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vendredi 14 juin 2013


Dedicated to people from whom I learned so much about the art of being a Physician
Dr Howard Lessner
Dr Julio Ferreiro
Dr Eric Reiss
All of whom I met during my various stays at the University of Miami School of Medicine.
I am one of the few practising physicians who devote at least two hours per day scourging through the Medical Literature (still I find it not enough to touch all that is relevant to my practice!). I have been influenced by the above teachers in the various facets of reading medical literature, which at one time meant, going to the Library or subscribing to the medical Journal.
Dr Lessner once said to me, a budding medical student at that time, do not read anything that you don't pay for. The full impact of that wisdom didn't surface until much later. Currently most doctors get their medical information not from what they pay for, but what the Drug companies have paid for directly or indirectly.
If you were reading one of the Free sources of Medical Information, such as MEDSCAPE which claims to have the largest number of Physician readers, a headlines may cry out: Calcium Supplementation Found to have no side effects in MEN. And if you have the time to find the original study that they refer to, published in the journal Heart or NEJM, you would see that, those women who took supplements had higher rates of heart disease and stroke and kidney stones but much less side effects were seen in men. So the true information is hidden under a barrage of propaganda, much like what Stalinist regime and Stalinists still do!
Instead of rationing information like in Cuba, the wealthy countries and the wealthy patrons who stand to gain by manipulating information, crowd the scene with information, knowing fully well that only a few will take time out to find out the source.
Dr Eric Reiss taught us: Most doctors read the journal article title, and the abstract and the results and some may even read the discussion but very few read Methods. If you don't understand what methods were used, your understanding of the results has become skewed.
Many doctors outside USA has questioned me about PIMA Indians thinking that they are the only Indians who live in the USA because almost all the articles are published about research among the PIMA.
If a drug company that make newer drug of questionable efficacy and of dubious safety want to market their drugs, they will study a group of people in whom they are guaranteed a good result. So you have to be a bit of an anthropologist these days before you can interpret clinical trials.


For example, to treat Diabetes, there are many new drugs, of two classes, one class has drugs like Byetta (Exanetide) and the other class has drugs like Januvia (Sitagliptin). I am very proud to say that I have never prescribed either of these medications in my patients who are mainly Native Americans. No study would be conducted among Native Americans since their blood sugar responds (like many other people) best to Lifestyle changes and Counselling rather than medications (only marginally). But if you go to any of the conferences, you would see doctors and professors who have stocks in the drug companies swearing by these drugs as if they are the best to arrive on the scene since Insulin, which still remain the best anti diabetes medication (as far as medications go).
BMJ in an article and two editorials published on line on June 10, 2013, two days ago make excellent reading.
What comes out almost reads like a detective novel in which the people who have financial interests, i.e. the drug company and the doctors promoting these drugs have withheld a lot of information from the public. Already in the USA there have been multiple court cases in which the drug companies and the doctors have been sued for withholding information from patients who later on had Pancreatitis or Pancreatic cancer when taking these medications.

So how to read a medical article?  Not what to read, but HOW to read it. Here is my method.
First of all at least subscribe to one or more, preferably more medical journals. There are also medical journals that come with the subscription to the Professional Society that you belong. Being a member of the Endocrine Society, I can read all the major endocrine journals.
If you don't have any access to paid journals, and that you rely upon things that come to you on a daily basis, you can be sure that drug companies sponsor them. But still there is a way to beat them in their own game.
By the way, advertisement is subtly hidden under an Unrestricted Grant from such and such drug company. Usually a well known, balding and paunchy Professor of this or that would be interviewing another professor who is chosen for his station in life but also paid. In general I do not listen to those videos. Videos those are worthy of listening to, are in and most of them have nothing to do with Medicine but do not insult your intelligence! But enhances it.
Then find a catchy headline that you want to explore. One thing you will quickly note that they are usually written or collaborated with some ageing professor about to retire. If you mention the subject I can reasonably tell you whose name is going to appear there.
They editorialize the contents of the article as if you are not capable of doing that, because in that way they can influence your way of thinking. How to beat them on this game? They usually give the link to the original article. I look for the link in the headlines that interest in me in these daily electronic offering and don't bother to read the editorializing by paid peons of the industry but go and read the article myself. Then the opinion I will have will be my own.
Attend some reputable Medical Conferences once or twice a year, I don't mean conferences in Vail Colorado in winter and Maui in the summer. But preferably the annual scientific meeting of your specialty would add to know your knowledge, in a somewhat unpolluted fashion. There again watch out for speakers at elaborate dinners, they are usually in the pay of the you know who?
The drug companies love Psychiatrists, Anaesthesiologists, and Dermatologists to promote their medications. As Diabetes is becoming more and more prevalent, Endocrinologists are also targeted, and once again the same ten or twelve endocrinologists among the hundreds in a country as vast as USA can be seen at all meetings displaying their wares.
To analyse the information available for the good of your patients, it is not only necessary to read the original articles and think about them, and it is good to have a friend, who can participate in this intellectual activity with you.

I am lucky to have one such friend with whom we can share our thoughts and feed into each other’s curiosity.
Luckily he is also an avid reader and scrounger of medical information, and at this moment he is vacationing at the port of Calvi.

Where the hell is that you might ask? Please find out. Curiosity is the sign of intelligence.