Back to the Future: Medical Students Can Matter Again

Over the last 5 years, we have spent considerable time directly teaching students and housestaff and have been involved in numerous meetings of academic physicians concerned about the apparent erosion in quantity and quality of medical student and resident teaching at our medical schools and teaching hospitals.

The causes of this progressive deterioration in what many consider the best medical education system in the world are myriad: Economic challenges forced faculty to spend much of their time doing direct clinical work rather than teaching; program directors have needed to spend more time and effort on regulatory documentation; administrative restrictions have been placed on medical student participation in patient care; duty hour constraints have been placed on resident work schedules, thereby decreasing the amount of time that residents can devote to teaching students as well as each other; and inpatient physicians are given performance metrics that emphasize efficiency of patient flow at the expense of bedside teaching and role modeling. Departments of medicine have evolved into business centers or “product lines” instead of the medical center's academic compass.

Teachers have less time to teach; residents have less time to learn; and medical students are often relegated to the role of voyeurs. And from this environment we hope to find the solution to reverse the trend of dwindling number of students seeking careers as general internists and academicians.

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-- Joseph S. Alpert, MD, Brian F. Mandell, MD, PhD

This article was originally published in the November 2009 issue of The American Journal of Medicine.

Should We Maintain an Open Mind about Homeopathy?

Once upon a time, doctors had little patience with the claims made for alternative medicines. In recent years the climate has changed dramatically. It is now politically correct to have an open mind about such matters; “the patient knows best” and “it worked for me” seem to be the new mantras. Although this may be a reasonable approach to some of the more plausible aspects of alternative medicine, such as herbal medicine or physical therapies that require manipulation, we believe it cannot apply across the board. Some of these alternatives are based on obsolete or metaphysical concepts of human biology and physiology that have to be described as absurd with proponents who will not subject their interventions to scientific scrutiny or if they do, and are found wanting, suggest that the mere fact of critical evaluation is sufficient to chase the healing process away. These individuals have a conflict of interest more powerful than the requirement for scientific integrity and yet defend themselves by claiming that those wanting to carry out the trials are in the pocket of the pharmaceutical industry and are part of a conspiracy to deny their patients tried and tested palliatives.

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-- Michael Baum, MD, ChM, Edzard Ernst, MD, PhD

This article was originally published in the November 2009 issue of The American Journal of Medicine.

Bayesian Meta-analysis of Hormone Therapy and Mortality in Younger Postmenopausal Women

This careful meta-analysis indicates that hormone therapy reduces total mortality by 25% in younger postmenopausal women. A similar reduction in mortality has been seen in randomized trials and observational studies.

Abstract

Background
There is uncertainty over the risks and benefits of hormone therapy. We performed a Bayesian meta-analysis to evaluate the effect of hormone therapy on total mortality in younger postmenopausal women. This analysis synthesizes evidence from different sources, taking into account varying views on the issue.

Methods
A comprehensive search from 1966 through January 2008 identified randomized controlled trials of at least 6 month's duration that evaluated hormone therapy in women with mean age <60 years and reported at least one death, and prospective observational cohort studies that evaluated the relative risk of mortality associated with hormone therapy after adjustment for confounding variables.

Results
The results were synthesized using a hierarchical random-effects Bayesian meta-analysis. The pooled results from 19 randomized trials, with 16,000 women (mean age 55 years) followed for 83,000 patient-years, showed a mortality relative risk of 0.73 (95% credible interval 0.52-0.96). When data from 8 observational studies were added to the analysis, the resultant relative risk was 0.72 (credible interval 0.62-0.82). The posterior probability that hormone therapy reduces total mortality in younger women is almost 1.

Conclusions
The synthesis of data using Bayesian meta-analysis indicates a reduction in mortality in younger postmenopausal women taking hormone therapy compared with no treatment. This finding should be interpreted taking into account the potential benefits and harms of hormone therapy.

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-- Shelley R. Salpeter, MD, Ji Cheng, MSc, Lehana Thabane, PhD, Nicholas S. Buckley, Edwin E. Salpeter, PhD (Posthumous)

This article was originally published in the November 2009 issue of The American Journal of Medicine.