Monday, 23 July 2012

Da Vinci: Connoisseur of corpses

Can you draw a heart? Not an I love you heart, a real ventricles and all heart? No? Maybe because you haven't seen one? I have, but I couldn't do it justice. The peak of my artistic talent came age 5 when I won a Disney drawing competition at school. Apparently my skillz with a crayon perfectly captured the true essence of Goofy. They displayed it in the local gallery. I could have been a contender. Now my stick men look forlornly out from the page, despairing with a wonky eye at my inability to endow them with legs of equal length. Sorry Bert.

One man who could definitely draw a symmetric stickman and a decent heart, though he probably never drew Goofy, was Leonardo Da Vinci. It's a name that conjures images of incredible inventions and divine paintings of deities, but Leonardo was also a connoisseur of corpses. He was an anatomist. Arguably the most accomplished anatomist, not only of his time, but ever. He described structures which weren't mentioned in the medical literature for another two to three centuries. Some of these findings were documented on paper, but others he painstakingly scratched into metal plates capturing every sinew of muscle and snaking nerve. What impresses even more than this raw artistic talent is the scale of his ambition. In the outline for his treatise on anatomy, he planned to trace every blood vessel, document every type of smile, and describe not only the form, but function of almost every structure in the human body.

One of Leonardo's most inspired attempts to understand function came in 1512, when he filled an ox heart with molten wax. From this he made a glass model of the heart and then pumped a grass seed suspension through it. Observing the turbulent movement of this suspension through the aortic valve Leonardo realised that the valve prevented blood re-entering the heart. This breakthrough flew in the face of how the world saw the circulatory system. It was widely believed that the venous and arterial systems were not linked, and that the heart simply pumped blood out and then sucked it back in. Now Leonardo Da Vinci, a genius by any standards, held in his hands evidence of how the heart worked. Surely this was a pivotal moment in medical science? Erm, no. Leonardo's mind, capable of such incredible leaps and bounds, could not release itself from the dogma of the day. Instead he scrabbled around for ways blood could re-enter the heart from the aorta, postulating ideas such as porous valves. Genius fail.

His mind remained shackled to this falsehood until his death in 1519, and with him died his drawings and discoveries. His collection was lost to the world for almost 400 years and by the time it was uncovered the knowledge it contained had been pieced together by Andreas Vesalius and other anatomists. The moral of this tale? Don't live with the results of other people's thinking, publish before you perish and even geniuses lack self belief.

As sad an ending as this is, it doesn't detract from the fact that Leonardo's drawings remain jaw droppingly awe inspiring 500 years on. I doubt anyone will be marvelling at my stickmen in 500 years. Sorry Bert.

If you want to marvel at Leonardo's handiwork, its on display at the Queen's Gallery until October 7th. If you don't live in London, or you don't want to pay the £10 entry fee, their website has a few examples online. Well worth a peek. 

Sunday, 15 July 2012

Sandwiches with strings?

Pharmaceutical giant GlaxoSmithKline recently plead guilty to criminal charges and were fined $3billion. They admitted encouraging the prescription of the antidepressant Paxil to children despite trials showing it was ineffective. They also bribed doctors and failed to report safety issues with the diabetes drug Avandia. People are horrified that this happened. But should they be shocked? This is from an industry that has lobbied to protect their Intellectual Property in a way that will choke access to cheap generic HIV drugs in developing countries. And what about the medics they bribed? GSK have been taking most of the negative press, but the doctors who traded their professionalism for profit have much to answer for.

Loveline radio show host Dr Drew is one such medic. Prosecutors said he took $275, 000 to promote Wellbutrin for unapproved uses. He suggested the wonder drug could give women 60 orgasms a night and help them lose weight. Emmmm, not according to any decent clinical trial that's been conducted. He also promoted a website- which told people about town hall meetings where depression experts would be talking about the illness. No mention was made of GSK. Today we know that GSK owns that website and it now redirects you to Wellbutrin.

Dr Drew intrigues as much as he disappoints. I wonder what his tipping point was- when he decided profit mattered more to him than professional ethics. Did he always feel that way, or was there once a young, altruistic Dr Drew?

Whilst our deceitful Dr Drew did particularly well out of GSK, he isn't alone in benefiting financially from pharmaceutical companies. GSK held luxury drug promotion events in Puerto Rico, Hawaii and California. According to the Guardian“Those who attended were given $750, free board and lodging and access to activities including snorkelling, golf, deep-sea fishing, rafting, glass-bottomed boat rides, hot-air balloon rides and, on one trip, a tour of the Bacardi rum distillery, all paid for by GSK.” Now, in fairness to those attending they didn't promise GSK anything in return. Nevertheless the na├»ve complaints of one psychiatrist grate somewhat: “this is supposed to be a scientific meeting. To me, the music, lights, videos, emcees are offputting and a distraction, even demeaning ”. Really, you thought you were going to a scientific meeting where they just gave you $750?!

But I'm standing in a glass house hefting a fairly heavy stone. I've accepted gifts from drug companies- from post-it notes to syringe shaped pens- I've got a small pencil case worth of booty. As a medical student the prospect of a pharma-funded lunch always made a day seem better and enticed me to listen to their chat of BOGOF chemotherapy. Sometimes I was appeased with offerings of M&S goodies, other days I was handed a Tesco basics sandwich and muttered to myself about declining standards. A New England Journal of Medicine survey found 94% of physicians had some relationship with pharma- at 83% the most common connection was receiving food and beverages in the workplace. But are these small gifts really problematic? I honestly can't remember which companies provided which sandwiches, so how could I possibly have been influenced by it? And even if I had noticed, their agenda is so clear can't I just apply a cynical filter to what I'm being told and enjoy a free lunch?

But that same cynical part of me thinks that whilst this view is appealing (I want the free lunch to be ok soooo badly) it doesn't answer one gnawing question: If it doesn't work, why does the pharmaceutical industry spend hundreds of millions of pounds on it? They aren't stupid. So, are we?

I had a dig around for some guidance to help me with this dilemma and found that the American Medical Association recommends against any gift that expects anything in return. The pharmaceutical companies are more charitable than I if they expect NOTHING in return. If I give you a present, I don't necessarily expect a gift in return but a nice thank you and some warm fuzzy feelings towards me would be good. In an article on gifts published in the American Journal ofBioethics, Katz, Caplan and Merz argued that social convention dictates that when you receive a gift, even one you didn't ask for, you feel compelled to provide something in return. They give the example of the Disabled American Veterans charity which appeals for donations through direct-mail. The response rate is about 18% when no gift is included and 35% when the envelopes contain an inexpensive gift such as address labels. The guidance also puts an emphasis on the size of gift. Indeed in 2001 the AMA launched a $1 million campaign to educate doctors about not taking big gifts from drug companies. Roughly $600,000 of the cost was covered by nine drug companies. Do as I say, not as I do....

The American Government shares the AMA's preoccupation with gift size. The Physician Payment Sunshine Act is set to make it compulsory for pharmaceutical companies to declare any payments or perks made to medics that exceed $10. Whilst this is definitely a step in the right direction, I cant help wondering whether the AMA and the US government are missing a trick by assuming gifts can ever be string free.

I love a good bit of evidence but I haven't turned up anything that examines the impact of small gifts on actual prescribing behaviour- do hospitals that are visited more by one particular company see higher prescribing rates of those drugs? Do people have subconscious warm fuzzy feelings for Pfizer after a tasty lunch?

I think there are lessons to be learned from the drug industry's willingness to splash out on sandwiches and stationery. One is that part of the reason I cherished the opportunity to grab a pen or a set of post-its was because I had to supply my own at work. Maybe hospitals should take a tip from the pharma marketing execs. They could draw up a list of drug names commonly prescribed by brand when they should be generic and provide pens and post-its with the generic names on them. Small, unsolicited gifts might even be a minor morale booster. Lord knows hospital management need to do something to make staff feel warm and fuzzy towards them.

Finally, GSK tell us they have definitely learned lessons from this case. According to IMS Health, in the time period covered by their $3billion fine Avandia made $10.4bn in sales, Paxil $11.6bn, and Wellbutrin $5.9bn. What lessons do you think they learned?