and less sense.  


      10.  Instead, it seems we are reliving Judith Miller's series of false NY Times stories that provided the drumbeat to war in Iraq, in 2002-3. We should not be fooled again.