Bakker's Blog

Back Again

It has been a very long time since I have been posting.  I am no longer working in a library, but I am still very much an academic medical librarian.  I am working in an IT department now.  There are a lot of reasons why I made this transition, some big and some small.  It was also not that there weren't opportunities to move up in libraries.  In fact, I had practically the dream job (right boss, right position, almost right leeway to explore) but i said no, but more on that crazy decision later. 

Basically, I just wanted to get myself going again. 
so - hope there are some of you still out there. 

Scholarly Communications again - self-archiving

Marcus had a good point in his comment from my last post - many publishers allow authors to self-archive. 
Many publishers do allow self-archiving, and it is a fact that many of us don't fully utilize.  The  giant in STM publishing,  Elsevier has a self-archiving policy  that allows for authors to use and distribute their articles for a variety of uses.  Peter Suber posted an excerpt on Open Access News on July 14th. 

With the right to post a manuscript version of an article (with peer-review changes) on the author's website or author's institutional website, it wouldn't be such a great leap to allow the manuscripts to be posted on PubMed Central (the funding institution's website).  Hmmm....maybe we are all closer than we realize to agreeing on this NIH policy. 

Scholarly Communications - Open Access legislation

In February 2005, NIH announced a new policy for published findings from publicly funded research to be made publicly available - basically making the information resulting from federally funded research available to the taxpayers.* 
Naturally, news of this new NIH policy sparked a lot of talk in academia (especially libraries) and among the publishers. By the time of the 2005 announcement, the NIH had backed off from requiring this new policy, and just strongly recommended it. This year, legislation on this topic made its way to Congress and the issue is once again on the table - should we have free access to the published findings of publicly funded research?  The issue is not as simple as it might seem.  Researchers live and die by their funding and the resulting publications - if they cannot publish in the most prestigious journals (if the best journals refuse to allow authors to make their articles freely available in compliance with the policy), it can severely, negatively affect their careers.  And the publishers, many of whom currently make unbelievable profits (by the way - there is a rapid and dramatic consolidation of academic scientific publishers underway, with only a couple of major players out there and almost exclusively all non-U.S. companies), could be significantly financially impacted if people do not need to buy subscriptions to get the research (remember, publishers are not in it for the greater good - these are profit-based companies or those who at least need to be cost neutral).  So, what to do? 
Now, most librarians are of the 'all information should be free' mentality, and while that's great, I cannot help but think it is not realistic and sticking to it as the only solution will continue to polarize both sides and potentially fail to make progress on an important issue.  But back to the NIH policy.  The voluntary policy from 2005 yielded a lot of interest, but a less than 5% rate of compliance - and that just isn't enough.  Sometimes you have to require something to make it happen.  I think the policy is good, logical and feasible for both the publishers and the researchers, and great for the public.  With an approximately $30 billion annual budget, the NIH has the ability to make people play their game - and I agree with the rules of this game; and so do 26 Nobel Laureates who signed a letter of support for the policy.   
ALA has saved me the job of explaining the details with a summary, FAQs and an action alert all rolled into one.  The House vote was supposed to be yesterday...let's wait and see.  In the mean time, check out the ALA site and hopefully you will like what you see and add your name to the list of support (it takes a few seconds and you can do it right from that page). 

*Those not in academia might say, "well, duh. of course" but that isn't an 'of course' statement - academic research publications have long been accessible only through subscriptions to the journals where the information is published.  The articles are not the property of the researchers, the NIH, or the taxpayers - by publishing them, they become the property of the publication. 

Another Reason to Worry About Sleep Deprived Doctors

New Scientist.com reported on a recent study showing that lack of sleep impacts people's moral judgement. 
Two interesting findings:

"While participants did not become less “moral” when sleep deprived, they did require two seconds longer on average to answer complex moral questions, Killgore says. However, questions without a moral component did not take longer to answer after participants were kept awake."  And...

"Sleep deprived participants also showed slight shifts in what they deemed appropriate actions compared to when they were well-rested. The changes were more pronounced in individuals who scored lower in  'emotional intelligence' tests."

Certainly facts worth considering when thinking about hours on call and training during residency.   

Drug interactions and Information

There was an article in the 27 February 2007 Washington Post, "A Dangerous Mix" that talks about the dramatic rise in deaths from accidental drug interactions.

"A report this month by the Centers for Disease Control and Prevention found that deaths from accidental drug    interactions rose 68 percent between 1999 and 2004, continuing a steady climb since the early 1990s. Unintentional drug poisonings accounted for nearly 20,000 deaths in 2004, said the CDC, making the problem now the second-leading cause of accidental death in the United States, after automobile accidents. "Prescription drugs, especially prescription painkillers, are driving the prolonged increase," the report stated."

In the age of information, technology in health care and consumer awareness and involvement in their health - how can this happen? Does every part (e.g. the physician, the patient, the pharmacist) think every other part is keeping an eye on things?  What about all those great interaction warnings at the pharmacy and in the electronic health record system?  What about the dramatic increase of consumer health information (including drug interaction information) available on the Internet? 
Health care technology has been lauded as the fix to medical errors, including drug errors.  Are we forgetting that as great as technology is, we still have to think and adapt as healthcare progresses?    

Literacies and Our Priorities

In this era of the public taking an active role in their health, people turn to consumer health information to help them make decisions about their health care.  With millions of people making decisions about their health based on the information they find - how they find and use that information becomes very important to America's state of health and health care. 

This week I had the opportunity to introduce a consumer health website - MedlinePlus - to students in a Masters of Public Health program  (the course was health literacy and the class was health information online).  The discussion began with some statistics about the number of Americans online and how they look for health information and progressed to an interesting discussion about the difficulties of making information accessbile to a wide variety of people.   Approximately 8 million Americans search for health information online everyday and more than half of them make decisions based on what they find online.  That makes loooking for information online as popular as paying bills and reading blogs.  But here is where it gets interesting - most of the health information online is clinically questionable and/or incomplete (from a 2001 JAMA article).   Health Literacy is an important and complex issue and the issues of computer/internet literacy add another dimension to finding and using health information online.   Beyond the basic issues of using a mouse and opening software, there are added issues of knowing how to navigate a website and evaluate the source of online information for reliability and accuracy. 

The issues of reliability and literacy of health information are important, so why do we spend more media time checking the accuracy of the latest reported celebrity pregnancy than on the reliability of the information that influences many decisions in a $2 trillon industry?

Laughter Really is Good Medicine

The article, "Laughter's Link to Health May Be in the Blood" (By Rob Stein) appeared in today's Washington Post (registration required).  The article discusses a study measuring the vasolidation (increase in the caliber of blood vessels [from Dorland's 25th ed.]) of 20 healthy men and women  before and after watching a stressful movie clip and a funny movie clip.  According to the study, "Overall, blood flow decreased by about 35 percent after experiencing stress but increased 22 percent after laughter -- an improvement equivalent to that produced by a 15- to 30-minute workout"  (quoted from the article).    This was not a major study and the hypothesis needs further proof, but I like where this is headed. 

I wonder if watching a funny movie could count towards my 60 - 90 minutes of daily exercise recommended by the UDSA?   Maybe I could get my health insurance to pay my netflix fee as preventative therapy. 
I guess Mom was right, laughter is the best medicine...or at least it's good medicine. 

More on Malpractice Liaibility reform - maybe malpractice claims are not such a big problem

The Washington Post article, "Malpractice Situation Not Dire, Study Finds"  discusses the state of malpractice insurance and claims in Texas.  Currently, malpractice issues are primarily dealt with at the state level; throughout the nation, insurance companies and many doctors claim that malpractice suits are driving up the cost of malpractice insurance.  This article looks at the evidence and finds a disconnect in that claim - at least in Texas. 
I have been looking into this issue and it has been very difficult to find hard evidence to support either side.  Statistics available are obviously manipulated to make a point instead of letting the facts speak for themselves.   The foggy perspective we have is understandable given some of the issues surrounding the issue: the intense politics on both sides of the aisle, the fact that we are attempting to generalize and make a national case from facts about 50 very different states, and the fact that keeping track of the issues involved (e.g. insurance rates, malpractice claims, suits, and medical errors) is a complex and politically-charged issue itself. 
However, the fact that this is an important issue remains true and clear.  What is the answer?  I think we should start with the insurance companies, but I am open to being convinced otherwise. 

Politics makes strange bedfellows

This morning's Washington Post  had an interesting op-ed by Newt Gingrich.  "Transform It, Don't Reform It" (2 March, 2005.  A17) gave an outline of Dr. Gingrich's opinion of the problems and possible solutions to the Medicaid problem.  Historically I have vehemently disagreed with most things Newt Gingrich has proclaimed, but I do agree with many of his ideas put forth in this op-ed.  In fact, I agree with a lot of what Newt Gingrich has to say about health care technologies.  Last year I was at a Congressional hearing on Health Information Technology and I was stunned by his testimony - but in a very good way. 
The gist of the piece discusses how Medicaid needs to reach a very diverse set of  beneficiaries, and it needs different rules and operating procedures to deal with the different groups.  Some of those changes include modernizing the system to maximize the efficiencies offered by new technologies.   Medicaid needs to crawl out from under the paperwork and the bureaucracy and start doing its job -  improving the health of the poor, the disabled poor, and the elderly poor. 

Medical Malpractice Liability Reform : is this the answer?

Recently I was reading the New York Times article, “Bush’s Next Target: Malpractice Lawyers" by Steve Lohr. (27 February 2005) and it got me thinking about the plan to cap pain and suffering awards to $250,000. A few months ago I was waiting in O’Hare when I met a family practice doctor from one of the Northern plain states and we had a lively discussion about malpractice liability reform. An hour and half later, I was not satisfied that this was the answer. His response was simple, “You don’t like it, then come up with a better plan.” Well, I don’t have a plan and the nagging doubt remains - there must be a better way!

I agree that the current system does not work. The now famous 1999 IoM report states that 44,000 – 98,000 people die annually in hospitals due to medical error, and approximately 82% of preventable errors are human errors. These errors cost many millions every year. Medical malpractice insurance is extremely high and is rising at alarming rates. There are many frivolous lawsuits initiated every year (most of which do not get to court, many of which are settled because it costs less to settle than to justifiably disprove malpractice). But there is also malpractice which dramatically alters the life of patients and their families.

But when we federally mandate a limit on what a jury can award a plaintiff, we enter potentially disastrous territory. Currently, liability reform and insurance rates are dealt with on a state level.  Why is it better, or even acceptable, to make liability reform a federal issue?  Doesn’t limiting what a jury can award take away an essential element of a trial by jury? Tort reform has taken place in many states, yet insurance rates continue to dramatically rise. What makes it the case that limiting jury awards will lower the rates of insurance? History shows us that many states’ liability reforms have had little to no impact on malpractice insurance rates.

Perhaps we could begin to solve this problem where it begins. Currently, insurance companies are unregulated (and heavily invested in politics). Perhaps the government should investigate the merits of regulating health and malpractice insurance. Many malpractice claims have little foundation in real medical malpractice. Why not have states seriously look at rules regulating malpractice claims? Why not have a stricter, nationwide, mandatory reporting system for physician error? A temporary bandaid doesn't begin to solve the problem, but it may cause more problems.    (Congressman Ron Paul (Texas) wrote a statement in 2002 addressing many of these points – it’s a quick read and worth a look). 

I don’t have the answers, but talking about it is always a good place to start.