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Cigarette taxes So what do increased cigarette taxes really do? Supply-Side Smokers: New York City is about to learn the cost of high cigarette taxes. This is a very well considered opinion piece about the recent New York City cigarette tax increase. (Registration required - but free) Posted byQuicker generic availability FTC Seeks Generic Drug Delay Limits
Hopefully, this recommendation will allow faster entry of generics into the market. Posted byThe war on drugs I did not watch this report last night, but the text makes sense. John Stossel has defined the problem in a way that I like. Just Say No: Governments War on Drugs Fails
This should remind us of prohibition. That worked just as well. The article goes on to consider the Dutch experience in legalizing marijuana. They have seen a drop in adolescent pot smoking. This story should make us think. While drugs can devastate lives, how many more lives are devastated by their illegality? This question should boil down to logical trade offs - risks and benefits of legalization. It seems like a 'no brainer' to me. Posted byPreventing diabetes This will take resources. I hope we understand that investing in prevention of diabetes will save future medical expenditures. Pre-Diabetes: Are You at Risk?: Interventions Can Keep Those with Pre-Diabetes From Developing Full Disease
One should not wait until given a pre-diabetes diagnosis. Diet and exercise can help us all. Posted byA good political idea As a physician, Senator Frist champions medical care. He also champions prevention. Senators Take Up Arms Against Obesity.
While I generally oppose government solutions, government funding can stimulate great research. On the surface this sounds like a well placed effort. Posted byBad news for insurers, good new for trial lawyers This leaves me in a quandry. The managed care organizations are (in my opinion) responsible for much malaise in physicians, and responsible for lower quality care (although admittedly I cannot prove that). The trial lawyers ... well you know how I feel about the trial lawyers. Health Insurers Lose Bid on Case Records. Posted by Will the fat lady sing? Or as Yogi once said, 'It ain't over until it's over'. The Senate will apparently try again today. I won't bore you with the details unless the bill passes - Big Senate Vote on Medicare Drug Benefits Is Set for Today. Passage is doubtful. Posted by9 miners and cost effective medicine What a feel good story! By now everyone knows of the amazing rescue of 9 Pennsylvania miners over the weekend. After so many heart wrenching stories, this one made the whole country smile. Fortunately, the decision to rescue the miners was not controlled by considerations of cost effectiveness. Medical care costs money. We can improve the quality and quantity of life for many patients. Primary prevention works for many problems (colon cancer,hypertension, hypercholesterolemia, adult onset diabetes, skin cancer). Secondary prevention works for coronary artery disease, congestive heart failure and diabetes mellitus (these come quickly to mind). Yet many medical decision come under the scrutiny of cost effectiveness. I have published papers on cost effectiveness. I find the subject intellectually fascinating. As a researcher, I understand the limitations of the technique. The key to understanding cost effectiveness comes from both words. We want to understand what benefit (effectiveness) we get for what cost. Cost effectiveness studies require estimates of costs and effectiveness, and often those data are not readily available. Recently, the US Preventive Services Task Force published their analysis of colo-rectal screening Screening for Colorectal Cancer: Recommendation and Rationale
Note two things. The USPSTF considers cost-effective as less than $30,000 per additional year of life gained. They are worried about the cost of colonscopy. Ask any gastroenterologist which one he/she would have. I believe that the cost issues prevented a strong endorsement of colonoscopy. Was the miners rescue cost effective? Did anyone ask? What makes medical care different? In times of crisis, our society ignores cost to save lives. Our understanding that we should expend such effort to save lives defines our country (in a very positive way I think). What is it about medical care that escapes this understanding? Why can politicians complain about costs of health care? I do not understand. I'm happy for the miners and their families, but frustrated over how Medicare and insurers fund health care. What about the value of life do I not understand? Since ranting this morning, while working out, I have thought about this piece. Just to clarify, I'm concerned that we think clearly how we prioritize medical spending. We should not use arbitrary methods, but rather clearly understand the trade-offs. If life has great value to our society (and all evidence that I see demonstrates that as true), then we should value patient's lives the same as accident victims lives. We apparently do not, and that is the point! Posted byValue of whole grains Recently, Medical Rants has focussed much attention on diet. This article summarizes a study about the value of whole grains in ones diet. Whole Grains Can Help Cut Insulin, Cholesterol
This study adds to a growing perception that refined carbohydrates are the bad actors. My wife has only provided whole grain foods for year. She has a point. I have now read the study. I am less impressed by the study than the news article. Often the press generalizes most results. I found this paragraph interesting
Perhaps the keys are dietary fiber and magnesium. Since this study depends on self report of diet, and has all the problems of epidemiologic studies, I would urge caution here. We call such a study 'hypothesis generating'. It does NOT answer the question. Posted byThe Lean Plate Club One Year Anniversary I really like this series from the Washington Post - A Year of Lean Living -- Together: Lean Plate Club Members Encourage One Another in Their Adventures in Good Nutrition Posted by The BMI controversy I continue to have a goal of getting my BMI to less than 25. I started at around 28. I'm stuck at around 25.2. Over the past 6 months my body fat decreased from 23% to 18% (measured by fat calipers). Weight lifting and a great personal trainer have made this possible. I am not overweight by body fat criteria; most people think I'm in very good shape, but technically I'm still 2 pounds overweight. This self revelation highlights the point of this article - Who you calling fat?
I consider BMIs between 25 and 29 and opportunity to discuss diet and exercise with patients. I should probably add fat calipers to my obesity screening. Knowing one's percentage of body fat is often chilling. Few with a BMI over 29 are just too muscular, and I do not need calipers to recognize them. Nonetheless, we may hear more abou this controversy. Posted byExercise helps adolescents also Budgets cuts have decreased the former emphasis on physical education in schools. Some have argued that physical education was not important for students. I would argue that we have a chance to create life long habits of exercise. I stole this idea from those who are trying to do that. Regimens: When P.E. Class Includes Exercise Posted by Osteoarthritis risk factors Physicians see these patients every day. Drug companies advertise to them constantly. Osteoarthritis plagues millions in this country. Jane Brody has written a beautiful summary of osteoarthritis today - Arthritis: Your `Reward' for Wear and Tear.
Read the entire article, and you may want to print it for patients. I never knew exactly what to say to the 250 pound, 5 foot 3 inch woman who complained that her knees hurt. She thought I had a magic pill that I was hiding from her. Could this article have helped? ... Nah Posted byLosing money on vaccinations I hope my economist friends read this one. Maybe they can explain it with the 'dismal science'. Doctors knock Medicare vaccination payments as too low: CMS' refusal to increase immunization pay rates may hurt chances of reaching Healthy People 2010 goals.
Medicare pays just over $3 for flu, pneumonia and hepatitis B vaccination. The vaccines cost much more than that. Medicare gives one payment, they do not take into consideration the cost of the vaccine, nor the supplies needed. And they have the audacity to consider vaccination rates a quality indicator. I wish I were confused about this, but it is very clear, and very unfair. Posted byAbout my blog Medical Rants started about 2 months ago. I spent some time this weekend thinking about the blog, why I blog, and what I hope to accomplish. As you can see I have nice new digs, and I also want to comment on those. Generally, I view myself as better at oral communication than written communication. My comfort zone comes on rounds, giving talks, and morning report. Speaking spontaneously feels comfortable. I never feel as comfortable when writing. Writing is more permanent, requires more thought, and is more easily dissected. Writing takes time. I have wanted to improve my writing, and have searched for the right place to practice. Earlier this year, I discovered blogging. I do not remember the first blog that I read. I do remember that the concept intrigued me immediately. I found Blogger, figured 'what the heck', and started blogging. But I did not really know what to blog about. My rookie blogging was very boring, even to me. I was not sure that blogging was my thing. Then I read Medpundit. Eureka! I had a role model. Time to blog about my passion - medicine. I seem to remember reading advice on writing. Write what you know. The best way to improve your writing is write everyday. I had a forum. I had a place to practice. And, if nothing else, I would enjoy the daily research involved in staying up to date on medical issues. This blog does not have a grand plan. I browse the web and look for stories that grab my attention. I rarely write about bioterrorism. The pharmaceutical industry grabs my attention. Fitness and weight loss have become a passion, so I concentrate on those issues. Medical advances intrigue me. I like reading the latest articles, and trying to put them into perspective. As my blogging became a daily passion, I wanted a better web page than Blogger could provide. Blogger is a very good site, and allows one to start blogging almost instantly. But I wanted to improve my site, mostly for myself. I wanted searching capability. Often I have written a piece and want to find it quickly. Adding searching helps me find the piece that I want to look over. I did not realize that I was going to be able to use categories, but have found that a nice touch. Already some readers are using the comments section. Comments keep me honest, make me think and force me to write more clearly. Thanks and kudos go to Sekimori. Stacy and especially Robyn (what a great design job she did [db claps enthusiastically] and how easy and smooth she made my transition) have my thanks and gratitude. I am personally very happy with the new site, and feel that it adds to my personal project. Thanks for visiting and commenting. I probably would continue to blog now even if I had no readers. But it certainly is more fun when you know a few readers enjoy what you say, and you induce thinking! Posted byMedpundit on drug pricing As I have come to expect, medpundit has written an excellent piece on drug pricing. Her numbers are chilling; her reasoning sound. The Sky’s the Limit: Posted byOsteoarthritis of the knee and obesity A British study will try to prove what we believe. Obese patients to diet for science Actually, they have an interesting hypothesis to test.
This is an interesting study design. I will be interested in the results, and especially at their success rate. Can we do a better job motivating patients and helping them lose weight and become more active? We probably should do many such studies. Posted byMore on diet - decrease grains We have our new diet philosophy emerging. Decrease grains, maybe even whole grains. Rethinking Our Daily Bread: As obesity and diabetes soar, some U.S. nutritionists and researchers back off from pushing pasta and rice. The emphasis is on vegetables and fruits. This article present a well balanced discussion of this current nutritional controversy. Few would argue with the mantra of increasing fruits and vegatables. Posted byEven more on estrogens The dust settles. Decision making replaces reflex actions. We reflect and put the latest data into perspective. Doctors Working To Clear the Fog Of Hormone Study is a good read, and makes the right points. Posted byMedicine as fashion I often give an impromptu talk on rounds about how medicine has changed since I graduated from medical school (class of 1975). We laugh about many things that I was taught. We marvel at the advances. As I share my personal view of medicine over the past 25+ years, I am often amazed at the advances, but also at our naivete. Ann Patchett, writing in the New York Times Magazine, has written an essay - Estrogen, After a Fashion - which mostly looks at how estrogen use has changed over the years. Embedded in that discussion, she makes some very important observations. What we want is for medicine to be a science. We want competent, well-informed doctors to give us consistent answers based on exhaustive research. We want them to be right. But medicine is a peculiar combination of science and fashion, half penicillin, half shoulder pads. It takes what is known at the moment, combines the knowledge with what the consuming public wants and comes up with a product. One doctor endorses the product, and while you can always go for a second opinion, it's hard to stop at just two, especially when the opinions turn out to be in direct conflict with one another. Read the papers. One doctor says to discontinue Prempro immediately. Another says more studies are needed and what we're facing is a massive overreaction. In the end it will be up to you, who never went to medical school, to make the decision your life may depend on, and while there might not be one definitive right answer, you can bet on the fact there are plenty of wrong ones. She has much more to say, and even comments (from a consumer perspective) on pharmaceutical direct to patient advertising. Posted byDoing the right efficacy studies This week Jane Galt and I have had a stimulating discussion - Discourse with Jane Galt. Many interesting issues have arisen, and today I would like to focus on knowledge. The chief of Cardiology discussed Congestive Heart Failure (CHF) at this week's Medical Grand Rounds. During his presentation, he discussed a variety of medical devices available for managing severe CHF. He made an important observation when he pointed out the the device manufacturers had no interest in funding studies which carefully delineate which patients should benefit from a particular expensive device. They would rather show efficacy, and do not apparently mind if physicians implant excess devices (two examples include automatic implantable cardioverter defibrillators (AICD) and atrial synchronous biventricular pacing (ASBP)). Each of these treatments cost approximately $30,000 per patient. We know that in carefully designed studies and carefully selected patients these devices work, improve quantity and often quality of life. We do not know the proper indications for the devices. For ASBP in particular, data suggest that not all patients benefit. Cardiologist would benefit from studies which examine predictors of efficacy. The device manufacturer will not fund these studies, and given our current regulations they have no such obligation. Economic advisors would tell them not to limit the potential market, and the right efficacy study would limit their market. Thus, the economic incentives for society (use these expensive devices only in those patients likely to benefit) clash with the economic incentives for the device manufacturer (sell as many devices as feasible). A naive response comes to mind. Let the NIH fund the study. But the NIH (actually in this case the NHLBI) will probably not fund that study, stating that they have higher priorities for their research dollars. Medicare rarely funds such studies - their bureaucracy does not seem to understand the importance of efficacy studies. Let me switch to a pharmaceutical example. Adult onset diabetes mellitus causes more kidney failure than any other disease in the United States (and probably the world). We have learned much about the onset and progression of kidney disease in diabetic patients. We know that very small amounts of protein in the urine predict eventual kidney failure. We have learned that we can both decrease the amount of protein in the urine (without treatment these small amounts become grams of protein) and delay or even prevent the onset of kidney failure. Recently published studies (for those interested, I have a slide series available from a talk I gave on this subject last year - Update in Nephrology) have documented both a decrease in urine protein and delayed progression of kidney disease. The studies that I cite in that talk all used a class of antihypertensives called angiotensin receptor blockers (ARBs). Of interest, earlier research in patients with childhood type diabetes used angiotensin converting enzyme inhibitors (ACE-Is). The firms that produce ARBs funded the recent studies. They have not, and likely will not fund studies to compare ARBs and ACE-Is. The ACE-I manufacturers will not fund any studies, because those drugs are nearing their patent expiration (at least 2 of that class have available generics, and that number will increase soon). One would expect that the ACE-Is should work as well as the ARBs, but how can we find out? One could easily design that study, but such studies are very expensive. No manufacturer has a financial incentive to fund the desired study, and the NIH apparently will not fund such a study. We need a new mechanism to insure that we fund important clinical studies. The current system works only when it benefits the manufacture or the issue is so large that the NIH funds the work. Therefore, I make this modest proposal. We should charge a research fee to device manufacturers and pharmaceutical manufacturers. I have not worked out whether a fee or a research tax makes more sense. We would then have moneys to fund efficacy studies. An expert clinical panel would prioritize proposed studies, and fund them in order until that year's moneys expire. This would allow us to do the right studies. I suppose that this idea has many flaws. It seems too simple to work. What do you think? How important are efficacy studies? Can we fund the right ones? Posted byBrave new fruits and vegetables? Pejmanpundit clued me into this article - Just What the Doctor Ordered. This article discusses genetic engineering of corn, tomatoes, etc. as factories for a variety of proteins even vaccines. Posted byAthletes and heat stroke - are supplements to blame? While I encourage exercise to everyone I know (and many I do not know), exercise and hot weather do scare me. Living in Alabama, we know heat. Anecdotes suggested that heat strokes (especially in summer football) had increased recently. We were interested in the perception that there were more deaths related to heat stroke in football in recent years, Dr. Julian Bailes, a neurosurgeon and team doctor at West Virginia University who led the study, said in a telephone interview.This team doctor believes that supplements are the problem. Writing in the journal Neurosurgery, Bailes and colleagues said deaths from heat stroke were nearly eliminated from U.S. football by 1985 because coaches and managers came to realize that players had to be kept supplied with water. He may be right. I rant often about the supplement industry. How do they stay unregulated? How many patients suffer from these snake oil salesmen? Posted byUnderstanding h. pylori Ulcer disease fascinates me. As a medical student and resident, the most common surgery at our VA Hospital was the Bilroth II. Stress and hyperacidity caused ulcers. Over the next decade we had the emergence of H2 blockers, which greatly decreased ulcer surgeries. Soon thereafter, we had the first proton pump inhibitor. And then this iconoclast - Barry Marshall (Smug as a bug ) figured out and proved that a bacteria caused most ulcer disease. This discovery has revolutionized our care of patients with peptic ulcer disease. Many questions remain, as h. pylori remains a risk factor for gastric cancer, and probably has other important implications. This fascinating article describes new work on how h. pylori lives in the stomach. Apparently this gives us hope for a vaccine. This many represent a very important medical science advance. Study may show how to knock ulcer bugs for a loop Posted bySenate persists on drug plan Being a doctor makes so much sense. Being a politician ... The posturing has occurred; the political points made; now the compromising begins. Apparently, we do have a reasonable chance for Medicare drug benefit - Senators Scale Back Drug Proposal. Did we not really know this all along? The compromise is a retreat from Democrats' longtime push for a comprehensive benefit that covers all senior citizens. But it also omits Republicans' push to have a plan that relies on private insurers. The compromise calls for a benefit administered through Medicare, according to one Senate Democratic aide, who spoke on the condition of anonymity. We are probably getting to the right place. Those senior citizens who can afford the medications do not need our subsidies. The poor need our help. I wonder if the plan could actually save some money. How many preventable hospital admissions come from financially induced drug non-adherence? Whether that speculation makes the true amount smaller, a compromise plan seems the right thing. More this week. Posted byLike a phoenix Rising from the ashes of the twin Medicare plan defeats, some Senators are trying to resurrect the issue - Medicare Drugs for Those in Need Sway Democrats in Senate. The bipartisan compromise emerging in the Senate would provide comprehensive Medicare coverage of prescription drugs for people with incomes under 150 percent or 200 percent of the federal poverty level. (The poverty level is $8,860 for an individual and $11,940 for a couple.) Medicare would also cover 90 percent of prescription costs exceeding $4,000 a year for any beneficiary, regardless of income. All beneficiaries could obtain drug discounts of the type already available to many people who receive private health insurance through their employers.Posted by I hope they both lose Sometimes you witness a competition and you root against both sides. This suit epitomizes the problem with dietary supplements - Andro firms to face lawsuits in at least 6 states: Attorneys seeking class-action status The suits, which also allege these companies are committing fraud because andro does not work, are being filed on behalf of all people who have bought andro products from the companies. Blah, blah, blah - why do we not have some regulation of these snake oil salemen? But why do we need another lawsuit? Posted byThey want to quit Survey finds most smokers want to quit. That simple title conveys our frustration. Working mostly as a teaching hospitalist, I see the ravages of cigarettes. I see end-stage chronic lung patients sneaking outside to smoke. I see patients sneak outside to smoke 3 days after their myocardial infarction. I talk to them, and they do not want to smoke, but say they just can not stop. What an insidious addiction! Posted byGrowing older, I'll drink to that Alcohol 'only benefits old' - according to a British study, one can (and perhaps should) drink more as one gets older. Previous studies have suggested that moderate consumption of alcohol can protect against heart disease.Posted by More from Bush on malpractice The President focussed attention on the malpractice problem (and the evil trial lawyers - oops I should not use redundant phrasing) during a campaign stop for North Carolina gubernatorial candidate Elizabeth Dole. Bush Urges a Cap on Medical Liability. Now for your daily dose of ipecac The trip put Mr. Bush squarely on the home turf of a potential political rival in 2004, Senator John Edwards, a Democrat who became wealthy as a medical malpractice lawyer. Slick politics, avoid the issue and blame the insurance companies! Posted byDiscourse with Jane Galt Since I responded to Jane Galt's discussion of pharmaceutical company budgets, and particularly marketing, I felt it polite to let her know of my discourse. She kindly emailed this reply I think we're arguing two different things. Doctors who (forgive me) are a little irrational on the subject of pharma advertising, are arguing that in some sort of ideal world, there would be no marketing. There are a couple of ways in which I think this is ill-informed; in fact, it costs pharmas a lot less to do junkets than it would to do advertising or direct mailings, which have a much lower hit rate; similarly, it costs them less to have sales reps than it would to staff a hotline 24-7. Physicians, left to their own devices, apparently have a very poor record of tracking developments in pharmaceuticals; those marketing efforts do serve a purpose, and in fact do so at a lower cost than many alternatives.Let me respond as best I can. First, Jane is speaking from an economic view, and therefore her use of the phrase irrational must be taken in the economic context. While I understand her economic argument, I (as well as many commentors on her site) disagree with some of her assumptions. In economic discussions, we always have the most fun when arguing the assumptions. I do take umbrage in the generalization that physicians have a poor record of tracking developments in pharmaceuticals. The longer one practices medicine, the more cautious one becomes over the latest and greatest advancement. I have seen too many new drugs found to have major side effects after FDA approval. Unfortunately, sometimes the pharmaceutical company had strong clues, but acknowledgement of difficulties would hurt their marketing efforts. I believe that there remain major rewards to new drug development. I'm in favor of a reasonable return on investment for advances. I am against the aggressive marketing of "me too" drugs. I am against legal games which delay the introduction of generics. I am against direct to patient advertising for a variety of reasons. When patients ask for a certain medication, I either have to spend time (and time is money) explaining why I do not want to use that drug, or I could just relent and prescribe the drug (even when it is not the best choice). That form of advertising places the physician in an uncomfortable position, can negatively impact the doctor-patient relationship, and rarely benefits anyone (other than the drug company). There are many new pharmaceutical companies. They are all trying for the big new advance. NIH basic science research allows new ideas and approaches. Not all drugs come from pharmaceutical sponsored research. I really do not believe that research will go out of business if prices decrease (by whatever means). Finally, I would argue that ethics should trump economics here. The implications of selling your drug by buying influence with physicians are worth considering. This is a societal concern. We should strive for the best care, not care which benefits AstraZeneca (to pick on my favorite target). Who is looking out for the patient? I believe that is the crucial question here. (db steps back off his soapbox - only to return in the near future). Posted byInstitute of Medicine to study supplements The prestigious IOM will report to the FDA on six supplements later this year. The supplements chosen for the first safety evaluations cover a variety of types and uses, the institute noted. The selected supplements and the reason they were chosen, are: These evaluations are overdue. We make it more difficult to release a medication with known benefits than these pseudomedicines. I look forward to the reports - Institute of Medicine to evaluate supplements Posted byThe risk of the Y chromosome Posted by Malpractice reform - or at least a hope The administration may try to help the malpractice crisis. Bush Addressing Malpractice Insurance -- The Bush administration renewed its push Wednesday to rein in medical malpractice litigation and address soaring insurance costs that are causing many doctors to flee certain communities and high-risk practices. I hope that this initiative focusses the debate, but I fear politics will intervene again. The trial lawyers are whining. I really do not like the trial lawyers. Posted byLawyers against obesity I only post these things because they are so ridiculous. Ailing Man Sues Fast-Food Firms. A New York City lawyer has filed suit against the four big fast-food corporations, saying their fatty foods are responsible for his client’s obesity and related health problems. One can only imagine the variety of suits over obesity. We should sue Hersheys for making good chocolate, or better yet Godiva! Why not sue Mrs. Fields - her cookies are irresistible to me? We could even sue the Wonder bread company. Maybe Shakespeare was right! Posted byThanks Bloviator Blovi8r just emailed me this link (which he has on his web site also) - This Promotional Pen Works so Great, Imagine how Well the Drug Must Work. This comes from the Onion and as one would expect is hilarious. Thanks Bloviator! Posted byArguing over pharmaceutical marketing Medpundit showed me the link to this long diatribe by - Jane Galt. Now I do not know Jane Galt, but I suspect she has not been on the receiving end of drug company marketing. I do understand the economics of new drug development. I understand market share. I do not understand the ethics of pharmaceutical company marketing. We have this problem in medicine. We want to find truth, not opinion, not guesswork, but truth. When confronted with a patient who has just entered menopause, I want as much information as possible to help her decide on potential prevention measures. I would like to either have read the literature, or have a competent expert summarize that literature as an aid to our decision making. The pharmaceutical companies have a different incentive. They want us to use their drug, at the highest feasible price. Given two potential drugs for the same indication, they will always "spin" the drug that they sell. Understanding their profit motive (which is not a bad thing per se), I understand that they do not necessarily care about the best therapy. They care that we use their therapy. Thus, they work hard to influence us. Influence comes in many forms (for a good start on understanding influence - Influence At Work: The Psychology of Persuasion). That is their job, but I do not have to like it. I prefer to obtain information from unbiased sources. I object to the flagrant boondoggles that they fund (dinner at expensive restaurants, vacations, tickets to football games, etc.). Each company seems to function under a different ethic. I find some companies more acceptable in their tactics. The general feeling we physicians have is that the drug reps are just salespeople, they rarely provide useful information, they are JUST SELLING. That is my objection. Posted byBenefits of weight lifting Frequent readers expect me to link articles like this one - Give me Strength! Researchers are learning that a moderate strength-training (weight-lifting) program can do wonders for our bodies. After we turn 30, we lose about 10 percent of our muscle per decade, or a half-pound of muscle every year. That may not sound like much - but by age 70 it means we've been sapped of at least 40 percent of our strength. Lugging a 20-pound bag of groceries at age 30 may be a chore; by age 70 it could be a pipe dream unless we do something to maintain muscle. Are you taking care of your body? Posted byThe importance of literacy We care for the broad spectrum of our society. At least many of us do. One knows anecdotally that the more intelligent, informed, and literate patients generally do better in their own medical care. We now know that observation is more than an anecdote - Poor literacy puts diabetics at risk. I assume that the less literate the patient, the more time we should spend educating them. We should be teaching these patients how to care properly for themselves. But there is the rub, teaching takes time. We do not have time. Our payment system only rewards quick visits. Get them in and out. The heck with complete patient care. The heck with quality. I so quickly jump back onto my soapbox. But I cannot let this issue go. We need more time to see patients each year. We can do so much more if we could only focus on all the issues with each patient. Posted bySpin time for a pharmaceutical company I was working with an intern in clinic yesterday afternoon. The Wyeth representative had bought him dinner the previous night (actually dinner for the entire team on call). That rep was downplaying the HRT study results. He got directions from the company. Wyeth Criticizes Media Coverage of Hormone Replacement Drugs The chief executive of Wyeth, Robert A. Essner, criticized the media yesterday for what he termed its "sensationalizing" of a study that found that the company's hormone replacement therapy, Prempro, did more harm than good. To Wyeth's credit they paid for the study. However, I am very tired of drug rep and drug company spin. Reps are salepeople. They always have the BEST drug compared to their competitors. Nothing is every wrong. one gets tired of the spin. Thus, I cannot believe anything they say. I must go elsewhere for drug information. So should you! Posted byNo surprise - Senate deadlocks Everyone wants a Medicare prescription provision. Each party wants their own - Two Parties' Plans on Prescriptions Falter in Senate Today's votes, the most significant in a two-week Senate debate on prescription drugs, were the latest illustration of the deep philosophical differences over the proper role of government in meeting one of the nation's greatest social needs. So instead of compromise we have posturing. Instead of compassion we have politics. But then, this is what we expected. Posted byScary report on patient confidentialty Apparently, some patient data are not confidential. I do not like this story at all. I do not like the implications. Selling Privacy: Lines of Health Care Confidentiality May Get Blurrier Posted byTips on controlling hunger Some interesting thought here, although I believe more in changing dietary patterns and exercising. Nonetheless, this might help someone. The best ways to banish your hunger cravings... Posted byThe latest on the Medicare drug benefit Senators Ready to Vote on Proposals While the are ready, there is no apparent compromise in sight. Many remain skeptical Senate Minority Whip Don Nickles, R-Okla., said over the weekend he was afraid the Senate might not be able to pass a bill. ``I'm afraid that might happen,'' Nickles said on CBS' ``Face the Nation.'' ``I hope not. I hope that we can pass something.'' I hope that they can develop a reasonable compromise. Posted byStudy: Women have better emotional memory Study: Women have better emotional memory Matrimonial lore says husbands never remember marital spats and wives never forget. A new study suggests a reason: Women's brains are wired both to feel and to recall emotions more keenly than the brains of men.Posted by Life-long exercise I have to link this article, as one of my faculty is a co-author. The findings are interesting - too bad I don't enjoy tennis. I hope that any ongoing exercise works. Score One for Tennis: It's Good for the Heart Posted bySSRIs effective or placebo The depression world has a great debate going. How much of antidepressant's effects are placebo, and how much real? Confidence Game: Antidepressants may be placebos, but that doesn't mean they don't work. Posted byRetainer medicine the LA perspective I don't find much new in this article, but given my fascination with retainer medicine I must include it. Free registration is required to read the LA Times online - A Visit With Dr. Deluxe: Red-carpet treatment can be had for a price. But is 'boutique' worth it? This article does frame the issue very well. Several problems with our current system are defined Doctors themselves are divided on the ethics of retainer medicine. Said Dr. Richard Roberts, chairman of the American Academy of Family Physicians, "I feel I'm already available to my patients 24-7, and so are most family physicians. We don't need to do a wallet check first." The American Medical Assn. has no objection to retainer contracts, however. A report delivered to the AMA board by Mauney last month raised concerns about doctors dropping patients to go boutique, but otherwise it found that the practices present no threat to patient care. "Our position is that citizens have the right to strike a contract with their doctor, just like they do with their lawyer or any other professional," said Dr. Yank Coble, president of the AMA.Posted by The Supreme Court and medical practice Given our current era of legisilation, pharmaceutical industry greed and big insurance companies, it makes sense that big issues end up at the Supreme Court. This session will include two major issues - U.S. Supreme Court weighs any-willing-provider laws: The high court's roster of medically related concerns also includes a look at Medicaid drug rebate programs When the high court starts its new session in October, it will examine whether states' efforts to ensure that qualified physicians and other health professionals don't get shut out of health plan networks are preempted by the federal Employee Retirement Income and Security Act of 1974.Posted by Perversions of meaning This Sunday I will focus on three phrases that, in my opinion, should mean something different than administrators and subspecialists think. To do this, I must go against the Dictionary. Primary Care -The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system.While I do little primary care at this time (I mostly attend on the inpatient internal medicine service), I have done many years of primary care internal medicine. I like the first contact concept - always have. I object to the phrase "before referral elsewhere ...". The implication bothers me. Reading this definition implies the dreaded gatekeeper concept. Why not consider primary care physicians as the anchor or the orchestra conductor. The good primary care physician provides continuity, accessibility, and complex care. He/she works to prevent disease as well as provide ongoing care for many medical problems. Primary care requires diagnostic acumen. Most important, the excellent primary care physician knows his/her management and diagnostic limits. Knowing when to refer, and to whom requires skill. Primary care medicine is very difficult, we should recognize that and reward that skill. Managed Care - Any arrangement for health care in which an organization, such as an HMO, another type of doctor-hospital network, or an insurance company, acts an intermediate between the person seeking care and the physician.As Frank Zappa captured in his classic Valley Girl (sung by his daughter), "gag me with a spoon". The managed care ideal has the primary care physician managing overall patient care. Under the original model, the first contact physician really functioned as an orchestra conductor. One could manage multiple complex problems, obtaining subspecialty help on an as needed basis. Where is the physician in that definition? Where is the patient? They exist on either side of the organization. Why would anyone think that such arrangements should lead to better care? They are business deals, where the organization controls the care. Given that we have limited health care dollars, we may need to ration some care. That is an easy intellectual concept which many European countries accept. Few in the United States believe that their health care choices should have limits. These organizations make the decisions and try to have the physicians "take the heat". The tide has turned - I first noticed while watching the movie As Good As It Gets. Hopefully, we will soon see the end of the managed care era. Until then, consider this from today's New York Times Health Care Appeals Are No Snap Productivity 1. The quality of being productive. 2. Economics. The rate at which goods or services are produced especially output per unit of labor. I like the first definition as it could refer to medical practice. I hate the economic definition. When I think of a productive physicians, I must consider quality. Has the patient had questions asked and answered? Are all pertinent issues addressed? Is prevention up to date? Is the patient receiving high quality care? The second definition just counts our patient visits, much like making widgets. But we aren't making widgets. I understand the drive to see more patients per session. It comes from how we are paid. Lawyers learned long ago to charge for their actual time. Maybe that would be a better model for medicine. Given the middlemen (the insurance companies), we probably won't see that revolution. Maybe that is why I keep wondering if retainer medicine may be a superior model. Posted byMore on low carb diet efficacy The low carbohydrate hypothesis has figured prominently on my soapbox recently. As I read more primary literature, I become more convinced that healthy eating decreases simple carbohydrates. This study adds to our database on the subject - Low-Carb Diet Reduced Weight by 10% in 6-Month Study (requires free registration). I look forward to reading the article which will appear in the July issue of the American Journal of Medicine (I'll look for it this week). The summary provides interesting data which support Atkins and the NY Times Magazine article from 2 weeks ago. I am personally trying to be more careful in my choice of carbohydrates, sticking with more complex carbohydrates, and more protein. I love scientific controversy for out of controversy we often arrive at truth! Posted byAnd what rational person objected The law allows doctors to recommend marijuana to relieve the often debilitating symptoms of AIDS, epilepsy, glaucoma and multiple sclerosis as well as the side effects of cancer treatment.I do not understand our drug laws anyway. While I have great concerns about the medical complications of crack and heroin, I've never treated medical complications of marijuana. Some drugs are very dangerous, others are less dangerous. The pursuit of drugs is a major health problem, leading to much violence, prostitution, and needle sharing. We need to reconsider our drug laws generally - The Ruinous Drug Laws - but especially the marijuana laws. It appears Great Britain has gone light-years beyond us. Posted by Dentists against piercings Law's gory details designed to deter piercings . The law says the following language must be added to the currently required consent form:I like that Ilinois law. Maybe the dentists in Alabama can push it down here. Posted by Bloviator comments on drug industry advertising Bloviator's permalinks do not work properly - so - click on Bloviator and go to Thursday, July 18. The Bloviator makes several excellent points about detailing. As I have documented previously, we theoretically have some new limits on direct to physician moneys. Nonetheless, I agree with the points made. I have not yet become totally radicalized over this issue (to read the most radical position go to No Free Lunch), but they are pushing me. Read Bloviator's comments, they are accurate and appropriate! Posted bySimple fitness tips I cannot resist little articles like this. In February I made a personal committment to climb the stairs at work. I work on the 6th floor, and come in on the 2nd floor. When I walk to the VA, our patients are on the 5th floor. I climb a lot of steps at work. I think it makes a difference. Fitness Timesaving Tips Posted byHealthy lifestyle benefits expanding Diet May Prevent Alzheimer's Disease New Research Indicates Heart-Healthy Lifestyle Could Prevent Alzheimer's Disease. I like this news. As I continue to strive towards a heart healthy lifestyle, I seem to receive multiple benefits. Researchers at Case Western University School of Medicine and University Hospitals of Cleveland, Ohio, found that a diet of more fruit and vegetables, and less red meat, offers more protection against the development of Alzheimer's.While these data are epidemiological, they are the best data we have. I hope bananas make a difference! Posted by Breast feeding decreases breast cancer Good news - Study: Breast-feeding lowers cancer risk. Of even more interest, the total duration of breast feeding correlates with the percent risk reduction. Thus, women who have more children, and breast feed longer, lower their. risk. Now we must figure out how to make a major societal change. I'm told that breast feeding declines as socio-economic status declines. I don't understand this from a financial standpoint - breast feeding is cheaper than formula. Does anyone have information on that phenomenon - if so please email me. The original article appears in today's Lancet. Posted byMore patients could receive implantable defibrillators Wow, I have mixed feelings about this one. FDA Urges Wider Use Of Heart Device: Defibrillator Could Aid Several Million. Under the new assessment, 3 million to 4 million Americans with a history of heart attack and with depressed heart functions would be eligible for the device. Previously, the FDA had approved the defibrillator only for patients who had survived cardiac arrest and had undergone an invasive test to determine they were suitable candidates. At an estimated cost of $30,000, what insurer will pay for these defibrillators. If we start implanting many defibrillators, I hope we undergo research to find out how to predict better which ones trigger and which ones don't. We really will have to be more selective than all patients having had a myocardial infarction and a decreased ejection fraction. Developing reasonable guidelines for this device will challenge the medical community. Posted bySenate passes a drug Medicaid bill Despite heavy opposition from the pharmaceutical industry, the Senate Votes to Expand Drug Cost Cuts Of Medicaid. Senator Debbie Stabenow, Democrat of Michigan, the chief author of the proposal, said it was meant to encourage state efforts to make prescription drugs more affordable. "We are saying yes to the innovation of the states," Ms. Stabenow said.Posted by More on the AHA primary prevention guidelines I have just summarized my feelings about each point - Primary Prevention of CV disease and stroke. Medpundit worried about 20 year old patients starting statins. I've commented on that possibility. Many physicians believe that NCEP III gets a bit overly aggressive in primary prevention of those below 45. I agree with that idea. Medpundit's take on this issue - Screen Everyone for Everything. RangelMD on the same subject - New American Heart Association Guidelines to prevent stroke and heart attacks. Posted byNo tricks to fat loss Tricks do not work, nor do the many advertised "supplements". This article has no surprises, but much data. Fat Busters Posted byThe best exercise Instead of looking for the "best exercise," think about the best reasons to exercise. Are you exercising this week? Do you recommend exercise to your patients? If you don't exercise, how can you get your patients motivated. Doctor, heal thyself. (Sometimes I just love having this soapbox!!) Posted byCheaper drugs from Canada? An 80 year old gentleman with whom I used to play golf, has a large medication bill. He imports his drugs from Canada. Is that legal? The Senate would like to make this easier. Plan to Import Drugs From Canada Passes in Senate But today his administration opposed Mr. Dorgan's proposal. In a letter to the Senate today, Dr. Lester M. Crawford, deputy commissioner of the F.D.A., said: I suspect that we will hear more on this issue. Posted byMore on advertising than research Surprise, surprise, surprise - Drug industry ad spending attacked: Top companies spend twice as much on ads as research. The group’s report, which uses numbers from the annual reports of nine leading drug companies, shows, for instance, that Merck and Co. Inc., which reported $47.7 billion in revenue in 2001, spent $6.22 billion or 13 percent of that on marketing, advertising and administration.You aren't surprised. We have all seen this especially with the direct to patient advertising. The industry tried to rebut the data. “When Families USA attacks our promotional spending, they are really attacking the $10 billion in free drug samples that we give away each year to doctors who often use these free medicines to help needy patients.” While free drug samples do help many needy patients, their purpose is to influence which medication we start. Once a medication works, we rarely change to another in the same class. The industry has the attention of Congress, and that is not good for the industry. Maybe patients can benefit. Posted byAnd the jockeying for position begins Survey Halted, Drug Makers Seek to Protect Hormone Sales When female patients have asked in recent days whether they should continue taking Prempro, the hormone replacement therapy, doctors have told roughly half of them to stop taking the drug or to switch to an alternative treatment, a survey of doctors has found.Bad news for one company could be good news for other companies. For example, sales representatives from Eli Lilly told doctors they visited last week that the company's drug Evista was a safe alternative to hormone therapy, according to the ImpactRx survey. We all love that quote - encouraging women to have a discussion with their doctor - a euphemism for telling your doctor what you want. I actually recommend olendronate (Fosamax) as a first line prevention and treatment for osteoporosis. I just object to the advertising tactics of the pharmaceutical firms. Posted byThe perceived stigma of depression You cannot treat what you do not diagnose. You cannot diagnose what you do not consider. You cannot diagnose if the patient does not come to see you. Depression confounds phyisicians. While some patients seek care promptly, others hide the diagnosis from themselves, their family and friends and their physicians. First step in beating depression is admitting it Nemeroff says it is hard for men to ask for help, and even harder for those in leadership positions. I often tell residents and students that depression may be the most important diagnosis in outpatient medicine. We do not really understand the diagnosis or treatment that well. My experience suggests that often just allowing the patient to tell his or her story allows progress to begin. Posted byDaily political update I hate this, I really do. How the Senate compromises on the prescription drug crisis has major implications to how we provide patient care. Thus, while I hate the posturing and attention to special interests, I feel obliged to read this stuff. So for your aggravation - Senate Divided Over Rival Plans For Prescription Drug Coverage In recent days, Democrats, Republicans and a bipartisan coalition have laid out new proposals, and each side is scrambling to pick up supporters with public rallies, behind-the-scenes negotiations and one-on-one lobbying of colleagues. But, even as debate began, senators conceded that none of the proposals has enough votes to pass, creating the risk of a stalemate that would leave older Americans without help for another year.Posted by Taxes and smoking cessation Do you remember Economics 101? One main issue was elasticity. Elasticity: a measure of the responsiveness of one variable to another.- Microeconomics: Elasticity Overview If price does not change demand significantly one states that demand for that good or service is inelastic to price. For years cigarettes seemed to have this property. However, now we may be finding the elasticity. Michael Krygowski curses his shortness of breath while coaching his 10- year-old son's baseball team. He dreads dying before his three children finish college. And the 40-cent tax rise that took effect July 1 brings his two packs of Marlboro Lights to $8.70 a day — $269.70 this month.Posted by AARRGGHH!!!!!!!!!!! Suit faults firm over menopause drug. I do not want to believe this story. And some people wonder why I hold some lawyers in such contempt. The suit, filed by the Chicago law firm of Kenneth B. Moll & Associates, alleges that Wyeth failed to issue proper warnings to the medical community about Prempro's potential side effects; failed to perform adequate testing of the drug, and misrepresented or concealed facts about Prempro's safety from the Food and Drug Administration. Booooooooooooooooooooooooooo!!!!!!!!!!!!!!!!!!!!!! Posted byGood diet advice As usual, the lean plate club provides common sense on eating. The Lean Plate Club: Gut Check: Are You Really Hungry? Getting back in touch with hunger -- and with its opposite, satiety -- is a smart strategy to help hold the line in the waistline wars. "It's a really good thing to ask yourself, 'Why am I eating now?' " says Mark Friedman, associate director of the Monell Chemical Senses Center in Philadelphia.Posted by Take Away My Hormones? Posted by My personal crusade against AstraZeneca - just say no to Nexium Readers of this blog know how upset I am over AstraZeneca's shenanigans in delaying generic omeprazole and releasing Nexium. The marketing budget for Nexium is staggering. I can not view MSNBC Health without running into a Nexium add. I see purple in my nightmares - and it isn't even a pill - it's a capsule! Last week I made a major decision. The AstraZeneca rep asked me to sign for free samples of Nexium for our resident's clinic. I refused. I will not approve the use of Nexium for any patient - even if the drug comes for free. Rabeprazole (Aciphex) and lansoprazole (Prevacid) are my preferred proton pump inhibitors now - for pricing reasons. When Prilosec OTC is released I'll recommend that (AstraZeneca is not handling Prilosec OTC). I will avoid AstraZeneca products as much as is feasible. I understand that my colleagues have signed for the samples. I understand that my protest will not accomplish much. But I feel good about this protest. Maybe one or two of you will join me. Who knows - it could become a movement? Your course is simple - just say no to Nexium. (db steps off the soapbox temporarily) Posted byAHA guidelines on primary prevention The American Heart Association released new guidelines on primary prevention of stroke and coronary artery disease yesterday - Heart Assn.: Prevention should start at 20 The AHA calls the new guidelines "risk factor screening." It includes having blood pressure, body mass index, waist circumference and pulse recorded at least every two years, and cholesterol profile and glucose testing at least every five years beginning at age 20.Posted by Politics and prescription drugs No surprise to me or readers of this blog, politics are stalling the debate on the generic drug proposal and the Medicare prescription drug plan - Prescription Drug Debate Stalled The dispute came as lawmakers scrambled to get enough votes for three competing Medicare prescription drug proposals, none of which currently has the 60 votes needed for passage. As predicted, we won't get much intelligent debate, but rather much politics. Posted bySmoking addiction overrides data Patients given information about their genetic predisposition to cigarette induced diseaes, still do not increase their abstinence rates. Nicotine really is an evil addictive drug. At Risk: Making an Impression on Smokers Posted byGoing out to eat You might want to learn how to eat at restaurants, or at least how to eat intelligently - How to Eat Out Without Tipping the Scales Posted byMaybe some Medicare payment relief The AMAnews reports Doctors closer to Medicare pay relief: An administrative change adds new funding as the House passes a Medicare payment fix. Physicians won't be too upset that Medicare officials don't think they're as productive as previously assumed. Well this could help a bit. The politics of Medicare payments continues in the Senate this week. More as I find links. Posted byOne more diet story I just noticed this cover story from last week's Time magazine. Living in Alabama I do not know many vegetarians. We do not have vegetarian options for BBQ. If so inclined, check out this story Should We All Be Vegetarians? Posted byNewsweek writes on HRT Another discussion of the story - The End of the Age of Estrogen Posted byMedpundit on excess appendectomies Medpundit provides a nice discussion of why surgeon's perform excess appendectomies - Scrutinizing Surgery. At the risk of redundancy, let me try to add to the discussion. As I commented on earlier today (on hormone replacement therapy), the decision to proceed to appendectomy must balance risks and benefits. As a medical decision making researcher, I have learned often that no diagnostic test gives perfect information. We must always trade some decrease in specificity to increase sensitivity. Let me take a brief aside to explain that statement. Sensitivity defines the probability of a positive test result in patients with disease (in this case appendicitis). Specificity defines the probability of a negative test in similarly presenting patients who do not have the disease (appendicitis in our example). One cannot improve sensitivity without worsening specificity. Thus, given the risks of missing appendicitis (as well described by Medpundit), one errs with higher sensitivity and lower specificity. Another way of saying that is that in order to get more true positives, we must accept more false positives. Surgeons (in my opinion correctly) assume that each missed appendicitis causes much more harm than a few unnecessary appendectomies. While we should strive to minimize the false positives, in many medical circumstances we cannot avoid them. As Medpundit writes, the press "spin" on these data show an unacceptable naivety (but are we surprised?). Posted byMore diet thoughts Here are two interesting pieces to consider. The first discusses the Paleolithic diet. The philosophy here states that evolution occurred with an available diet. We should eat like those ancestors - Against the Grain: The case for eating like a caveman. There is, and one burgeoning argument about what it is is the agricultural revolution. Step back for a moment. We evolved as hunters and gatherers. A graduate student in my Rutgers department, Matt Sponheimer, published an article in Nature in 1999 showing from the microanalysis of wear on fossil teeth that our ancestors were eating meat over 2.5 million years ago. We mainly ate meat, fish, fruits, vegetables and nuts. We have to assume our physiology evolved in association with this diet. The balanced diet for our species was what we could acquire then, not what the government and doctors tell us to eat now.The second article presents research. It comes from Christian Finn's Facts about Fitness - a site that I read weekly. This article reviews data refuting the low fat diet theory - Why low fat diets aren't the best way to lose weight... If you've ever tried to lose weight with a low-fat diet, chances are you felt hungry most of the time. That's because certain types of low-fat foods can trigger hormonal changes that stimulate your appetite. This promotes excessive food intake in people who are overweight. While I believe we are still searching (and hopefully researching) for the answer, I'm leaning towards decreasing refined carbohydrates and not totally restricting fats. I'll continue to follow this issue closely. Posted byThe politics of pharmaceuticals - now the Senate Michigan Senator Will Lead Democrats in Prescription Drug Debate Senator Stabenow frames the problem "We have an industry that is the most profitable in the world," Ms. Stabenow said. "And I don't begrudge that in any way. But when an industry is allowed to make 18 to 20 percent a year, at the same time it's raising prices three times the rate of inflation, and people who need life-saving medicine cannot afford it, I think it's time to ask where the corporate responsibility is." As one would expect the pharmaceutical industry responds Brand-name drug makers oppose the bill to speed the marketing of generic drugs. They say it would undermine patent protections, reducing incentives for the discovery of new treatments beneficial to patients. Generic competition often causes precipitous drops in sales of brand-name products. More from the Senator Although Ms. Stabenow has spoken to Mr. Holmer and other drug company representatives, she said: "I've gotten more and more frustrated because they fight everything. I would love to find a way to work together on something meaningful. But they have the financial capacity, and a financial incentive, to fight everything, because so much money is at stake." While I generally lean towards the conservative Republican position on economic issues, this one is different. I see what tactics the pharmaceutical industry uses, and how those tactics effect patients. The industry does good research, and without a strong pharmaceutical industry we could not care for our patients as well. However, this time I seem to side with the Senator. Obviously, I will be following this debate closely. Posted byMore on hormone replacement therapy The natural counterargument to data comes from anecdotes. This piece humanizes the decision process. Many Taking Hormone Pills Now Face a Difficult Choice Remember that the data do not tell us that women should not take estrogen replacement therapy. Rather, the data define the risk. We must always balance risks and benefits with our patients. Some patients will make a rational decision to continue therapy while cognizant of the risks. Posted byobesity an American battle We are overweight. We aren't in good cardiovascular shape. Our most endemic disease is the metabolic syndrome - diabetes mellitus, hypertension, hyperlipidemia and all the consequences of that syndrome. While our genetics vary, and some (at the extreme the Pima Indians) have a greater tendency to these problems, I venture that all our diverse peoples suffer with the syndrome. Why are we overweight and obese? The simple answer probably reflects reality - we eat more calories than we burn. We eat the wrong foods, although we can't easily obtain general agreement on our ideal diet. Few of us exercise enough, either aerobic exercise or strength conditioning. Too many become "coach potatoes", minimizing their caloric expenditure, allowing their natural muscles to atrophy slowly, while eating empty calories. I know, I've been there. Thirty pounds ago I wore size 38 pants. I had frequent heartburn. My energy level decreased monthly. One day I looked at myself in the mirror, and wondered how it had happened. I've been an athlete my entire life - not a great one - just a dedicated recreational athlete. I played basketball (full court) until around age 45. Basketball kept me in shape. Nonetheless, I still struggled a bit with my weight. When I stopped playing basketball, I didn't have an exercise plan. I played golf regularly, but I didn't fool myself. Riding in a golf cart doesn't represent exercise. Golf is a great game which benefits from ones physical conditioning, but it doesn't create the level of exercise that I needed. So 3 years ago, I made a commitment to myself. A commitment to get in shape! Being relatively naive, I started with cardiovascular conditioning. That was a very reasonable place to start. I bought an expensive treadmill (I now know that when you use the treadmill regularly it isn't really expensive, it just costs some money). At first I walked at 4 MPH for 20 minutes. I was sweating, and tachycardic. I started dieting (not a very healthy diet, just worked on decreasing calories). The treadmill was my challenge. Running became my goal. Each day on the treadmill I would increase my speed a little. One day I could job at 5 MPH. While not very fast, this success excited me. Over time I could actually run on the treadmill - as fast as a 9 minute mile or even better. At that time, my progress stalled. I needed more information on diet, and probably needed some strength training. I got to strength training through golf. One day I'm talking to one of my golfing buddies, and asked him if he knew anyone who specialized in golf training. He does a weekly golf radio show, and had a sponsor who had such a program. 11 months ago I walked in and started. The first month we mostly stretched and learned balance, but over time my program has evolved to strength training and body shaping. My trainers (I've worked with several) have exposed me to nutrition and muscle. Being inquisitive, I began to read medical journal articles about nutrition and the importance of muscle mass. Readers of this blog know that I do focus on such articles often. This past February, we developed some goals. I had a complete evaluation of strength, flexibility, measurements, and body fat (using calipers). My July evaluation (5 months later) showed dramatic results. I've lost no more weight, yet my body fat percentage decreased from 23 to 18. As you can imagine, my proportions are changing. My road thus far has been a long one; one which has become a central activity. So what does my personal journey tell me about working with the average patient? I'll suggest some principles, without demanding a randomized controlled trial.
I hope that this ride on db's soapbox and personal journey was acceptable. The obesity battle requires hard work but that hard work is worthwhile. As physicians we should constantly encourage our patients to modify their lifestyle. Our research industry (especially the NIH) should fund research so that we can give our patients better information. And I will continue to cite articles that address this general topic. Posted byThis is just in - Avoiding Doctors: A Guy Thing . No surprises here - we guys don't seek medical care as frequently as women. This observation almost rates a duh - but it probably makes our jobs more difficult. Posted byDean Ornish on last Sunday's NY Times piece on carbohydrates Posted by Problems with Pennsylvania's pharmacy program What are we going to do about the price of drugs? If any economists are reading this, not that I said price, not cost. The Pennsylvania experience gives some important lessons - Pennsylvania Struggles to Repair Model Prescription Aid Program The average number of prescriptions filled for each person in the program now exceeds 3.5 a month, up from 2.5 in 1997 and just 2 in 1987. The state pays an average of $42 for each prescription, up from $27 in 1997 and $14 in 1987.Posted by Pump it up!! Frequent readers (both of you) know that I love this story - Women urged to pump iron: In search of fitness, women discover new kind of strength Perhaps the biggest misconceptions women have about weight-lifting is that they will build large, unfeminine, man-like muscles.Posted by More advice on losing weight Several weeks ago I linked to an interesting column on the "super-size" problem and obesity. Here is super-size part II which contains some practical (not novel) advice Super Size It, Part II: Dr. E's Foolproof Diet . You can read my comments about Part I also Obesity, a physician's opinion. Posted byTreat smoking cessation and obesity simultaneously Very interesting data suggests that patients randomized to bupropion SR (Wellbutrin) lose more weight and keep it off than patients taking placebo. Report: Anti-depressant helps keep weight off, too "There are no magic bullets for treating obesity. Diet and exercise are still the keys to long-term weight loss. But this does give us another arrow in the quiver in helping to treat it."Posted by Generic drug firms win one in the Senate A Senate committee yesterday supported easier release of generic drugs. Under current law, a maker of brand-name drugs can often get a 30-month delay in federal approval of generic drugs by filing a lawsuit that alleges infringement of its patents. Critics say that some companies have delayed generic competition for years by repeatedly seeking 30-month delays.This bill would impact one of the "dirty tricks" that the big pharmaceutical companies play. Committee Backs Expansion of Access to Low-Cost Drugs Posted by A rational analysis of the hormone study Amidst the furor comes this reasoned analysis of the hormone study - Study shouldn't panic women Posted byBingo! If you don't love this article, then you are a Scrooge - Bingo 'boosts the brain' Posted byArthroscopic surgery doesn't work for osteoarthritis Congratulations! Kudos! Well done! The New York Times has the title wrong - A Knee Surgery for Arthritis Is Called Sham. Conventional wisdom (and you know how I adore conventional wisdom) supported this surgery. It involves making three small incisions in the knee; inserting an arthroscope, a thin instrument that allows surgeons to see the joint; and then flushing debris from the knee or shaving rough areas of cartilage from the joint and then flushing it.Investigators at the Houston VA randomized patients to surgery or sham surgery. They found no objective differences in function over a 2 year period. We have very few randomized controlled trials of surgical procedures. We should delight in the appropriateness of this study, whose results may save many health care dollars. The NEJM article has an accompanying editorial and Sounding Board. The ethicists writing in the Sounding Board end with this pearl: A full ethical assessment must include consideration of the consequences of not conducting rigorous trials of surgery. Arthroscopic surgery has become a common treatment for osteoarthritis of the knee in the absence of rigorous scientific evaluation of its efficacy. According to data cited by Moseley et al., the costs of this intervention are approximately $3.25 billion per year. Yet the results of this important study demonstrate that two methods of arthroscopic surgery are no more effective than a placebo operation. Thus, patients have been exposed to risks and third-party payers have incurred substantial costs for a treatment that offers no benefit to the patient. Trials of surgical procedures that include the use of placebo surgery should be conducted before the procedures become standard treatments, provided that these trials meet the ethical requirements that are appropriate for clinical research.Well stated, and a study well done. Congratulations! Kudos! Posted by Medpundit on the health care crisis Glad to see Medpundit's comments on the health care crisis - Healthcare Crisis Redux: She challenges my optimism on retainer medicine. Good! We need constructive debate. My point - while retainer patients want everything, many expensive test requests originate from busy physicians not having time to take a bit more history and think carefully. The patients may remain willing, their insurance may pay, but the test not order. A couple of years ago, my colleagues and I took over responsibility for an indigent clinic funded by a private hospital in town (we supervise residents there 3 afternoons a week). All tests and medications are funded by the hospital for a small number of deserving patients. When we took over, costs dropped precipitously. We order less MRI/MRAs. We more often use generic medications. We don't "lab them up" on every visit. We teach evidence based "thinking" medicine. The hospital likes us - and we have increased the patient load for less money. Our patients get excellent care. I hope that the physicians practicing retainer medicine have that attitude. We need research to answer the question which I postulated. Obviously, we can't know the answer - I'm glad to stimulate debate and thought. Posted byMore on estrogens Whenever study results go against conventional wisdom, we get aftershocks. We do studies because conventional wisdom isn't always right. That's why I'm against "supplements and herbal medicines" - they haven't had the scrutiny of careful study. The New York Times follows up with reactions to the estrogen study - Hormone Replacement Study a Shock to the Medical System. I'm not shocked - and we shouldn't be shocked. The HERS study gave us all the clues. This well written article outlines how we got to this study. In 1990, when Wyeth, the leading maker of estrogen, went before the Food and Drug Administration with a request to label the drug as protective against heart disease, Ms. Pearson was there.Posted by Get serious about education Teaching hospitals urged to learn better approaches: A competitive hospital market and an emphasis on research are taking a toll on student education and resident training. We need to do a better job of teaching concludes a Commonwealth Fund study and report - The original 80 page report in pdf format. I'm fortunate to work at an institution where teaching has some status. Interestingly I've been invited to attend a conference sponsored by AHRQ to study medical education outcomes (July 22). I'll give a report after I attend that meeting. I generally agree with this article - and only wonder how to affect solutions. It comes down to time, money and status. We can convey status more easily than time or money. We need solutions as medical education does make a difference. Posted byEstrogen revisited A reader of this blog (I'm so happy that a few people read my indulgence) asks Interesting article. Is there some consideration on it's impact on hormonal replacement as it's used for protecting against bone density in postmenopausal women, in your opinion?The study does show some benefits - A statement from the institute noted the benefits of estrogen combined with progestin, "including fewer cases of hip fractures and colon cancer, but on balance the harm was greater than the benefit."So where do I stand - exactly where I stood for the past few years. I strongly prefer bisphosphonates (usually olendronate - Fosomax one a week) as I believe the data are stronger for their benefit to the bones. So what do I teach my residents? At menopause I obtain a bone mineral density and start prophylaxis in patients with significantly decreased bone mineral density. I also test anyone who has another indication. I had already stopped recommending estrogens for prevention - but would still use them for symptoms in selected patients. Interestingly, my wife and I had this exact conversation last night. I expect to have this conversation several more times, as our friends are generally perimenopausal - at least the wives! Posted by In response to the New York Times Magazine article on obesity The skinny on 'good fats' - which discusses good fats and "bad fats" as well as good carbs and "bad carbs". Posted byIt's hot - drink plenty of water Nice article on water and the selling of "enhanced" water - Enhanced Waters: All Wet . This might be a good article to print and make available to patients. Posted byThe crisis returns Health Care's Soaring Cost Takes a Toll: Squeeze Hits Workers, Firms and Government The crisis never really left. The managed care fiasco called a revolution, hid the problem for a while. But the problem hasn't been gone. Society has just noticed it again. The causes cited most often are hospitals, pharmaceutical companies and overzealous malpractice attorneys -- all contributors to the problem, say analysts who track health spending. Larger forces, such as an aging population, expensive new technology and a backlash against the strictures of managed care, have further complicated the equation.Reread those paragraphs. They are well written and accurate. Note that we physicians are not blamed. Fortunately, they do understand that physician income has decreased. Well I would like to propose a novel concept. Pay generalists at a more reasonable rate so that they can spend more time with the patient. Often one orders tests because it saves office time! Perhaps we should spend a little more time talking to patients, and using the best test - tincture of time. I hope someone studies retainer medicine in an objective manner - it might even save money on UNNECESSARY tests. Time also allows us to better give preventive advice, and do appropriate preventive testing. We certainly save more by preventing disease than treating disease. Congress must address the malpractice issue (but they won't). We also need a creative solution to the problem of pharmaceutical costs. As the say in the South - "push has come to shove". It's time for creativity - but include physicians in the solution. We probably understand health care better than the lawyers and bureaucrats. Posted byFinal blow for estrogen as a preventive drug The final nail is struck. Citing Risks, U.S. Will Halt Study of Drugs for Hormones The data indicate that if 10,000 women take the drugs for a year, 8 more will develop invasive breast cancer, compared with 10,000 who were not taking hormone replacement therapy. An additional 7 will have a heart attack, 8 will have a stroke, and 18 will have blood clots. But there will be 6 fewer colorectal cancers and 5 fewer hip fractures.Not huge risks, but clearly unnecessary risks. Dr. Nannette Wenger, a cardiologist at Emory University, said the only reason she could see for taking the hormone combination was for the temporary relief of severe symptoms of menopause. But, Dr. Wenger said, "I would not tell anyone to start taking it."Posted by Primary care problems in Great Britain The more I learn, the more I believe that primary care problems exist everywhere. As we expect more from our primary care physicians, we make their jobs untenable. You cannot ask them to do more in less time with higher quality. Postcode lottery in GP services The report says that shorter hospital stays and increasing numbers of elderly patients are placing GPs under more pressure.Posted by Obesity and glycemic index - further reflections I've just spent the last 1/2 hour reading the JAMA article referenced below on the Glycemic Index. Over the last year, I've slowly become more aware of this concept. The article, while a bit dense, explains the literature well. If one were to follow such a diet, what principles should one use? whereas the concept of glycemic index may be complex from a food science perspective, its public health application can be simple: increase consumption of fruits, vegetables, and legumes, choose grain products processed according to traditional rather than modern methods (eg, pasta, stone-ground breads, old-fashioned oatmeal), and limit intake of potatoes and concentrated sugar. Indeed, these recommendations would tend to promote diets high in fiber, micronutrients, and antioxidants and low in energy density.These recommendations aren't unusual, seem relatively easy to follow, and represent the diet I'm personally striving to achieve. Posted by Treating BPH I missed this one. It didn't appear in the news. It is important. The NIH released the results of a study showing that finasteride plus an alpha blocker work synergistically - helping symptoms now, and retarding progression - Two-Drug Therapy is Best for Symptomatic Prostate Enlargement. How did I find this reference? Prescriber's Letter is one of my main sources for keeping up to date on pharmaceuticals. The July issue discusses this press release. Posted byEloquently said Read this short piece sent to Medpundit - you'll be glad you did - Thoughts of a Young Surgeon. The surgeon understands. Why doesn't society? Posted byRethinking obesity and diets? What if It's All Been a Big Fat Lie? Maybe Atkins was right all along. Some experts are finally considering the possibility that low fat diets are not the answer. We didn't always believe that. With these caveats, one of the few reasonably reliable facts about the obesity epidemic is that it started around the early 1980's. According to Katherine Flegal, an epidemiologist at the National Center for Health Statistics, the percentage of obese Americans stayed relatively constant through the 1960's and 1970's at 13 percent to 14 percent and then shot up by 8 percentage points in the 1980's. By the end of that decade, nearly one in four Americans was obese. That steep rise, which is consistent through all segments of American society and which continued unabated through the 1990's, is the singular feature of the epidemic. Any theory that tries to explain obesity in America has to account for that. Meanwhile, overweight children nearly tripled in number. And for the first time, physicians began diagnosing Type 2 diabetes in adolescents. Type 2 diabetes often accompanies obesity. It used to be called adult-onset diabetes and now, for the obvious reason, is not. In the 1970s we bought into the low-fat hypothesis. Nonetheless, once the N.I.H. signed off on the low-fat doctrine, societal forces took over. The food industry quickly began producing thousands of reduced-fat food products to meet the new recommendations. Fat was removed from foods like cookies, chips and yogurt. The problem was, it had to be replaced with something as tasty and pleasurable to the palate, which meant some form of sugar, often high-fructose corn syrup. Meanwhile, an entire industry emerged to create fat substitutes, of which Procter & Gamble's olestra was first. And because these reduced-fat meats, cheeses, snacks and cookies had to compete with a few hundred thousand other food products marketed in America, the industry dedicated considerable advertising effort to reinforcing the less-fat-is-good-health message. Helping the cause was what Walter Willett calls the ''huge forces'' of dietitians, health organizations, consumer groups, health reporters and even cookbook writers, all well-intended missionaries of healthful eating. If you decrease fat in the diet, you generally replace it with carbohydrates. As a result, the major trends in American diets since the late 70's, according to the U.S.D.A. agricultural economist Judith Putnam, have been a decrease in the percentage of fat calories and a ''greatly increased consumption of carbohydrates.'' To be precise, annual grain consumption has increased almost 60 pounds per person, and caloric sweeteners (primarily high-fructose corn syrup) by 30 pounds. At the same time, we suddenly began consuming more total calories: now up to 400 more each day since the government started recommending low-fat diets. Maybe we should finally learn about the glycemic index. Welcome to Endocrinology 101 - The Glycemic Index: Physiological Mechanisms Relating to Obesity, Diabetes, and Cardiovascular Disease The gist of the glycemic-index idea is that the longer it takes the carbohydrates to be digested, the lesser the impact on blood sugar and insulin and the healthier the food. Those foods with the highest rating on the glycemic index are some simple sugars, starches and anything made from flour. Green vegetables, beans and whole grains cause a much slower rise in blood sugar because they have fiber, a nondigestible carbohydrate, which slows down digestion and lowers the glycemic index. Protein and fat serve the same purpose, which implies that eating fat can be beneficial, a notion that is still unacceptable. And the glycemic-index concept implies that a primary cause of Syndrome X, heart disease, Type 2 diabetes and obesity is the long-term damage caused by the repeated surges of insulin that come from eating starches and refined carbohydrates. This suggests a kind of unified field theory for these chronic diseases, but not one that coexists easily with the low-fat doctrine.So we have a concept, time to test it. None of these studies have been financed by the N.I.H., and none have yet been published. But the results have been reported at conferences -- by researchers at Schneider Children's Hospital on Long Island, Duke University and the University of Cincinnati, and by Stern's group at the Philadelphia V.A. Hospital. And then there's the study Stunkard had mentioned, led by Gary Foster at the University of Pennsylvania, Sam Klein, director of the Center for Human Nutrition at Washington University in St. Louis, and Jim Hill, who runs the University of Colorado Center for Human Nutrition in Denver. The results of all five of these studies are remarkably consistent. Subjects on some form of the Atkins diet -- whether overweight adolescents on the diet for 12 weeks as at Schneider, or obese adults averaging 295 pounds on the diet for six months, as at the Philadelphia V.A. -- lost twice the weight as the subjects on the low-fat, low-calorie diets.Read this long article from the New York Times Magazine. Read the JAMA article. Rethink obesity and diet - it is the right thing to do. Posted by prevention: an opportunity yet problems The past decade has seen remarkable advances in our ability to prevent disease or disease progresion. We can decrease the probability of coronary artery disease, congestive heart failure, diabetes mellitus, colon cancer, skin cancer, etc. We can treat patients with those diseases and retard progression. Yet we only do a mediocre job. As I consider various posts since starting this blog, several common themes relate to prevention:
I believe that we have several underlying problems. Medication costs continue to spiral upward. We are frustrated when we know what to prescribe, but the patient cannot afford the medication. Over the next several years, I believe that we will develop a rational method for addressing medication costs. At least I hope so. Physician time pressures have negative effects on patient care. Prevention often takes time. One cannot just write a prescription for exercise or diet, and expect excellent results. These issues take exploration, reinforcement, and questioning. Physicians don't have the time to do this right. We aren't trained that well in behavioral modification, and generally don't develop those skills. Our time pressures also decrease our ability to remember the increasing list of prevention issues. If you only have 15-20 minutes per patient, some issues cannot have full exploration. Finally, we have conflicting recommendations. Specialty societies often develop guidelines based on their beliefs, rather than objective data. When independent groups develop alternate guidelines, physician confusion reigns. At what age should I start ordering mammograms, or PSAs? Is an annual rectal examination worthwhile? Which patients with hypercholesterolemia deserve treatment? I hope medical leaders will address these issues. Interesting that most things generally boil down to time and money. Regardless, continue to consider prevention. Try to develop your system to maximize your patient's future health. Posted byStatins - important secondary prevention While we have interesting debates about the scope of primary prevention of coronary artery disease, we should have little debate on secondary prevention. While I have not yet added that discussion to my Ward Attending site, I will at sometime.. We now have even more data as reported by the BBC - Call for heart drug lifesaver This study solidifies much that we already suspected. Statins help these patients greatly. The study involved 20,000 UK adults with heart disease, diabetes or other kinds of arterial disease, who were given either a statin, or a dummy placebo for five years.The original article is in the Lancet - I haven't yet read the article - I plan to read it this week and glean more information. It seems to extend the results of the HOPE trial (reference available on Ward Attending). While the article requires a subscription (which I don't have - thus the copy machine on Monday) - the editorial is free if you register and log in The Lancet - go to the July 6th issue, log in, and scroll to the commentary section. Clear benefits were also seen in several subgroups of patients who were poorly represented in previous trials. These subgroups include those over 75 years of age, women, those with concentrations of LDL below 2·5 mmol/L, individuals with diabetes and no vascular events, and those with known cerebrovascular or peripheral arterial disease. The reduction in ischaemic stroke, without an excess of haemorrhagic stroke is noteworthy, and confirms the findings from previous trials. The reductions in vascular events were observed in addition to other effective therapies, such as aspirin, ß-blockers, and ACE inhibitors...Posted by Medicaid and drug benefits While Congress debates the Medicare drug benefit - actually while they posture - some states are instituting a Medicaid drug benefit. High drug costs are driving health care policy. States Split as U.S. Offers Drug Subsidy for Elderly With Congressional passage of a Medicare drug benefit still far from certain, about half the states are at least considering joining a Bush administration program that will provide federal matching money to extend drug coverage to elderly people whose incomes are modest but too high for Medicaid.Posted by Malpractice crisis in Vegas Medpundit is back, and as usual on top of the malpractice issue. Read this piece about the closing of the major trauma center in Las Vegas - Malpractice Crisis Update. Read what the trial lawyers are saying - it works better than ipecac. Posted byScreening for prostate cancer - another dilemma Should I order a PSA or even do a screening rectal exam? I'm perplexed, and have been for several years. This report adds to my confusion. Primum Non Nocere: "First Do No Harm". Prostate Cancer Test Leads to Overdiagnosis, Research Finds Posted byPhysician assisted suicide - the Oregon experience While I am personally against physician assisted suicide, I do understand the desire from patients. Some physicians can accept assisted suicide as a legitimate option. This article adds to our knowledge of how we should help patients who ask us - Study: Most Change Mind About Assisted Suicide Many patients also incorrectly believe that physician-assisted suicide involves a lethal injection. "It's not legal in Oregon, let alone anywhere in the United States," Tolle stated. They are given a prescription and told an overdose will kill them, then allowed to decide what to do.Posted by On errors and uncertainty I found this reference on Arts & Letters Daily - a beautifully written book review - Whoops! By Sherwin B. Nuland Complications: A Surgeon's Notes on an Imperfect Science His review focusses mostly on the book section devoted to errors. Errors in medicine are very chic, yet very old. This book discusses them frankly and openly. The book also addresses uncertainty and the doctor patient decision process. This quote struck me as appropriate. Like so many physicians whose experience vastly exceeds his own, and like so many patients too, Gawande doubts that the principle of autonomy can be universally applied. Even when it is clear to a dispassionate reader (as it is in the case of the woman to whom he recommended breast biopsy) that he is guided only by his own interpretation of the laws of probability, he looks for ways to convince patients that the doctor really does know best. In this, he is no different from most of his more experienced colleagues, myself included, in doubting?sometimes with dubious reason?the unquestioned value of total reliance on a patient's ability to choose wisely:This is a long read, but when you have the time, it is worth the effort. Nicely done review of what promises to be an interesting book. Posted by Use DEET this afternoon This out just in time for your July 4th BBQ (although I suspect few readers will access this page this morning) - DEET Found Best in Foiling Mosquitoes Posted bySchizoprenia genetic? Many years ago, while in college, I worked with emotionally disturbed children. I found the job challenging, yet doable, except for the schizophrenic patients. I remember discussing this with my father (a clinical psychologist) and commenting that it seemed like their neurochemistry differed from ours. During my entire medical career I've held the belief that omething causes schizophrenia which we might find one day. Apparently we're getting closer. This article doesn't surprise me. I only hope that once we truly understand the defect, we can find novel treatments. Schizophrenia May Be Tied to 2 Genes, Research Finds Posted byLimiting resident's hours - more thoughts Read this excellent report from the AMA News - Medicine limits resident hours before legislation can David Leach, MD, executive director of the ACGME, said work hours are an issue because of a changing environment. "Hospital stays are shorter, patients are sicker and there's more pressure from falling reimbursement rates to do more with less staff. As a result residents are doing more in less time, with less help."Leach is correct, he partly identifies the problem. We must look at the ACGME regulations like any law. Most laws have "unintended consequences". What are the consequences here? This article again challenges Leach, and he admits that he doesn't really know. While shorter hours ought to reduce errors from fatigue, they're likely to increase errors from patient handoffs, Dr. Leach said, and transfers from doctor to doctor will require better patient management systems.Nice unilateral work from the ACGME! We now have new regulations which MIGHT harm patient care. I'm in agreement with the general principle. However, I've learned over the years, that prior to instituting major reforms, one MUST understand the problems those reforms cause. Might minor adjustments taken over time make more sense. Would some pilot projects give valuable information? Perhaps the ACGME and AMA should think this through, not based on an ideal world, but rather adjusting to our real world. What a controversial thought I've advanced! Posted by Treating hypertension - maybe mundane, but not trivial Poor choice of title there, but I'll stick with it. Treating hypertension really isn't mundane, it just seems that way. During my residency, our first line drugs were alpha methyldopa and hydrochlorothiazide. Since then we have available beta blockers, calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers. We still have a variety of the older drugs available. Yet both patients and physicians are doing worse in treating hypertension. Read this very nice article from Jane Brody of the New York Times (I usually link on Jane's stories as she writes so well, and accurately) - Methods Are Many to Reduce Blood Pressure As usual let's include some quotes from the article (with my pithy commentary). In trying to account for these changes, experts point to a number of factors. One is the sharp increase in the percentage of Americans who are overweight or obese, creating for themselves the leading risk factor for hypertension.No surprise here that I would focus on exercise and obesity. We have to figure out the exerice and obesity problem in our society. I'll remain a zealot - I hope you are one too! Further complicating the picture are the insurance-dictated constraints on doctors. Many of them don't take the time to educate patients about the importance of continually monitoring their pressure readings.Again a big surprise for readers of these rants. Both the insurance companies and pharmaceutical industry get a nice slap here. These issues seem so obvious to physicians, what doesn't society understand about this. Congress clearly doesn't understand (or apparently want to ever understand). This may be a good article to give to patients (seeing that you don't have enough time to talk to them! (Writer adds a sardonic comment at the end - obviously in a very sarcastic mood this morning) Posted by News reports on HERS As I mentioned yesterday, I assumed that various papers would treat this story differently. The New York Times is cautious - Hormone Therapy Study Finds Risk for Some Days before The Journal was published, groups that support some uses of hormone therapy issued statements citing limitations of the study's findings, saying they do not apply to most women approaching menopause, because the women in HERS had an average age of 67 and a diagnosis of heart disease.The Washington Post has a different title - Doubts on Hormones, Heart Risk Bolstered They lead their article emphasizing the negative aspects of the study, and quote from the editorial "The bottom line is . . . there's no evidence to support routine hormone replacement therapy except for treatment of menopausal symptoms," said Diana Petitti, director of research for Kaiser Permanente of Southern California, who wrote a commentary accompanying two articles on the findings.MSNBC has an accurate report - Hormones offer no heart benefits: Plus, supplements may increase risk of blood clots, gallbladder disease This title highlights the important adverse effects. These effects pertain in any woman. The Chicago Sun-Times uses the AP story with this title - Research questions hormones benefits Very interesting reactions to these important articles. We do know that symptomatic woman benefit greatly in the short term during early menopause. We have better osteoporosis treatments (in my opinion), and now clearly we have no reason to assume a heart disease benefit. Finally, the risks of estrogen therapy (increased DVTs and biliary tract surgery) are very clear. Posted byMenopause and estrogens - more evidence against Tomorrow's JAMA contains 2 articles from HERS II(Heart and Estrogen/Progestin Replacement Study). First the links - Cardiovascular Disease Outcomes During 6.8 Years of Hormone Therapy and Noncardiovascular Disease Outcomes During 6.8 Years of Hormone Therapy Quick recap - HERS randomized A total of 2763 postmenopausal women with coronary disease and average age of 67 years at enrollment in HERS; 2321 women (93% of those surviving) consented to follow-up in HERS II.The patients received either 0.625 mg/d of conjugated estrogens plus 2.5 mg of medroxyprogesterone acetate or placebo for the duration of HERS (avg. 4.1 years). During the subsequent followup period, estrogen use was at the patient and her physician's discretion. These studies look at longer term outcomes. There were no significant decreases in rates of primary CHD events or secondary cardiovascular events among women assigned to the hormone group compared with the placebo group in HERS, HERS II, or overall.Thus, the epidemiologic promise of estrogen's positive effects on coronary artery disease are not supported (at least as secondary therapy). Patients receiving estrogen had more venous thromboembolic disease, more biliary tract surgery, but no significant difference in cancer rates or death rates. Thus, this study does not support estrogen therapy as preventive medicine. The study doesn't address other beneficial effects of estrogen - sense of well being, sexual function, skin changes, bone density. Women entering menopause should no longer have estrogens encouraged for preventive reasons only. I wonder how the press will review these articles later tonight and tomorrow. I'll be watching and linking. Posted by Just say no to Alternative Medicine Wonderful long philosophical piece about alternative medicine - Put alternative medicine back in its box. Very nicely written, complex but helpful. Posted byWill Medicare fees increase a bit? The Medicare budget grows rapidly. But physician fees aren't the cause of the expense. Hopefully Congress is getting the message - Medicare pay fix, drug benefit closer to reality I'm only cautiously optimistic, and doubt that this bill would turn the tide of physicians opting out of Medicare. We need both tort reform and Medicare reform. Good luck, politics will clearly get in the way of progress (gee, I can really state the obvious). Posted byAMA on malpractice While I rarely write about malpractice and tort reform, I can't resist this link. AMA readies for battle on tort reform: The ambitious plan passed at the Annual Meeting could cost more than $15 million to carry out, with $12 million set for a national ad campaign to educate the public. I only can yell "hear, hear". This is a major issue, and as usual we are at odds with lawyers. Generally, Medpundit writes eloquently about this topic. I'm too angry and simple. Tort reform must occur if we are to provide good medical care to the largest number of patients. Posted byUnderstanding risk In a related issue, read this well written piece about risk. The beginning of this article will remind you how easy one can lie with statistics. Experts Strive to Put Diseases in Proper Perspective Be sure to click on the graphic - VERY well done! Posted byAdvice and consent Thank you Sandeep for writing a wonderful piece about informed consent - Advice Rejoins Consent. This story explains our dilemma as physicians. Not everyone wants or can make complex medical decisions. Most patients want us to guide them. That I was having this conversation at all is testament to how much medicine has changed in the last two or three decades. In hospitals today, "patient autonomy" is the ruling ethical mantra, even superseding beneficence. But it can be a problem.Well done Sandeep! He has said it better than I ever could. We must consider this dilemma carefully. Most patients want help in medical decision making. They find the process daunting. The complexities which we juggle from years of study and experience cannot be easily expressed. We've seen the good outcomes and the poor outcomes. I agree that we must avoid a return to pure paternalism, but we also must help the patient make the best decision (for them). Posted by AMA against boxing About 15 years ago, I decided to quit watching boxing. While I'll concede that many find boxing exciting, I reasoned (influenced by the data) that the boxing's goal was to inflict brain damage. While that may represent a gross oversimplification, I would contend that when one "knocks out" an opponent, that implies brain damage. The AMA has a consistent position against boxing, which they reiterated last week. Hurray! AMA pulls no punches, reiterates boxing ban Posted byNational health service - more problems than one might imagine While I do understand my colleagues who favor a "single payor" health reform, I fear the implications. My first concern comes from the VA system. I work there on the inpatient service, and see some decisions that are made for financial reasons. Then I read about the problems in Great Britain and shudder - Politicians 'trample over' patient privacy The following captures my concerns - He also warned that doctors were fed up with being constantly set targets.I believe that many physicians in this country would echo these sentiments. Administrators and insurers too often adopt the production line model. We need a revolution in defining health care delivery. We need enough time to do our job correctly. (db steps off his soap box) Posted by Providing more physicians for rural areas Physicians don't locate in many rural areas. This problem has many reasons, ranging from spouse refusal to the lure of the big city to finances to the decrease in generalists. The government (Department of Agriculture) is working to help this problem. This solution will give short range solutions, but short range solutions are better than no solutions - Washington attempts to boost number of rural docs. This solution gives a visa exemption to internal medical graduates for the two years after training - provided they work in an underserved area. They will. This isn't the best long-term solution, but it is a reasonable short-term fix. Posted byDepression, antidepressants and placebos We read the headlines, placebos work as well as antidepressants. Being the skeptic (over 25 years as a physician will do that to you), I wondered what the catch was. Richard Friedman, writing in the NY Times, has clarified that study well - Can the Placebo Treat Depression? That Depends This helps me the most - To get into a study, a subject needs both to meet diagnostic criteria for depression and to have the requisite symptom severity, which varies from study to study. But depressed people who enroll in antidepressant clinical trials are a very select group who are not representative of depressed patients in general. For example, they tend be only mildly or moderately depressed and are never actively suicidal. And they also are usually free of other psychiatric or medical illness that are common in the general population.The NY Times also has a article on Prozac - probably to herald generics of that drug - Antidepressants Lift Clouds, but Lose 'Miracle Drug' Label. When I was seeing private outpatients, depression was one of the major diagnoses in that practice. I did find Prozac and similar drugs very valuable in helping some patients. This is an important field, but I do worry always about abuse of medications. Given that the antidepressants are probably very important when patients have severe depression, we need reasonable alternatives when the depression is mild or modest. This article speaks well to that subject and (surprise) exercise comes into play! Lighter Moods Without Drugs Posted by |
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