Irrational Nonsense

 

Maternal Mortality Rates In History

Modern maternal mortality in England is now about 98% lower than it was prior to 1935. 

In the pre-industrial era, maternal mortality in child birth was about 0.4%-0.5% per pregnancy, with a lifetime risk of dying in childbirth on the order of 4% (given eight births per lifetime in the early pre-modern era, implying about twelve pregnancies given a typical rate of miscarriages). 

Maternal mortality actually rose in the 1800s and early 1900s during to medical assistance that did more harm than good. It only significantly improved after 1935.

The history of maternal deaths in England from the earliest records in the 1700s to 1935, concentrating on the influence of medical practice, is recounted. The rate lay between 4 and 5 per 1000 until 1935, with the advent of sulfa antibiotics to prevent puerperal infections. 

The practice of midwifery by men began in the early 17th century in Britain, but attendance at normal labors by medical practitioners, that is, surgeon-apothecaries, did not become common, and then only in urban areas, until 1730. The use of forceps became widely known about that time, and lying-in hospitals were begun. Obstetrics was held in contempt by professionally educated and registered physicians and apothecaries, however, because of the immodesty and messiness of the work and the long hours involved. Estimates of maternal mortality, from the 1st recorded unselected series, in the late 18th century range from 5-29/1000. Some of the high figures are from specialists in obstetrics, who treated complicated cases. From these data the maternal death rate was estimated at about 25/1000 among unassisted women. Some institutions achieved results better than the national average in the 1920s, suggesting that by the end of the 18th century, a fairly good understanding of childbirth had been reached. At that time the overall forceps rate was conservative, less than 1% compared to 15% now. Use of the perforator, hook and crochet, and manual dilatation of the cervix had been abandoned. 

In the 19th century, lying-in hospitals became more common and their death rates were higher, probably due to less conservative methods, up to as high as 85/1000, until the advent of antisepsis in 1880. Nevertheless, hospital births were the minority, amounting to 15% in 1927, 54% in 1946, 87% in 1970, 98.8% in 1980. Sepsis, due to casual use of sterile technique, remained the cause of half the total deaths until 1937. 

It is difficult to assess the contribution of toxemia or obstructed labor in maternal deaths. Rickets was a common cause of obstructed labor, and there are recorded epidemics of both. Similarly, abortion-related deaths are even more difficult to estimate, because of poor reporting. In evaluating the undiminished maternal death rate before 1935, the author believes that maternal survival is remarkably resistant to the ill effects of socioeconomic deprivation, but is very sensitive to the good and bad effects of medical intervention. Hence, there is evidence that the rural and poor in some cases had better results that those given the best medical assistance, especially with regard to puerperal sepsis. The midwifery laws of 1902 provided for training of midwives, and slowly corrected quality of care, as well as hostility between midwives and physicians. The current maternal death rate is about 0.1/1000.

I Loudon, "Deaths in childbed from the eighteenth century to 1935" 30(1) Med Hist 1-41 (January 1986) doi: 10.1017/s0025727300045014.

Medical Billing Still Amazingly Abusive

A Sunday New York Time story highlights the fact that health care industry billing practices remain incredibly abusive and bear no meaningful resemblance to the markets seen for other kinds of services.

Somehow, when physicians are involved, it is perfectly O.K. for service providers to bill whatever they want, without entering into a contract agreeing on the price in advance, and without any meaningful connection between the amount charged and the services rendered.

They highlight services rendered by an assistant neurosurgeon in a neck surgery whom the patient never met and had no reason to expect who charged $117,000 for an afternoon's job, when in a Medicaid case, he would have been limited to $800.

It is not so much to ask that health care providers quote a single price in advance and that all bills for a single procedure flow through a single vendor, as it most ordinary markets do.  It is also not much to ask that all bills to insured persons be billed to insurance with the insured responsible only to pay his share to his insurer.  But, this is almost never how it actually works.

Graduate Student Benjamin Hayempour Shows Pattern Of Plagiarism

Benjamin Hayempour is apparently a graduate student in Oxford in radiation biology working towards a PhD and doing his best in a publish or perish academic climate to get ahead.  Unfortunately, it appears that he has engaged in serious academic misconduct while doing so. [Ed. Correction: based upon his e-mails to me, he appears to be a graduate student at the UC Berkeley Department of Engineering and UC San Francisco School of Medicine, despite indications from other online sources that he was at Oxford, perhaps a past affiliation.]

A paper that he was a co-author of from 2011 entitled “Neuroradiological advances detect abnormal neuroanatomy underlying neuropsychological impairments: the power of PET imaging,” was retracted because of "unexplained close similarity of some passages to parts of a previous publication" (i.e. possible plagiarism), and the blog Retraction Watch noted this fact in a blog post.  

Benjamin Hayempour alleges that he played only a minor almost clerical role in preparing the paper, yet, he is listed as the corresponding author for the paper and his co-author is the one who requested the retraction claiming that he was unaware of the plagiarism.

Hayempour hired inexperienced Los Angeles real estate lawyer Eyal Aharonov to write a cease and desist letter directing Retraction Watch to retract its truthful and factual coverage of the retraction notice or face a lawsuit for defamation (the legal basis for the threatened suit wasn't clear).  

This triggered the Streisand Effect, i.e. "the phenomenon whereby an attempt to hide, remove, or censor a piece of information has the unintended consequence of publicizing the information more widely."  After learning of the groundless legal threat, readers of Retraction Watch tried to determine if any of Benjamin Hayempour's other published work showed evidence of academic misconduct or deceit on his part.

The readers of Retraction Watch found a great deal when they dug around a little more into the situation and found a lot of troubling additional facts.

(1) According to one RW reader, On his linked in profile (no longer public or since edited) Benjamin Hayempour claimed that: 

Even though he just started as graduate student, he is editor-in-chief of a journal: “Journal of Nuclear Medicine and Radiation Therapy” and is on the editorial board of three other journals: Journal of Neurological Disorders 

The Journal of Alzheimer’s Disease & Parkinsonism 

Journal of Family Medicine and Medical Research.

All of which are published by OMICS Publishing Group, which has a reputation with another RW reader as something of a hybrid of a vanity publisher and diploma mill.  While this is not illegal, it is certainly unethical morally and reflects poorly on the integrity and honesty of anyone involved in the venture.  It manifests a clear intent to blatantly deceive third parties presented with these articles about the significance of these publications.

(2) RW Readers note in the comments to the posts linked above, very similar plagiarism problems in seven other papers listing Benjamin Hayempour as an author including:

* “Biological Imaging Instrumentation…” J Nucl Med Radiat Ther. 2013 Jul 20;4(3). doi:pii: 1000157

*  “Should Antidepressants be our Choice of Treatment?”

*  “The Controversy of Conventional Psychiatric Diagnostics”

*  “Clinical Medical Physics Methods in Radiotherapeutic Cancer Treatments”

*  "Brain Disorders: Evaluation by Radiological Techniques and Nuclear Medicine of the Primitive Neuropsychiatric Disorders."

* J Psychiatry Law. 2011 Winter; 39(4): 537–566.

* "Neuromolecular Imaging Instrumentation Demonstrating Dysfunctional Brain Function in Schizophrenic Patients" (2013)

Benjamin Hayempour, rather that admitting wrongdoing as he participates in the discussion tries to argue that he believes that the many instances cited (sometimes despite several long plagiarized passages in a single paper) that his conduct was considered acceptable academic practice when writing review papers.

Eight papers in just a few years with plagiarized passages, dubious claims of editorial roles in four diploma mill journals including an "editor-in-chief" claim, a refusal to acknowledge wrongdoing when presented squarely with black and white evidence of his misconduct, and a doubtful claim that the authors of the RW blog misquoted him despite support in contemporaneous notes of a conversation about what was said all point to an obvious conclusion.

I used to be a full time associate professor in a master's degree program at the for profit "College for Financial Planning" which developed the Certified Financial Planner designation, and later became a sister college of the for profit 'University of Phoenix" system.  Not a particularly prestigious post within academia, to be sure.  

But, even in that little outpost, I would have immediately assigned an "F" grade to any paper from a student that had instances of unattributed quotation from another source of the type illustrated by Benjamin Hayempour in all eight of the papers identified by RW or its readers, and would have expelled him from the program with a negative academic dishonesty reference if I ever saw that kind of behavior repeated even a single time.  The plagiarism examples present in those works are easy and clear cases of intentional academic misconduct, not gray areas.  Any college sophomore would be expected to know better, and Hayempour's academic credentials are from schools where knowledge that this is not acceptable academic conduct is widespread.

The fact that Benjamin Hayempour felt the need to hire a lawyer to try to cover up and intimidate people who were revealing Benjamin Hayempour's academic misconduct with threats of defamation lawsuits that have no substantial justification also tends to indicate an awareness on his part of just how damaging the truth would be to his reputation.

In my opinion, Benjamin Hayempour has engaged in a widespread, intentional pattern and practice of academic misconduct and plagiarism that no reasonable graduate student at Oxford University could have possibly been unaware was improper, and certainly conduct that no one who was legitimately Editor-in-Chief of an academic journal could possibly believe was acceptable.  He did so, apparently, for the purpose of inflating is academic reputation and professional credentials.  And, in my opinion based upon this evidence, deceit is so second nature to him that he may very well be irredeemably some sort of psychopath, or just a habitual liar and con man. 

He claims ignorance, a desire to fix his past mistakes, and so on.  But, there are simply too many implausible statements in his reactions to the accusations against him, and too many blatant instances of conduct that couldn't be anything other than intentional, to make his statements believable.

The only just sanction for this kind of widespread academic misconduct, in my opinion, would be to expel him from his program at Oxford with a bad recommendation reflected on his transcript, together with a termination of any scholarships or stipends, to retract all eight of these papers and to investigate all of his other published work for similar misconduct, to revoke any professional certifications that he has obtained to date, and to advise the appropriate officials at the National Institute of Health of the academic misconduct that he engaged in when doing work funded by one of their grants.

No responsible educational institution, professional regulatory body, or employer could continue to keep him on in any capacity where integrity or honesty was required.

Neuroskeptic and others in the blogsphere have similarly noted Benjamin Hayempour's academic misconduct which otherwise might have gone unnoticed.

So, there you have the story of Benjamin Hayempour's pattern of plagiarism.

Footnote: Eyal Aharonov, an incompetent rookie lawyer

Of course, it is also the story of his lawyer Eyal Aharonov's gross incompetence and professional malpractice in handling the situation.  Aharonov's bad advice and ill drafted cease and desist letter has made the situation a hundreds or thousands of times more damaging to Benjamin Hayenpour's reputation than it otherwise would have been.  Aharonov's actions have probable turned a minor hiccup in Hayenpour's career into a situation that will probably destroying Benjamin Hayenpour's career prospects for life, deny him any hope of ever becoming a doctor or a professor, and thus may cost him millions of dollars in lost income over the decades.  Aharonov's bad judgment may also expose Benjamin Hayenpour to a substantial risk of sanctions and anti-SLAPP law penalties such as the attorneys' fees incurred by people who he sues (if he does).

As a lawyer, one of your first priorities had to be to act in a way that does not call more attention to the myriad instances of misconduct that your client has committed.

Aharonov is slightly more sympathetic, as he has apparently been dumped into self-employment as a lawyer more or less right after graduating from a second rate law school (Pepperdine), and has only had a couple of years of experience without the kind of post-law school mentoring necessary to develop good judgment.  But, on the other hand, I was in more or less the same boat when I finished law school and somehow managed to avoid harming any of my clients so seriously with my own incompetence.

Still, Aharonov's mistakes were merely a product of incompetence and don't reflect all that badly on his integrity.  Most junior lawyers, with enough experience and guidance can learn not to repeat catastrophic mistakes like the one he made in this case.  And, he is probably too broke to be worth suing for malpractice at this point.  If you must screw up, it is better to screw up when you are poor, than to screw up once you have accumulated substantial wealth.

Meanwhile, I have no doubt whatsoever that the Retraction Watch blog will be fully vindicated in this dispute.

UPDATE 3/27/2014:  This post was the subject of an improper DMCA takedown notice.  More than fourteen days have passed since I was notified that a DMCA counterclaim was served and no federal lawsuit has been filed regarding this post in the appropriate forum.  Therefore, I am republishing it.  Further discussion of the takedown notice drama and comments re further plagarism by Hayepour can be found here.

UPDATE 4/06/14:  As noted in the related post, I got the official notice of the all clear in the wake of the takedown notice and my counterclaim only on April 4, 2014, more than two months after the original take down notice, although I had already restored it a week earlier, once fourteen days from acknowledgement of receipt of my counterclaim passed without incident.  Thus, the takedown and reinstatement process actually takes about nine weeks, rather than the two weeks it should take in theory, for a blogger post takedown.  Since then, there have been twists to the underlying story, in addition to the metastory told at the companion post.  The following comment was made anonymously at the metastory post and is included her because it relates to the original post:

"BTW, I though you might be interested to learn that Ayden Jacob (aka Hayempour) is still plagiarizing.

(also posted to RetractionWatch)

---------
Hayempour (now going by Ayden Jacob) is *STILL PLAGIARIZING*. I admit to being stunned, but there we go...

Ayden's new website contains the following two sentences:

"Using patented nerve monitoring technology, the surgeon gains lateral (side) access to the spinal column, avoiding any major nerves in the area between the incision and the column. The XLIF procedure does not require an anterior (front) or posterior (back) exposure, and thereby does not present the same risks of vascular and/or neural injury as traditional approaches."

(from http://www.aydenjacobmedicine.com/orthopedic-surgery.html , archived here: http://archive.is/c0lYJ )

They are copied, word-for-word, from http://www.nuvasive.com/patient-solutions/nuvasive-surgical-solutions/extreme-lateral-interbody-fusion/ (archived here: http://archive.is/6fiyx ).

There is no citation, no quotation marks, not even a link to the site he stole from.

He learned *nothing*.

3/19/2014 3:27 PM "

Benjamin Hayempour, has identified himself as "Ben Jacob" in some of his correspondence to me. So both "Ben Jacob" and "Ayden Jacob" appear to be aliases of Benjamin Hayempour.

ICE "Beyond Cruel"

The immigration system has no natural advocate for immigrants in the political system, and as a result, has developed a culture of indifference. The results are sometimes deadly, as the U.S. District Court notes in recent court ruling finding in favor of the survivors of an immigrant in a suit against the federal government and the involved federal officials, which the government parties moved to dismiss.

The Facts

The Court recounts the facts, which are well documented -- most come from documents disclosed by the federal government, and the remaining relevant facts are corroborated by third party medical records:

On March 27, 2006, Plaintiff Francisco Castaneda – an immigration detainee – informed the Immigration and Customs Enforcement (“ICE”) medical staff at the San Diego Correctional Facility that a lesion on his penis was becoming painful, growing in size, and exuding discharge.

On site doctors contacted "the Division of Immigration Health Services (“DIHS”), requesting approval for a biopsy and circumcision" because there was strong concern that the problem was penile cancer. It was denied, were further efforts to have that decision changed.

Plaintiff has submitted thirty-three exhibits of Defendants’ own official medical records documenting their knowledge of the fact that several physicians had concluded that Plaintiff’s lesion was very likely penile cancer, and that he needed a biopsy – a straightforward procedure – to rule cancer out. These documents show that nevertheless, Defendants refused to grant Plaintiff this simple procedure for almost eleven months, even while they noted that his pain and suffering were severe and increasing, that his penis was emitting blood and discharge, and that a second growth had developed. Therefore, if Plaintiff’s evidence proves true, from the first time Castaneda presented with a suspicious lesion in March 2006 through his release in February 2007, the care afforded him by Defendants can be characterized by one word: nothing.

As a result he suffered “'ten months of pain, bleeding, anxiety, loss of sleep, and humiliation while in ICE’s custody, the amputation of his penis, and nearly a year of grueling chemotherapy,' not to mention his eventual death." . . .

As the opinion notes (citations to the record omitted):

[A] biopsy was finally scheduled for early February. However, a few days before the procedure, Castaneda was abruptly released from ICE custody. Castaneda then went to the ER of Harbor-UCLA Hospital in Los Angeles on February 8, 2007, where he was diagnosed with squamous cell carcinoma. His penis was amputated on Valentines Day, 2007. . . . Harbor-UCLA confirmed that Castaneda had metastatic cancer. Castaneda began undergoing chemotherapy at Harbor-UCLA. However, the treatment was not successful, and on February 16, 2008, Mr. Castaneda died.

The Court's Analysis

The Justice Department argued (among other points) that the immigrant detainee had not alleged enough to state a claim against the government at all. In response, the Court ruled that:

The evidence that Plaintiff has already produced at this early stage in the litigation is more thorough and compelling than the complete evidence compiled in some meritorious Eighth Amendment actions. . . . the evidence suggests that not only did the individual Public Health Service Defendants ignore doctor recommendations to provide Castaneda with a simple procedure, they may also have lied about those recommendations.

The Court concluded by noting that:

If Plaintiff’s evidence [Ed. consisting almost entirely of federal government documents produced by the government] holds up, the conduct that he has established on the part of Defendants is beyond cruel and unusual.16

FN 16: After all, Plaintiff has submitted powerful evidence that Defendants knew Castaneda needed a biopsy to rule out cancer, falsely stated that his doctors called the biopsy “elective”, and let him suffer in extreme pain for almost one year while telling him to be “patient” and treating him with Ibuprofen, antihistamines, and extra pairs of boxer shorts. Everyone knows cancer is often deadly. Everyone knows that early diagnosis and treatment often saves lives. Everyone knows that if you deny someone the opportunity for an early diagnosis and treatment, you may be - literally - killing the person. Defendants’ own records bespeak of conduct that transcends negligence by miles. It bespeaks of conduct that, if true, should be taught to every law student as conduct for which the moniker “cruel” is inadequate.

Particularly culpable in the Court's summary of the records was Esther Hui, M.D. at the Division of Immigration Health Services who played a central role in overriding the medical judgment of the treating physician and denying care despite having detailed knowledge of the case and the medical skills to evaluate that information.

Also troubling was the conduct of Claudia Mazur, a DIHS nurse, who appeared to have lied about what the doctor's had recommended in a denial report of October 26.

As the Court explains, this was essentially a case of murder by spreadsheet (citations to the record omitted):

Dr. Hui and the DIHS included this false characterization in official reports despite the fact that a TAR recognized that both doctors “strongly recommend admission, urology consultation, surgical intervention via biopsy,” and despite that fact that [Ed. treating] Dr. Wilkinson reported that he had spoken to “the physicians at the correctional facility” and “[t]hey understand the need for urgent diagnosis and treatment.” Indeed, Dr. Hui herself recognized in a report that Castaneda might have cancer but “[s]ince this is an elective outpatient procedure, we decided that we would not admit him [to the hospital to have the procedure] at this time.” Plaintiff’s evidence also suggests why Dr. Hui was so interested in characterizing the surgery as elective; “as such the Federal Government will not provide for such surgery.”15 Plaintiff has thus submitted compelling evidence that Defendants purposefully mischaracterized Plaintiff’s medical conditions as elective in order to refuse him care. Dr. Wilkinson reported that Defendants refused to admit Castaneda to the hospital for a biopsy because they wanted a “more cost effective” treatment. Official records document Defendants’ circular logic that because they would not allow him to have the biopsy, “he DOES NOT have cancer at this time”; because he does not have cancer, he therefore does not need a biopsy. In other words, as long as they could label Castaneda’s condition elective, Defendants could remain willfully blind about his lesion and avoid having to pay for its treatment.

FN 15 The Court has serious questions as to the constitutionality of a policy of refusing to pay for all medical treatment that can be characterized as “elective” because, as evidenced by this case, the label fails to identify accurately who needs care. DIHS labeled the treatment in this case “elective” even while acknowledging that Castaneda’s condition was so “severe” that he would need a “resection” - full or partial removal of the penis. Indeed, Plaintiff’s evidence suggests that Dr. Hui defined “elective” so broadly that she believes the term to encompass life-saving treatment.

Harvard's Medical Malpractice Case Study

The Harvard School of Public Health did a study of medical malpractice cases published in Thursday's New England Journal of Medicine (abstract here).

Many of the lawsuits analyzed contained no evidence that a medical error was committed or that the patient suffered any injury, the researchers reported. . . .

[T]he Harvard researchers reviewed 1,452 malpractice claims randomly selected from five insurance companies. The cases were resolved -- meaning they ended in a verdict, a settlement or a dismissal -- between 1984 and 2004.

The claims resulted in a combined $449 million in verdicts and settlements.

The researchers examined medical records, depositions and court transcripts to determine if the patients were injured and whether the injury was due to a medical error.

It found that 97 per cent involved a severe disability or death, while 3% involved no verifiable medical injury. Note that some medical malpractice cases, those involving indignity to the patient causing only emotional harm (such as circulating embarassing photos of a person secured in violation of medical ethics around a medical office, for example), would probably not count as a verifiable medical injury for purposes of the study, nor would some cases where pain associated with a soft tissue injury was the only reported harm.

Only 6 cases in the sample were found by the researchers to involve no verifiable medical injury, and yet still resulted in some compensation to the patient (84% were dismissed without any compensation payment), and some of those payments could have been token payments only.

It found that 27% were dismissed without any judgment or settlement payment to the defendant in cases that the researchers felt lacked merit, that 10% resulted in a judgment or settlement payment in a case that the researchers felt lacked merit, that 46% involved medical mistakes causing injuries and were settled or resulted in judgments, and that 17% of cases were found to involve medical mistakes causing injuries and were dismissed.

Thus, the current system is roughly accurate only, and appears to be biased against patients as it dismisses meritorious cases more often than it pays cases where the researches found no evidence of a medical mistake or no injury.

Some of the cases the study viewed as not involving medical mistakes, however, cast doubt on the methodology used by the researchers. For example:

In one instance, a young woman with no family history of breast cancer underwent routine breast exams for four years and came back with a clean bill of health.

But doctors later found she had breast cancer that had spread to other parts of the body.

The researchers determined the case did not involve medical error because proper procedures were followed. The woman filed a malpractice claim and received an undisclosed settlement.

In a case like that one, of course, there is not going to be any documentation that one or more of the breast exams was conducted improperly, but it is nevertheless reasonable, indeed likely, that in fact, one or more of the exams was improperly conducted because it would be unlikely for breast cancer to reach such an advanced state in the course of one year. An absence of direct evidence does not always, or even often, mean that a mistake was not made by the medical professionals involved. Indeed, in any failure to diagnose case, the absence of documentary or testimonial evidence of a mistake can itself be damning. Fault is a slippery thing.

One suspects that procedural mistakes by the patient's counsel and failures to meet the statute of limitations requirements would be common causes for dismissals of meritorious claims, although jury decisions are also relevant.

Medical malpractice attorneys are not dumb, and medical doctors are less likely to settle cases where they don't feel that they have done something wrong than any other kind of defendant in my experience, in part, because the settlements can't be truly confidential due to regulatory requirements. The study states that the average settlement in cases where there was no identified medical mistake was $313,000, and in truth, smart doctors and attorneys don't pay that kind of money in truly groundless and frivilous cases. Cases found by researchers to involve both injuries and mistakes resulted in larger payments (an average of $521,560), however, which indicates that close cases require both sides to recognize that they are not slam dunk cases.

With regard to administrative costs the study found that:

For every dollar spent on compensation, 54 cents went to administrative expenses (including those involving lawyers, experts, and courts). Claims involving errors accounted for 78 percent of total administrative costs.

This shows that defense efforts in cases of genuine injury are responsible for far more litigation costs than groundless or frivilous cases.

According to the abstract: "Overall, claims not involving errors accounted for 13 to 16 percent of the system's total monetary costs." This would involve both settlement payments and administrative costs. According to the absract, about claims not involving errors according to the study accounted for 22% of administrative costs, that administrative costs were 54% of the total, and that 13-16% of total monetary costs went to cases not involving errors according to the study. Thus, contrary to the media report, only 2-11% of total settlement payments and judgments went to cases which the study found to not involve errors.

When only about 5% of compensation payments went to people who weren't injured or to cases where there were no injuries, that isn't bad at all.

The study also shows that a strict liability system, which would provide full compensation to any suffering from a serious medical injury, regardless of whether or not the doctor was at fault, and thus dramatically reducing the amount of administrative costs involved in handling claims, would cost doctors no more than what they are paying now, while providing compensation to many more people than the existing system does, including the one in six people who now bring meritorious claims only to have them rejected by the legal system.