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August 12 2017

18:31

I am opening a private internal medicine practice in Ellsworth, Maine

I hope to see patients with challenging disorders, those who wish to reduce their medications and/or use diet and lifestyle changes to improve health (especially diabetes and hypertension), and those with illnesses occurring after tick bites, or related to military service or anthrax vaccine.  I will also treat the range of illnesses seen in primary care internal medicine, and I love to work with patients to achieve optimal wellness.

Throughout my career, I have had patients referred to me who were not helped by standard western medicine. While I cannot help everyone, I often take a unique look at the illness, and have a broader palette of measures to use than most doctors.

I believe everyone deserves great healthcare, so have made my charges considerably lower than standard rates.  I also offer sliding scale fees for low income patients.  However, in order to make this practice work, I cannot accept any insurance plans, and patients must pay for my services, when services are rendered.

Appointment may be made at (207) 522-5229.

July 23 2017

19:37

WHO DREAMS UP US FOREIGN POLICY? In Syria, there is no answer that makes sense. Has our foreign policy been privatized?

from  What the demise of the CIA’s anti-Assad program means

Washington Post Opinion by David Ignatius
July 20, 2017


"What did the CIA’s covert assistance program for Syrian rebels accomplish? Bizarrely, the biggest consequence may be that it helped trigger the Russian military intervention in 2015 that rescued President Bashar al-Assad — achieving the opposite of what the program intended. 
Syria adds another chapter to the star-crossed history of CIA paramilitary action. These efforts begin with the worthy objective of giving presidents policy options short of all-out war. But they often end with an untidy mess, in which rebels feel they have been “seduced and abandoned” by the promise of U.S. support that disappears when the political winds change..." x
... Run from secret operations centers in Turkey and Jordan, the program pumped many hundreds of millions of dollars to many dozens of militia groups. One knowledgeable official estimates that the CIA-backed fighters may have killed or wounded 100,000 Syrian soldiers and their allies over the past four years.  
"...  The United States didn’t have a political strategy to match the CIA’s covert campaign. “There was no ‘there’ there, in terms of a clearly articulated national security objective and an accompanying strategy,”  said Fred Hof, a former State Department official who has followed the Syria story closely."
... Contrast the sad demise of the CIA’s anti-Assad program in western Syria with the rampaging campaign against the Islamic State in the east. What’s the difference? In the east, motivated, well-organized Syrian fighters are backed by U.S. warriors on the ground and planes in the sky. In this game, halfway is not the place to be. 

June 23 2017

03:57

Evidence based medicine manifesto for better healthcare/ BMJ

Here is a very good start at diagnosing inherent problems in the medical research enterprise, and suggestions for correcting them.--Meryl

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2973 (Published 20 June 2017)
  • Carl Heneghan, director1,
  • Kamal R Mahtani, deputy director1,
  • Ben Goldacre, director EBM DataLab1,
  • Fiona Godlee, editor in chief2,
  • Helen Macdonald, head of education2,
  • Duncan Jarvies , multimedia editor 2
    1. A response to systematic bias, wastage, error, and fraud in research underpinning patient care Informed decision making requires clinicians and patients to identify and integrate relevant evidence. But with the questionable integrity of much of today’s evidence, the lack of research answering questions that matter to patients, and the lack of evidence to inform shared decision how are they expected to do this? Too many research studies are poorly designed or executed. Too much of the resulting research evidence is withheld or disseminated piecemeal.1 As the volume of clinical research activity has grown2 the quality of evidence has often worsened,3 which has compromised the ability of all health professionals to provide affordable, effective, high value care for patients.” The BMJ and the University of Oxford’s Centre for Evidence Based Medicine have collaborated on Evidence Live, a yearly conference designed to “develop, disseminate, and implement better evidence for better healthcare.” Through this work and other projects, we know of substantial problems but also progress and solutions spanning the breadth of the evidence ecosystem, from basic research to implementation in clinical practice. The EBM manifesto offered here grew from that awareness. It is an open invitation for others to contribute to and join a movement towards better evidence by providing a roadmap for how to achieve the listed priorities and to share the lessons from achievements already made. Its aim is to complement and unite existing efforts as well as create new ones.

      Why can’t we trust the evidence?

      Serious systematic bias, error, and waste of medical research are also well documented (box 1).4 Most published research is misleading to at least some degree, impairing the implementation and uptake of research findings into practice. Lack of uptake into practice is compounded by poorly managed commercial and academic vested interests15; bias in the research agenda (often because of the failure to take account of the patient perspective in research questions and outcomes)1617; poorly designed trials with a lack of transparency and independent scrutiny that fail to follow their protocol18 or stop early19; ghost authorship20; publication and reporting biases5721; and results that are overinterpreted or misused,22 contain uncorrected errors,14 or hide undetected fraud.923

      Box 1: Problems with current evidence

      • A landmark review suggested that results from half of all trials are never published, and that positive trials are twice as likely to be published as results from negative trials5
      • The cost of clinical drug trials rose fivefold in one decade and is hindering the development of new medicines6
      • 85% of research spending currently goes to waste 4
      • In a study of systematic reviews, 86% of 92 Cochrane reviews did not include data from the main harm outcome 7
      • A systematic review of 39 studies found no robust studies evaluating shared decision making strategies8
      • From 2009 to 2014 the drug industry received fines totalling $13bn (£10bn; €12bn) for criminal behaviour and civil infringements—few systematic changes have occurred to prevent such problems occurring again9
      • “Despite repeated calls to prohibit or limit conflicts of interests among authors and sponsors of clinical guidelines, the problem persists”10
      • One third (34%) of scientists report questionable research practices, including data mining for statistically significant effects, selective reporting of outcomes, switching outcomes, publication bias, protocol deviations, and concealing conflicts of interest11
      • A 2012 survey of 9036 BMJ authors and reviewers found that of the 2782 (31%) who replied, 13% had witnessed or had firsthand knowledge of UK based scientists or doctors inappropriately adjusting, altering, or fabricating data during their research for the purpose of publication12
      • 8% of authors from 630 articles admitted they had lied in their authorship statements13
      Poor evidence leads to poor clinical decisions. A host of organisations has sprung up to help clinicians interpret published evidence and offer advice on how they should act. These too are beset with problems such as production of untrustworthy guidelines,10 regulatory failings,23 and delays in the withdrawal of harmful drugs.24 Collectively these failings contribute to escalating costs of treatment,25 medical excess (including the related concepts of medicalisation, overdiagnosis, and overtreatment)26 and avoidable harm.24

      Developing more trustworthy evidence: the EBM manifesto

      The steps required to develop trustworthy evidence (box 2) have been refined through a series of activities with stakeholders, including seminars, round table discussions, online consultations, and direct feedback. Tackling the problems will take time, resources, and effort. The evidence based medicine community should take responsibility for this. However, it is a vast project that is being led, and will be led, by disparate groups around the world. We hope to focus attention on the tools and strategies most effective at delivering change, so that we can all work together to improve healthcare using better quality evidence. The manifesto document and priorities are a living document and will evolve over time to advocate for trusted evidence for better healthcare. If you want to have your say and join the discussion then visit (http://evidencelive.org/manifesto/).

      Box 2: EBM manifesto for better health

      • Expand the role of patients, health professionals, and policy makers in research
      • Increase the systematic use of existing evidence
      • Make research evidence relevant, replicable, and accessible to end users
      • Reduce questionable research practices, bias, and conflicts of interests
      • Ensure drug and device regulation is robust, transparent, and independent
      • Produce better usable clinical guidelines
      • Support innovation, quality improvement, and safety through the better use of real world data
      • Educate professionals, policy makers, and the public in evidence based healthcare to make an informed choice
      • Encourage the next generation of leaders in evidence based medicine

      August 12 2017

      18:31

      I am opening a private internal medicine practice in Ellsworth, Maine

      I hope to see patients with challenging disorders, those who wish to reduce their medications and/or use diet and lifestyle changes to improve health (especially diabetes and hypertension), and those with illnesses occurring after tick bites, or related to military service or anthrax vaccine.  I will also treat the range of illnesses seen in primary care internal medicine, and I love to work with patients to achieve optimal wellness.

      Throughout my career, I have had patients referred to me who were not helped by standard western medicine. While I cannot help everyone, I often take a unique look at the illness, and have a broader palette of measures to use than most doctors.

      I believe everyone deserves great healthcare, so have made my charges considerably lower than standard rates.  I also offer sliding scale fees for low income patients.  However, in order to make this practice work, I cannot accept any insurance plans, and patients must pay for my services, when services are rendered.

      Appointment may be made at (207) 522-5229.

      July 23 2017

      19:37

      WHO DREAMS UP US FOREIGN POLICY? In Syria, there is no answer that makes sense. Has our foreign policy been privatized?

      from  What the demise of the CIA’s anti-Assad program means

      Washington Post Opinion by David Ignatius
      July 20, 2017


      "What did the CIA’s covert assistance program for Syrian rebels accomplish? Bizarrely, the biggest consequence may be that it helped trigger the Russian military intervention in 2015 that rescued President Bashar al-Assad — achieving the opposite of what the program intended. 
      Syria adds another chapter to the star-crossed history of CIA paramilitary action. These efforts begin with the worthy objective of giving presidents policy options short of all-out war. But they often end with an untidy mess, in which rebels feel they have been “seduced and abandoned” by the promise of U.S. support that disappears when the political winds change..." x
      ... Run from secret operations centers in Turkey and Jordan, the program pumped many hundreds of millions of dollars to many dozens of militia groups. One knowledgeable official estimates that the CIA-backed fighters may have killed or wounded 100,000 Syrian soldiers and their allies over the past four years.  
      "...  The United States didn’t have a political strategy to match the CIA’s covert campaign. “There was no ‘there’ there, in terms of a clearly articulated national security objective and an accompanying strategy,”  said Fred Hof, a former State Department official who has followed the Syria story closely."
      ... Contrast the sad demise of the CIA’s anti-Assad program in western Syria with the rampaging campaign against the Islamic State in the east. What’s the difference? In the east, motivated, well-organized Syrian fighters are backed by U.S. warriors on the ground and planes in the sky. In this game, halfway is not the place to be. 

      August 12 2017

      18:31

      I am opening a private internal medicine practice in Ellsworth, Maine

      I hope to see patients with challenging disorders, those who wish to reduce their medications and/or use diet and lifestyle changes to improve health (especially diabetes and hypertension), and those with illnesses occurring after tick bites, or related to military service or anthrax vaccine.  I will also treat the range of illnesses seen in primary care internal medicine, and I love to work with patients to achieve optimal wellness.

      Throughout my career, I have had patients referred to me who were not helped by standard western medicine. While I cannot help everyone, I often take a unique look at the illness, and have a broader palette of measures to use than most doctors.

      I believe everyone deserves great healthcare, so have made my charges considerably lower than standard rates.  I also offer sliding scale fees for low income patients.  However, in order to make this practice work, I cannot accept any insurance plans, and patients must pay for my services, when services are rendered.

      Appointment may be made at (207) 522-5229.
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