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June 30, 2006

Tour de France riders suspended

The big news in the cycling world is the suspension today of top Tour de France contenders Jan Ullrich and Ivan Basso.

Were they caught with drugs in their system? Steroids in their suitcases? Common sense would suggest that a top rider would need to be caught red-handed in order to get kicked out of the Tour just days before it starts. But cycling apparently works differently.

Basso and Ullrich are being suspended because of evidence that they've been "in contact" with Spanish doctor Eufemiano Fuentes. Since Fuentes is tainted by "being at the center of a massive doping ring," merely being in contact with him is enough to get a rider booted out of the Tour. To which I reply: you've gotta be shitting me.

I've been looking forward to this Tour for years. I like Lance Armstrong, but quite frankly he'd made the Tour a bit boring. He was such a machine that he sucked all the suspense out of the race (except for years like 2003 when Ullrich almost beat him). This year, with Armstrong in retirement, I couldn't wait to see who'd step up. Basso and Ullrich were two of the top contenders -- but now they're out. Sorry. Tune in again next year.

Adding insult to injury is the withdrawal of Alexander Vinokourov's team, spurred by the suspensions of Francisco Mancebo and Joseba Beloki for the same "associations" that tainted Ullrich and Basso. Vinokourov was possibly the most audacious and aggressive rider in the race, and now he's probably out too. We Tour fans might have to start scraping the bottom of the barrel to find a guy we can root for, and even if he does well, we'll never know how he would have done had the big dogs been in the race.

This is ridiculous. I'd like to see a higher standard of proof before a rider is suspended. If it's just too hard to prove that a rider is doping, race organizers ought to allow it. Then at least everyone will have access to the same advantages as everyone else, even if some of those advantages involve extraction and reinjection of your own blood.

You can follow the story at the Tour de France blog.

June 29, 2006

Chicago EMS triage

In Denver (unless things have changed), the paramedics decide on scene where to transport a patient, and then they call their chosen hospital to let them know they're enroute.

In Chicago, the paramedics don't determine their own destination. Instead, they call their "resource hospital" (U of C, Illinois Masonic, or Northwestern) and the nurse or doc at that hospital decides where the ambulance will take the patient.

Which system is better? One complaint that's been made about the Chicago system is that the resource hospital appears to have a conflict of interest. The resource hospital doc may often have to decide whether to send a patient to her own hospital when she's stressing because her ED is so busy.

As a colleague of mine put it: "I don't see that it adds anything when the doc, and not the paramedic, makes the destination decision."

June 26, 2006

Moving back to Hyde Park

One of the side effects of being a resident at the University of Chicago is being able to live in Hyde Park again.

Now, it's true that many of my fellow first-year residents (great people, all of them) have not chosen to take advantage of this opportunity. With a few exceptions, they've all rented apartments within a two block radius of each other near Clark and Diversey. Ok, I'm exaggerating. But not by much.

Anyway, Hyde Park: it has its good and bad sides. On the bad side, it's not anything like Clark and Diversey. Not as many restaurants, nowhere near as many bars, and there's no Bed, Bath & Beyond within a ten mile radius. On the good side, it's nothing like the north side. It's not as yuppified, and it's not as homogenous. People other than late-20-something professionals live here, and you'll see some of them walking home from the grocery store. Unfortunately, some of them will be carrying guns and will stick you up for your wallet, cell phone, and Dogfish Head 60 minute IPA -- but I don't think those guys actually live in the neighborhood.

Besides, Hyde Park has the best bookstores in the city of Chicago, and some of the best in the country.

How does it compare with Ann Arbor? You can read this great blog post (including all the comments), which gets it almost entirely right. The most insightful comment: "Not sure if this goes for the over or under side, but Hyde Park’s flocks of feral parakeets give it a certain flair that AA’s pigeons can’t attempt."

June 23, 2006

Getting processed

I've spent the last few days at the hospital getting processed by the hospital bureaucracy. They need to transform me from an ordinary civilian into a first-year resident so I can start seeing patients on July 1.

It's been boring and exciting both. The boring part: hours of talks and PowerPoint presentations about the computer system, the benefits packages, the infection-control programs, etc. All accompanied by an avalanche of handouts: flyers, brochures, booklets, pamphlets, and laminated cards. Where I'll put them all I don't know yet. The amazing thing is how much of this orientation material is mandated by various federal laws or agency regulations. I was handed an evaluation form and told that my opinions were really important, but I don't see how that can be true when the hospital doesn't have the option of getting rid of the HIPAA compliance presentations or the OSHA-mandated demonstrations of how to use a fire extinguisher.

But I'm glad I sat through all of that, because some parts of the hospital orientation have been pretty damned exciting. It's cool to get my hospital name badge : University of Chicago Hospitals, baby. Then there's my printed prescription pads. Carey Cuprisin, MD. Yep, I guess if I'm gonna be a resident, people are gonna start calling me a doc and expecting me to write them some scripts for generic Zocor. I'd better start getting used to it.

June 12, 2006

More AMA junk mail

I received another piece of junk mail from the AMA today. Ever since I graduated from medical school in 2002, they've tried to drown me in solicitations for everything under the sun. Especially offers for insurance policies.

But today's envelope was worse. It was a real, honest-to-goodness USPS priority mail envelope containing an invitation to join for half price. Oh, goody: only $210.00 for a six-month membership.

Sorry, but I'll pass. I don't like the thought that if I join, some of my dues money will be used to buy priority-mail envelopes for the next round of solicitations. That seems like a waste of money to me.

There are, I'm sure, many good reasons to belong to the AMA. Physicians can do a lot of good when they act together, and sometimes the AMA itself will entertain some creative proposals (like a tax on soda). But in my limited experience, the AMA just isn't providing the kind of leadership that a physician organization is capable of.

Maybe when I see a few more good policy suggestions, and a bit less junk mail in my mailbox, I'll think again about joining the AMA.

Quote for the day

"Tomorrow's landscape is being created by the way each of us spends our money on food." -- Joel Salatin

June 11, 2006

The wacky academic right

Says Mark Schmitt at The Decembrist:

"On reading this, my first reaction was that if the academic left can be a little wacky and irresponsible, the academic right is wacky and despicable."

I ask, why "despicable?" Oh, yeah -- Jean Bethke Elshtain and Leon Kass think we should withhold the rights and privileges of marriage from gay people, but they can't come up with any good arguments for their position. So they use bad arguments instead.

I laughed especially hard when I read this in Section I of their "Princeton Principles":

The health of marriage is particularly important in a free society such as our own, which depends upon citizens to govern their private lives and rear their children responsibly, so as to limit the scope, size, and power of the state.

Reconciling a social conservatism with an avowed preference for limited government can get kind of tricky sometimes. If you want to rely on the state to use its coercive power against unwelcome cultural developments, then you're not asking to limit the scope, size, and power of the state. You're just hijacking state power for your own cultural and religious ends.

Elsewhere in their "Princeton Principles," these leading right-wing academics say this:

Marriage is under attack conceptually, in university communities and other intellectual centers of influence. To defend marriage will require confronting these attacks, assessing their arguments, and correcting them where necessary. We are persuaded that the case for marriage can be made and won at the level of reason.

By which you apparently mean, not at the level of religious faith and preaching. Well, reason tells me that you still don't understand that there's a difference between "attacking marriage" and defending gay marriage. Marriage between men and women is harmed by infidelity, lack of commitment, dishonesty, and all the other things we already know about and, sadly, already succumb to. Fight against those things, if you want. You only distract the public from these very real evils by trying and failing to build a case that gay marriage somehow harms marriage in the way that dishonesty and infidelity do.

Nothing you say in your "Principles" is sufficient to justify the gender distinctions you're so eager to make. You could be honest at this point and just admit that you simply believe, based on religious or on some other faith-based grounds, that man/woman marriage is the only way to go. But "reason"? Call me a skeptic. If this argument was based on reason, I have faith that you could have come up with some more persuasive arguments by now.

Robert G. Kaiser defends the press, convincingly

The Washington Post's Robert G. Kaiser asks an interesting question: "Why does The Washington Post willingly publish "classified" information affecting national security?"

His answers are entirely persuasive.

"Some readers ask us why the president's decisions on how best to protect the nation shouldn't govern us, and specifically our choices of what to publish. The answer is that in the American system of checks and balances, the president cannot be allowed to decide what the voters need to know to hold him accountable. A king may have such power, but the elected executive of a republic cannot, or we will have no more republic."

NYT editor Bill Keller probably agrees with most of Kaiser's nuanced but appropriately combative piece. Unfortunately, the evidence of Keller's good sense is cited by some right-wing watchdog groups as evidence of a "liberal bias" at the NYT.

Anti-fascist bias would perhaps be a better way to describe it.

Employers, and the employees who grovel before them

This story in the NYT made me realize that if I had to hire someone, I wouldn't hesitate to Google them if I had the time and the curiosity. If I found out that the candidate had a myspace page that typically looks something like this (sorry, Shelby, I just needed an example and your page came up), I suppose I'd flush their resume down the toilet too. Not for doing drugs or posting immature shit online (that's none of my business), but for being stupid enough to act as if they think the things they put online are private.

The one thing that troubled me about the NYT article, though, is the way employers are getting access to Facebook information:

Facebook, though, has separate requirements for different categories of users; college students must have a college e-mail address to register. Personal pages on Facebook are restricted to friends and others on the user's campus, leading many students to assume that they are relatively private.

But companies can gain access to the information in several ways. Employees who are recent graduates often retain their college e-mail addresses, which enables them to see pages. Sometimes, too, companies ask college students working as interns to perform online background checks, said Patricia Rose, the director of career services at the University of Pennsylvania.

In other words, new employees sell out their former classmates to their employers.

If the Facebook posters think what they've put online is any less private than a myspace page, they deserve what they get. But it's still disappointing to know that employers can co-opt their new employees so easily.

One of my supervisors during my law school years (who shall of course remain nameless) was a bit put out when I refused to use my summer Westlaw and Lexis passwords to do job-related legal research. I'm not usually a stickler for the rules, but I'd clearly agreed that I wouldn't use my personal summer access to Westlaw for my employer's benefit. I would have been even more reluctant to use my Facebook access (if I'd had it) to help my employer run background checks. That kind of thing feels groveling and supine to me. But there's no guarantee that even I -- hard as it may be to believe -- would always say no to these kinds of employer requests. What if I liked my boss and hated my ex-classmate? Then it'd be, "Sure, I'll dig up this guy's Facebook page for you. Heh heh."

The moral of the story, again, is if you don't want the whole world to read it, don't put it online. There's always an old classmate out there who's too eager to say "yes" to their boss.

June 09, 2006

First they put RFIDs in the immigrants. . .

Corporate leaders are excited about a new "guest worker application" that will "help the U.S. with its current immigration crisis." In other words, they're looking forward to implanting radio frequency identification devices (RFIDs) into Mexican guest workers.

But there's really nothing to worry about here. “First and foremost, a VeriChip is not a locating device. VeriChip technology has no GPS capabilities whatsoever." That's a relief.

"It is simply a voluntary passive identification device that is only “awakened” by a proprietary scanner within a very short range of a few inches.” Well, when you put it like that, it doesn't seem so bad. In no time at all we'll be using them in our children (to prevent abductions), our employees (for employment-related uses only) and ourselves (to make things more convenient).

Nothing to worry about.

June 08, 2006

Academic freedom?

Lindsay Beyerstein links to this interesting story about Juan Cole's near-appointment at Yale.

Net neutrality

This one might be worth writing your elected representatives. Not that they'd listen.

Congress is about to cast a historic vote on the future of the Internet. It will decide whether the Internet remains a free and open technology fostering innovation, economic growth and democratic communication, or instead becomes the property of cable and phone companies that can put toll booths at every on-ramp and exit on the information superhighway.

Here's a taste of what the world might look like if the cable and phone companies get their way. (Via The Health Care Blog.)

A bad idea: implied preemption of state law requirements for drug labels

Should drug manufacturers, assuming they meet all the labeling requirements imposed by the FDA, be subject to liability for failing to meet more extensive or different labeling requirments imposed by the states?

This article in the NEJM ($), criticizing the FDA's new labeling regulations, buries its most important paragraph deep in the middle of the piece:

The most troubling aspect of the FDA's new plan, however, has nothing to do with providing information to prescribers. In an unusual move after the end of a five-year period of comments on the initial rule, the agency used the passage of the new labeling regulations to quietly add a new section to its preamble that will make it extremely difficult for anyone to bring legal action against a drug manufacturer for harm caused by one of its products.

Whether you find this troubling or not will depend on what you think about the trustworthiness of the FDA and drug manufacturers, the appropriateness of private lawsuits in areas subject to extensive government regulation, and the relative role of state and federal law.

For years, the pharmaceutical industry had sought to pass legislation that would prohibit litigation over adverse effects as long as the medication was approved by the FDA; Congress has consistently rejected this idea. But after the comment period for the new labeling regulation had closed, language was added to the final rule stating that any FDA-approved label, "whether it be in the old or new format, preempts . . . decisions of a court of law for purposes of product liability litigation."

Drug manufacturers would love for Congress to explicitly preempt state laws governing drug labeling, but so far, Congress has chosen not to do so. There's nothing that explicitly prevents states from passing drug labeling laws that impose more extensive requirements on drug manufacturers than imposed by the FDA under the federal Food, Drug, and Cosmetic Act.

Usually when an industry wants federal preemption of state laws, but can't convince the Congress to go along, the industry relies on the doctrine of implied preemption to argue that courts should refuse to enforce state laws anyway. Their argument is that when Congress legislates extensively about a given subject, it has implicitly exercised its power to preempt state law. State legislation on the same subject, even if it doesn't actually conflict with federal requirements, would alter the federal regulatory regime in ways that Congress would never have intended.

This doctrine leaves the preemption decision to the courts. But federal agencies do influence the final decisions about implied preemption, and that's why this new language from the FDA is important. When courts are presented with the argument that federal law implicitly preempts state law, they will often grant some deference to the interpretation of that federal law by the agencies charged with implementing it. For example, if the FDA interprets the Food, Drug, and Cosmetic Act to preempt state labeling requirements, it's more likely that a court will find that state law is preempted. That's why this part of the article is misleading:

Beginning at the end of this month, the new regulations would preempt nearly all action by patients in state courts against drug manufacturers for unanticipated injuries resulting from the use of their products. This immunity would apply even if a company failed to warn prescribers or patients adequately about a known risk, unless a patient could prove that the company intentionally committed fraud — a very hard test to meet.

The FDA's opinion about preemption isn't itself legally binding, but it does make it more likely that the courts will go along with drug manufacturers' preemption arguments.

Is any of this a good thing? There's a strong case to be made that in the absence of any state law to the contrary, a state jury shouldn't be able to hold a drug manufacturer liable for a "failure to warn" in a case where the manufacturer complied with FDA labeling requirements. The FDA does rely on clinical trial data to determine what warnings are appropriate. Its judgments shouldn't be routinely discarded by lay juries.

However, things are different when a state passes a specific law requiring warnings in addition to those imposed by the FDA. Contrary to what the FDA suggests, a drug's "safety" isn't something objectively inherent in the drug, and that can be objectively determined in scientific studies. Does a 1 in 5 chance of constipation make a drug unsafe? A 1 in 300 chance of a heart attack? Although the statistical likelihood of adverse side effects can be objectively measured, the safety of a drug is in the eye of the beholder. There's no reason why the FDA's decision that some risks are insignificant enough to be left off a warning label should prevent states from requiring that these risks be disclosed anyway. At least, not until the Congress decides to explicitly preempt state laws that require this additional disclosure.

The FDA argues that "State-law attempts to impose additional warnings can lead to labeling that does not accurately portray a product’s risks, thereby potentially discouraging safe and effective use of approved products or encouraging inappropriate use and undermining the objectives of the act." But this just amounts to an assertion that what's "appropriate," "safe," and "effective" is exclusively a matter for the FDA to decide -- and Congress hasn't explicitly given it this authority.

Implied preemption arguments should be approached skeptically, especially in cases where Congress has considered and declined to exercise its power to expressly preempt state law. The FDA's arguments for preemption should be treated even more skeptically, since they essentially restate the position of the drug manufacturers that has not succeeded in Congress.

The new regulations are here: www.fda.gov/OHRMS/DOCKETS/98fr/06-545.pdf.

June 02, 2006

Sounds delicious

Creamy olive oil gelato as a stand-in for coconut. Who'da thunk it?