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)

FTC Seeks Generic Drug Delay Limits

The Federal Trade Commission wants to limit the ability of drug companies to delay the marketing of generic competitors and to require the firms to disclose agreements covering the sales of generic drugs.

``The commission's recommendations today are designed to accomplish two goals: to facilitate generic entry and to maintain appropriate incentives for the development of new drug products,'' said FTC chairman Timothy J. Muris.

Hopefully, this recommendation will allow faster entry of generics into the market.

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: Government’s War on Drugs Fails

We know the terrible things drugs can do. We've seen the despair, the sunken face of the junkie. No wonder those in government say that we have to fight drugs. And polls show most Americans agree. Drug use should be illegal. Or as former "drug czar" Bill Bennett put it: "It's a matter of right and wrong."

But when "right and wrong" conflict with supply and demand, nasty things happen. The government declaring drugs illegal doesn't mean people can't get them, it just means they get them on the black market, where they pay much more for them.

"The only reason that coke is worth that much money is that it's illegal," argues Father Joseph Kane, a priest in a drug-ravaged Bronx neighborhood in New York City. "Pure cocaine is three times the cost of gold. Now if that's the case, how are you gonna stop people from selling cocaine?"

Kane has come to believe that while drug abuse is bad, drug prohibition is worse — because the black market does horrible things to his community. "There's so much money in it, it's staggering," he says.

Orange County, Calif., Superior Court Judge James Gray agrees with Kane. He spent years locking drug dealers up, but concluded it's pointless, because drug prohibition makes the drugs so absurdly valuable. "We are recruiting children in the Bronx, in the barrios, and all over the nation, because of drug money," he says.

Besides luring kids into the underworld, drug money is also corrupting law enforcement officers, he argues.

Cops are seduced by drug money. They have been for years. "With all the money, with all the cash, it's easy for [dealers] to purchase police officers, to purchase prosecutors, to purchase judges," says Oliver, the Detroit police chief.

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.

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

"Progression to type 2 diabetes can be prevented by lifestyle modification," says Dr. Joann E. Manson, chief of the division of preventive medicine at Brigham and Women's Hospital in Boston, Mass. "Most importantly, lose weight and become physically active."

Medications, such as metformin, may be used in some instances to lower blood sugar. But some experts emphasize the importance of diet and exercise over medical intervention.

"We know that losing weight is effective," says Daly. "In order to create a calorie deficit, which is how you lose weight, you've got to decrease what's coming in the door and increase what's going out the door. You need to work on both sides of that energy equation. You can try to be a couch potato and eat like a bird, but it isn't going to work."

One should not wait until given a pre-diabetes diagnosis. Diet and exercise can help us all.

As a physician, Senator Frist champions medical care. He also champions prevention. Senators Take Up Arms Against Obesity.

"Obesity is, for the most part, preventable," said Frist, R-Tenn. "There is no single solution, but better information, improved nutrition and greater opportunities for physical activity will guarantee progress."

To provide those resources, the three senators are proposing spending as much as $217 million next year and additional money in future years on a variety of programs to encourage proper nutrition and increased physical activity.

The money would go to the Institutes of Medicine, the Centers for Disease Control and Prevention and the Department of Health and Human Services to identify risk factors, analyze government food assistance programs and work with state governments on nutrition and exercise programs.

While I generally oppose government solutions, government funding can stimulate great research. On the surface this sounds like a well placed effort.

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.

Aetna Inc., the Cigna Corporation, Humana Inc. and other health insurers lost a bid to bar plaintiffs' lawyers from obtaining internal records in cases that accuse the companies of skimping on patient care.

Judge Federico Moreno of United States District Court in Miami issued a one-page ruling today instructing the insurers that, beginning Sept. 30, they must provide documents requested by lawyers for the plaintiffs, according to a court order.

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.

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

There are insufficient data to determine which screening strategy is best in terms of the balance of benefits and potential harms or cost-effectiveness. Studies reviewed by the USPSTF indicate that colorectal cancer screening is likely to be cost-effective (<$30 000 per additional year of life gained) regardless of the strategy chosen.

It is unclear whether the increased accuracy of colonoscopy compared with alternative screening methods (for example, the identification of lesions that FOBT and flexible sigmoidoscopy would not detect) offsets the procedure's additional complications, inconvenience, and costs.

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?

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

In their study of close to 3,000 middle-aged adults, these foods were associated with lower levels of total cholesterol and LDL (the so-called "bad" cholesterol) and improved insulin sensitivity. Insulin, the body's key blood-sugar-regulating hormone, tends to be elevated in those at risk of type 2 diabetes.

People who consumed the most whole-grain foods also had a lower body mass index (BMI), a measure of weight in relation to height that is considered a more reliable gauge of overweight than weight alone. Indeed, adults who were overweight or obese had the highest insulin levels and consumed the least amount of whole-grain foods, researchers report in the August issue of the American Journal of Clinical Nutrition.

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 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

The Lean Plate Club, once a mere nugget of an idea, marks its first anniversary today as a solid corps of enthusiastic members who help each other to eat and live more healthfully by sharing their triumphs, their tips, their recipes and, yes, their stumbles.

The club -- formed around the Health section's weekly nutrition column and accompanying Web chat -- is not about dieting, but rather about eating smart and setting realistic goals. It's about rediscovering the joy in eating good-tasting, healthful foods and finding the fun in being physically active -- whether you do it by walking, stretching, tap dancing, riding a bike or simply taking the stairs instead of the elevator.

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?

These questions ring with new resonance following the release last week of a report from the state Department of Public Health showing that 52 percent of adults in the state are officially fat. In fact, researchers discovered that the number of people who are overweight or obese ballooned by 29 percent during the 1990s.

Those findings relied on the body-mass index, the same standard employed by the US Centers for Disease Control and Prevention when it declared an epidemic of obesity last year.

''It definitely has some drawbacks - it's not perfect,'' said Megan McCrory, a Tufts University nutrition research scientist. ''If somebody is relatively muscular, because muscle is more dense than fat, they'll have a BMI that's relatively high. It might look like they're overweight, but, actually, if you measured their percentage of body fat, they would be really lean.

''But,'' and McCrory paused, ''let's be honest. Most people in the United States who have a high BMI are not going to have a high BMI because they have too much muscle.''

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.

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

When they looked at physical education classes for 1,140 older children, ages 11 to 14, the researchers found that some classes required students to take part in as little as 6 to 10 minutes of aerobic exercise.

They then set out to modify the classes by tripling the amount of time some of the students were active.

After eight weeks, the students in the group that exercised more were found to have slightly lower blood pressure readings, and when "skin-fold" tests were used, those students also had lower levels of body fat.

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.

But the leading risk factor for arthritis is obesity, particularly excessive weight gain in midlife and beyond. The heavier you are, the more stress is placed on your spine, hips, knees and ankles.

Also, heavier people tend to resist exercise, resulting in another risk factor — weak muscles, particularly in the thigh. Weakness in the thigh, in turn, places extra stress on the knees.

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

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.

In its recent proposed rule on the Medicare physician fee schedule for 2003, CMS increased payment rates for most immunizations but not for influenza, pneumococcal and hepatitis B vaccine administration. Physician practices may not be able to continue to absorb those losses along with increases in costs.

"When you consider the fact that physicians are facing financial pressure from so many sources, such as the reduction in Medicare payment for physician services and increasing medical liability insurance premiums, it's very difficult to handle inadequate reimbursement for individual services such as this one," said Ronald M. Davis, MD, a preventive medicine physician from East Lansing, Mich., and an AMA trustee.

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.

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!

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:

A British study will try to prove what we believe. Obese patients to diet for science Actually, they have an interesting hypothesis to test.

Researchers are hoping to recruit 400 overweight and obese people for a study to see whether excess weight and a lack of exercise causes the joints of the knee to fail.

...

They will be split into two groups, one undergoing a tough weight loss programme, the others will simply get advice leaflets.

Half of both groups will also be put through an exercise programme to strengthen the quadricep muscles in their knees.

This will allow scientists to study whether it is the lack of exercise or the excess weight which has caused the problems.

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.

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.

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.

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.

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?

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.

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.

“So we studied the last three decades and we found out in fact there has been substantial increase — there were 11 (health-related) deaths last year, four of them from heat stroke.”

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.

But a new trend may be counteracting the healthy habit of drinking plenty of water — taking supplements. Bailes cited studies that show up to 70 percent of college athletes and between 30 and 50 percent of high school athletes take performance-enhancing or body-building supplements.

The trouble is, he said, creatine, ephedra — also known as ma huang — and amphetamines can affect the brain’s ability to regulate body temperature. “It causes constriction of the peripheral blood vessels that diminish the ability to sweat,” he said.

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?

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

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.

The proposal would cost between $400 billion and $450 billion over 10 years and would cover about half of the 40 million senior citizens on Medicare, Kennedy said. That's substantially smaller than the $594 billion plan Democrats unsuccessfully brought to the House floor earlier this week. That plan, as well as a $370 billion proposal offered by a coalition of Republicans, a Democrat and the Senate's lone independent, failed to get the 60 votes necessary for passage.

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.

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.

Democratic senators had insisted on an expansive program of prescription benefits that would have cost the federal government $594 billion from 2005 to 2012. But today many said they could accept a $400 billion program. "If we have to compromise to get something done, then so be it," a Democratic aide said.

...

The majority leader, Tom Daschle, Democrat of South Dakota, said the Senate must pass a prescription drug bill by Aug. 2, when it plans to begin a monthlong recess.

"Our highest priority is to get this bill done," Mr. Daschle said today. "We won't do other things, which are very important, until we get it done."

The Congressional Budget Office estimates that nearly one-fourth of Medicare beneficiaries will have prescription drug costs of more than $4,000 a year in 2005.

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.

...

According to the suits, the companies claim their andro products "are effective at promoting muscle growth, are legal and are proven to be effective."

"We believe the makers and sellers of andro are caught in a Catch-22," Lynch said. "If andro works, they are criminally liable, and if andro doesn't work, they are liable for civil damages."

Blah, blah, blah - why do we not have some regulation of these snake oil salemen? But why do we need another lawsuit?

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!

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.

But this latest study suggests that any benefits only apply if people drink later in life.

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.

In a telephone conference call with reporters, Mr. Edwards said today: "I spent most of my life before I came to the Senate fighting for kids and families against insurance companies, and I think that's the right side to be on. If the president wants to be on the side of the insurance companies, we'll let him do that."

Slick politics, avoid the issue and blame the insurance companies!

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.

But I certainly wouldn't dispute that there are excesses in the marketing budget, or that pharmaceuticals attempt to get people to take drugs when there are perfectly viable alternatives that are cheaper and just as good. However, the question I was asking is not whether in some ideal world there would be less marketing, but whether lowering drug prices would have the effect of lowering R&D or marketing spending; I think that the evidence indicates that it would be the former rather than the latter. And as you are probably well aware of all the ways in which nationalizing health care would call quality of care to suffer, you should not have difficulty understanding why I believe that there would be similar effects on pharmaceutical research.

So I'm not making an ethical judgement on what I think should happen, but an analytical judgement on what I think will. And I think that reimportation would damage R&D beyond repair. I view the excessive advertising etc. as a small transaction cost to pay for a largely efficient research process.

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).

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:

• Chaparral, because of concerns about liver toxicity. Used in an herbal tea.
• Chromium picolinate, because of reports of kidney toxicity and effects on insulin regulation in diabetics. Promoted to reduce body fat.
• Glucosamine, because of concerns about its use by diabetics. Sold as an arthritis treatment.
• Melatonin, because of reports of complications. Used to treat sleep disorders and jet lag.
• Saw palmetto, because of reports of heart problems. Sold as a prostate treatment.
• Shark cartilage, because of a report of hepatitis following ingestion. Promoted as a treatment for cancer and other health conditions.

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

Being a man 'is bad for health'

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.

The fresh effort to restrict awards in malpractice cases was seen in a report Wednesday by Health and Human Services Department. President Bush also was making the issue a centerpiece of his visit Thursday to a hospital and university in High Point, N.C.

...

The result has been closed practices, rising health care costs overall as doctors defensively prescribe unnecessary tests and treatments, and fewer physicians entering high-risk areas.

The solution is to limit damages for pain and suffering in malpractice cases, the report suggests.

"We must put an end to the malpractice litigation lottery that favors a handful of powerful personal injury lawyers and instead create a commonsense system," HHS Secretary Tommy Thompson said.

Legislation in Congress would limit the pain and suffering and punitive portions of malpractice awards. The bill, intended to override state laws, would curtail lawyers' fees and allow juries to hear about the plaintiffs' other sources of income.

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.

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.

Samuel Hirsch filed his lawsuit Wednesday at a New York state court in the Bronx, alleging that McDonald’s, Burger King, Wendy’s and KFC Corporation are irresponsible and deceptive in the posting of their nutritional information, that they need to offer healthier options on their menus, and that they create a de facto addiction in their consumers, particularly the poor and children.

"You don't need nicotine or an illegal drug to create an addiction, you're creating a craving," Hirsch said. "I think we'll find that the fast-food industry has not been totally up front with the consumers."

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!

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!

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.

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.

Whether you are 20 or 90, strength training stops muscle loss and builds new muscle tissue. That muscle will burn calories, give your body shape, influence your flexibility and sense of balance, and protect you against several diseases.

To a certain extent, strength training even reverses some of the changes normally associated with old age, such as decreased stamina, energy and balance.

Are you taking care of your body?

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.

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.

"Once the media sensation over the study subsides, the data will speak for themselves and hormone replacement therapy will remain an important part of women's health care," Mr. Essner said in a conference call with analysts.

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!

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.

Democrats wanted the government to establish uniform drug benefits, while Republicans wanted the government to pay subsidies to private insurers to provide coverage for drug costs, with insurers allowed to vary premiums and other details.

"We are not going to give up," said the Senate majority leader, Tom Daschle, Democrat of South Dakota. "Everything is on the table. If we can find a role for the private sector, for the insurance industry, I would not be averse to doing that."

Likewise, when asked if he would consider a proposal to provide drug coverage just to Medicare beneficiaries with low incomes or high drug expenses, Mr. Daschle said, "I'm not averse to that."

But Senator Edward M. Kennedy, Democrat of Massachusetts, said he would prefer not to make such concessions in a program that provides health insurance to virtually all the elderly, regardless of income.

So instead of compromise we have posturing. Instead of compassion we have politics. But then, this is what we expected.

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

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...

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.''

A spokesman for Finance Committee Chairman Sen. Max Baucus, D-Mont., conceded Monday that a compromise could take some time.

``Our commitment to this issue is to get the right bill,'' said Michael Siegel. ``We're operating under no self-imposed deadlines, which means we could be at this well beyond this week.''

I hope that they can develop a reasonable compromise.

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.

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

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.

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.

...

The issues are different for doctors in solo practice. "You just become a rat on a treadmill working in the HMO system, taking 30 to 35 patients a day," said Smith, who quit practicing for a year after almost a decade working at a large group practice in Laguna Beach. "In starting this service, all I wanted was to practice medicine again, to return to an old-fashioned family practice where the patients felt like family."

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.

Justices also will look at how far states can go in trying to use their Medicaid programs to negotiate prescription drug rebates with pharmaceutical companies for non-Medicaid-eligible residents. The court may add other health-related cases to its docket as its new term approaches.

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.

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.

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.

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!

State court gives medical pot users new protections Justices rule its use is OK when prescribed by a doctor .

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.

Law's gory details designed to deter piercings .

The law says the following language must be added to the currently required consent form:

"I understand that the oral piercing of the tongue, lips, cheeks, or any other area of the oral cavity carries serious risk of infection or damage to the mouth and teeth, or both infection or damage to those areas, that could result in but is not limited to nerve damage, numbness, and life threatening blood clots."

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!

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

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.

Collecting data regarding what foods people ate during adulthood, Grace Petot and her colleagues discovered that low-fat diets containing vitamins such as A, C and E in fruit and vegetables are associated with a reduction in risk for Alzheimer's.

Three other studies to be presented at the conference in Stockholm, the largest gathering ever of Alzheimer's researchers, bolster evidence that taking cholesterol-lowering drugs could reduce the chances of developing Alzheimer's.

A study by Dr. Robert Green at Boston University School of Medicine found that people taking cholesterol drugs called statins reduced their risk of developing Alzheimer's by 79 percent. With 2,378 patients, it is the largest study to investigate the connection and the first to include large numbers of black people, who are disproportionately likely to develop Alzheimer's.

The study also found that types of cholesterol-lowering drugs other than statins were not linked with a reduced risk of Alzheimer's.

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.

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.

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.

The Pharmaceutical Research and Manufacturers of America, a trade group for brand-name drug companies, has gone to court to stop drug discount programs adopted in Maine, Vermont, Florida and Michigan, among other states. The organization denounced Ms. Stabenow's proposal, saying it could embolden more states to try to control drug costs by restricting access to certain medicines for low-income people.

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.

Tricks do not work, nor do the many advertised "supplements". This article has no surprises, but much data. Fat Busters

Finding the "Best" Exercise.

Instead of looking for the "best exercise," think about the best reasons to exercise.

Take weight control. The fundamental principle of weight loss or control is simple: Burn more calories than you consume. Use up 100 excess calories, and it doesn't matter if you do it by running, washing your car, digging in your garden or even cross-country skiing - you will lose weight.

Likewise, your heart and muscles aren't picky about the activity you choose; they'll be happy whether you choose to jog or play tennis. What matters is the regular physiological stress placed on the various body systems, which results in improved fitness.

...

So, when I am asked, "What is the best exercise?" I have a very simple answer: "The one that you like to do."

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!!)

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:

"The bill would create an incentive for unscrupulous individuals to find ways to sell unsafe or counterfeit drugs that while purported to be from Canada may actually originate in any part of the world. Canada could become a transshipment point for legitimate or nonlegitimate manufacturing concerns throughout the world. In many cases, we would not be able to determine the true country of origin."

Counterfeit drugs could easily be commingled with authentic products, and "there is no sampling or testing protocol sufficient" to detect them, Dr. Crawford said.

I suspect that we will hear more on this issue.

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.

Merck reported a net income, or profit, of $7.28 billion —15 percent of revenue, or triple the $2.46 billion it spent on research and development, Families USA pointed out.

Pfizer, which makes the blockbuster Viagra impotence pill, spent 35 percent of its $32.2 billion in revenue on marketing, advertising and administration and 15 percent on research and development.

“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.”

But Pollack said the numbers, available in each company’s annual report, speak for themselves. “At the same time drug prices are skyrocketing, drug companies are spending more and more promoting their drugs,” he said.

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.

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.

The survey of 338 doctors, conducted last Friday by ImpactRx, a drug marketing intelligence firm, bodes poorly for sales of Prempro and for the drug's maker, Wyeth.

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're doing a lot of education," said Lauren Cislak, a Lilly spokeswoman. She said the company wanted to make sure that patients and doctors knew that Evista did not include estrogen or progestin, like Prempro and the other hormonal treatments.

Merck & Company ran a full-page ad in The New York Times on Sunday, promoting Fosamax, another drug that treats osteoporosis. The ad made it clear that Fosamax is a nonhormonal treatment.

"We're encouraging women to have a discussion with their doctor," said Gregory Reaves, a spokesman for Merck.

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.

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.

"They view this not as a true disorder but as some kind of weakness of character, and if only they could just pull themselves up by their bootstraps they would be fine," Nemeroff said.

"And for them, asking for help is a sign of weakness. When in fact, they've asked for help many times in their professional careers to solve problems."

And CEOs are experts at surrounding themselves with the best people who can help mask their condition. Johnson had his assistants plan meetings around his down times.

"I just felt that you didn't want a leader who was at times going into his side office, lying on the floor, putting a pillow on his head," Johnson said.

Johnson's wife pulled him into treatment after he lost his job as publisher of the Los Angeles Times.

But he said it wasn't until he moved to Atlanta and his job at CNN that he found a treatment that worked for him: talk therapy and the drug, Effexor.

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.

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.

Do you remember Economics 101? One main issue was elasticity.

Elasticity: a measure of the responsiveness of one variable to another.

Elasticity is the concept in economics that measures the responsiveness of one variable in response to another variable. The best measure of this responsiveness is the proportional or percent change in the variables. This gives the most usable results for any type or range of data. Thus elasticity is the proportional (or percent) change in one variable relative to the proportional change in another variable.

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.

"That's a pretty big car payment," Mr. Krygowski, 39, who lives in Hirscher, Ill., lamented during a call to a smokers' "quit line" today. "I am just sick of smoking. I'm tired of the way I feel.

"I wanted to quit even before the price went up," he added. "The cost just kind of sealed the deal."

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!!!!!!!!!!!!!!!!!!!!!!

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.

Take Away My Hormones? Over My Dead Body

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)

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.

The recommendations don't end there. The researchers also suggest using a technique of combining information from all existing risk factors to determine a person's percentage risk for developing heart disease in the next 10 years of his or her life.

This should be done every five years starting at age 40 or for anyone with two or more risk factors, according to the guidelines.

And having more areas of slight risk can be more dangerous than having one area of very high risk.

Those drafting the guidelines incorporated recommendation from other groups -- such as the American Diabetes Association and the U.S. Preventive Services Task Force -- developed over the past five years.

Other notable additions since the guidelines were last released in 1997 include:

• Low-dose aspirin for people at increased risk for heart disease.
• Blood-thinning drugs to reduce stroke risk in those with an abnormal heart rhythm called atrial fibrillation.

You can read the guidelines in Circulation - AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update

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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.

Two Republicans, Sens. John Ensign of Nevada and Chuck Hagel of Nebraska, entered the fray Monday by offering a 10-year, $160 billion proposal, the least expensive so far.

That plan relies mostly on a Bush administration proposal to have seniors buy private discount drug cards at $25 a year for savings. Government help would kick in once a senior citizen reached limits set according to income. For instance, the poorest seniors would have a $1,500 cap. After the cap was met, a beneficiary would pay no more than 10 percent of the cost of each prescription.

As predicted, we won't get much intelligent debate, but rather much politics.

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

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

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.

By downgrading its estimate of physicians' ability to increase their income by being more productive, the Centers for Medicare & Medicaid Services has proposed restoring more than $1 billion in physician Medicare payments through 2005.

The change was announced just as the House of Representative voted 221-208 to adopt a Medicare reform package that included a prescription drug benefit and a three-year fix of the physician payment update formula. The measure would eliminate deep cuts in Medicare payment rates, setting the update at about 2% for each of the next three years.

Well this could help a bit. The politics of Medicare payments continues in the Senate this week. More as I find links.

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?

Another discussion of the story - The End of the Age of Estrogen

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?).

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.

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.

Dietary fat has been demonized over the past two decades. However, this study shows that a low-calorie diet deriving 35% of its total calories from fat will help you lose weight and keep it off for longer.

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.

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.

Drug companies also oppose efforts to import cheaper prescription drugs from Canada. Inevitably, they say, such imports will include products that are counterfeit, contaminated, adulterated or misbranded.

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."

Mr. Holmer said that the drug industry favored Medicare coverage of prescription drugs, "offered through competing private insurance plans that rely on marketplace competition to control costs."

Ms. Stabenow said such coverage would be unreliable and unstable, like the coverage provided by health maintenance organizations. Many H.M.O.'s have found federal payments inadequate and pulled out of Medicare, dropping 2.2 million beneficiaries since 1998.

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.

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.

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.

• Incorporating fitness into one's lifestyle is the goal - if one does - the weight generally takes care of itself
• We have an excess of dietary theories - but I'm certain that we shouldn't eat excess fats or "unrefined" carbohydrates. Calories matter, but so does the composition of the diet.
• Cardiovascular fitness and muscle fitness complement each other
• One should contemplate each week with a plan - when will I workout - how will I balance my diet
• As a country we must encourage studies which evaluate methods for making fitness easier and a greater priority for Joe and Jill six-pack

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.

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.

A Diet Rich in Partial Truths

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.

"The big problem we have, which causes escalating costs, is utilization," Mr. Snedden said. "People are using more and more prescription drug products. If we could get utilization under control, drug prices would not be such a big problem."

Ray Landis, a lobbyist for AARP here, said the situation in Pennsylvania should teach federal officials to be cautious in making assumptions and projections. "In our program," Mr. Landis said, "both utilization and price increases have been much greater than anticipated."

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.

“The myth of women looking like men because of large muscles is really not possible genetically for women due to less muscle fiber,” explains University of Connecticut’s Dr. William Kraemer, who has studied strength training for 20 years. “It’s a fear that really isn’t founded scientifically.”

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.

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."

The study, reported in July's Obesity Research, was paid for by the drug's manufacturer, GlaxoSmithKline.

During the first half of the 48-week study, 227 obese people were randomly assigned to take one of two doses of bupropion or a dummy pill each day. Participants also were on a restricted diet and asked to increase their exercise by about 50%.

Those on the higher dose of bupropion lost 10% of their body weight compared with 7% for those on the lower dosage. Those who took the dummy pill lost about 5% of their body weight.

In the second 24 weeks, 192 participants who completed the first part of the study were all given bupropion and were able to sustain their weight loss.

Those on the higher dose maintained an 8.6% loss and those on the lower dose maintained a 7.5% loss.

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.

The bill approved today would allow a single 30-month delay, to protect patents listed at the time a brand-name product is approved by the Food and Drug Administration.

Brand-name drug companies adamantly opposed the measure, saying it would reduce patent protections for their products, thus reducing incentives for the discovery of cures and treatments.

Amidst the furor comes this reasoned analysis of the hormone study - Study shouldn't panic women

If you don't love this article, then you are a Scrooge - Bingo 'boosts the brain'

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.

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.

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.

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.

"We stood there and said, Hello? You couldn't approve a drug for healthy men without a randomized clinical trial. Even aspirin had to have a randomized controlled trial with healthy men," she said, alluding to the data that persuaded the F.D.A. to allow aspirin makers to market their product as protective against heart attacks. In a randomized controlled trial, patients are divided at random into groups, with each group taking a different treatment or placebo. They are considered the gold standard of scientific evidence.

The agency's advisory committee recommended that the company be able to market estrogen as protective against heart disease, but the panel was overruled by the agency, which said better data were needed.

In the end, Wyeth began a randomized controlled study that most doctors and researchers assumed would prove estrogen's beneficial effects on the heart. The study, known as HERS, involved women who had already had heart disease, a group in whom effects should be easiest to find.

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.

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?

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."

The skinny on 'good fats' - which discusses good fats and "bad fats" as well as good carbs and "bad carbs".

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.

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.

But if there is one overarching cause of soaring health care expenditures, it is Americans' insatiable appetite for each and every medical test and treatment available, the experts agree.

"The truth is Americans want everything and they don't want to pay for anything," said Gov. Howard Dean (D-Vt.), who is running for president on a health care platform. "We need to admit to ourselves that health care is expensive because we all want the best for our families."

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.

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.

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."

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.

This is further intensified by the demands of having to monitor more specialist drugs and treatments, and by patients who are demanding a quicker service and more say on their own care.

At the same time, general practice is experiencing an increasing staffing problem:

• In some inner-city areas one in five posts are vacant.
• In some areas 50% of GPs are over the age of 50, and close to retirement

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.

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.

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?

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.

...

What's forgotten in the current controversy is that the low-fat dogma itself is only about 25 years old. Until the late 70's, the accepted wisdom was that fat and protein protected against overeating by making you sated, and that carbohydrates made you fat. In ''The Physiology of Taste,'' for instance, an 1825 discourse considered among the most famous books ever written about food, the French gastronome Jean Anthelme Brillat-Savarin says that he could easily identify the causes of obesity after 30 years of listening to one ''stout party'' after another proclaiming the joys of bread, rice and (from a ''particularly stout party'') potatoes. Brillat-Savarin described the roots of obesity as a natural predisposition conjuncted with the ''floury and feculent substances which man makes the prime ingredients of his daily nourishment.'' He added that the effects of this fecula -- i.e., ''potatoes, grain or any kind of flour'' -- were seen sooner when sugar was added to the diet.

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.

Few experts now deny that the low-fat message is radically oversimplified. If nothing else, it effectively ignores the fact that unsaturated fats, like olive oil, are relatively good for you: they tend to elevate your good cholesterol, high-density lipoprotein (H.D.L.), and lower your bad cholesterol, low-density lipoprotein (L.D.L.), at least in comparison to the effect of carbohydrates. While higher L.D.L. raises your heart-disease risk, higher H.D.L. reduces it. What this means is that even saturated fats -- a k a, the bad fats -- are not nearly as deleterious as you would think. True, they will elevate your bad cholesterol, but they will also elevate your good cholesterol. In other words, it's a virtual wash. As Willett explained to me, you will gain little to no health benefit by giving up milk, butter and cheese and eating bagels instead.

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.

If these trends are correct, then the obesity epidemic can certainly be explained by Americans' eating more calories than ever -- excess calories, after all, are what causes us to gain weight -- and, specifically, more carbohydrates. The question is why?

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.

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.

In all five studies, cholesterol levels improved similarly with both diets, but triglyceride levels were considerably lower with the Atkins diet. Though researchers are hesitant to agree with this, it does suggest that heart-disease risk could actually be reduced when fat is added back into the diet and starches and refined carbohydrates are removed. ''I think when this stuff gets to be recognized,'' Stunkard says, ''it's going to really shake up a lot of thinking about obesity and metabolism.''

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:

• The cost of preventive medications


• Conflicting data on whether a preventive measure works


• Physician's inconsistency in prescribing preventive measure


• Patient's reluctance to accept screening tests


• Risk benefit ratios change as new studies are published

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.

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.

In the placebo group, 14.7% died during that period - compared with 12.9% in the statin group.

Deaths from heart problems were 18% lower than in the placebo group, and strokes and heart attacks were down approximately 25%.

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...

The past 25 years have seen the establishment of aspirin, ß-blockers, ACE-inhibitors, and lipid-lowering therapies to lower the risk of future vascular events, by about a quarter each, in high-risk patients (panel). The benefits of each intervention appear to be largely independent, so that when used together in appropriate patients it is reasonable to expect that about two-thirds to three-quarters of future vascular events could be prevented. Add to this the potential benefits of quitting in smokers (which lowers the risk of myocardial infarction by a half), and blood-pressure lowering (a 10 mm Hg reduction in systolic blood pressure could reduce the risk of vascular events by a quarter) in hypertensive patients, and it may be possible to lower the risk of future events by more than four-fifths in high-risk individuals. Therefore, the potential gains from the combination of currently known preventive strategies are large. Given that over 80% of cardiovascular disease occurs in developing countries,10 a priority is to make these interventions affordable, accessible, and convenient (perhaps even a combination pill). Ensuring that patients worldwide receive these treatments will lead to substantial clinical and public-health 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.

Some states are shunning the program, however, warning of financial risks for their Medicaid budgets and the low-income people they already serve. In addition, said Ray Hanley, chairman of the National Association of State Medicaid Directors, many states simply cannot afford to spend more on health care, even with federal help, at a time of economic sluggishness and squeezed budgets.

Medicaid already accounts for 20 percent of most state budgets, and Joan Henneberry, a health policy expert with the National Governors' Association, said that to maintain services in the year ended June 30, states used up reserves they had amassed in previous years, and dipped into money from tobacco settlements as well.

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.

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

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.

"What a doctor needs to do is take a deep breath and say 'Why do you ask?' rather than indicating either that you are willing to participate or that you are unwilling to participate," Tolle said.

"The doctor should ask, 'What are you afraid of? What are you worried about?"' she advised.

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:

...The conundrum remains: if both doctors and patients are fallible, who should decide? We want a rule. And so we decide that patients should be the ultimate arbiter. But such a hard-and-fast rule seems ill-suited both to a caring relationship between doctor and patient and to the reality of medical care, where a hundred decisions have to be made quickly.... The doctor should not make all those decisions, and neither should the patient. Something must be worked out between them, one on one?a personal modus operandi....
...Medicine will continue to struggle with how patients and doctors ought to make decisions. But, as the field grows ever more complex and technological, the real task isn't to banish paternalism; the real task is to preserve kindness.

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

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

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."

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.

"We think a broader redesign effort is needed," he said. "There will need to be a culture change [for physicians] from lone ranger to Navy SEAL -- from doing it on your own to teamwork and redundancy. We expect this will precipitate a major change in health care delivery."

This approach could also face funding problems. "We know it will cost more," said Dr. Leach. "We don't know how much."

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.

Another is a basic quality of the condition: it is a silent disease, and a vast majority of people with it feel fine, even as it causes life-threatening or fatal damage. About 30 percent of people with hypertension don't know they have it.

A third factor is the unwillingness or inability of most people with high blood pressure to change their diets and try exercise and relaxation techniques that can bring their readings down to normal.

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.

Last but hardly least, the drug companies with the greatest financial interest in getting all people with hypertension into treatment may have had a detrimental effect on the acceptance of drug therapy.

At the expense of older, less expensive drugs, pharmaceutical companies have heavily promoted newer and more expensive medications that may not always be the best for a particular patient. These may also be too costly for many older patients, who, since Medicare does not pay for drugs, have been known to take half the prescribed dosages to stay within their budget.

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.

A doctors' group, the American Society for Reproductive Medicine, issued a statement that said for women in early menopause, hormone replacement was the best way to relieve menopausal symptoms like hot flashes and prevent bone loss, "with minimal risk of side effects."

The group added, "The HERS study is not relevant for this younger patient population."

Wyeth, the company that makes Premarin, the most widely used form of estrogen replacement, issued a similar statement.

"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.

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.

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.

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.

Wonderful long philosophical piece about alternative medicine - Put alternative medicine back in its box. Very nicely written, complex but helpful.

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).

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.

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!

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.

Patient autonomy often seems to be more important to doctors than patients. As a first-year cardiology fellow, a big part of my job is to obtain "informed consent" for procedures. I tell patients the risks ? bleeding, infection, heart attack, death ? but rarely does this prompt a meaningful discussion. Instead, I am invariably told, "You're the doctor, I'll go along with whatever you say."

Most of my patients seem to think "informed consent" is a sham, either asking them to ratify decisions that have already been made or to make decisions they are not equipped to make. Informed consent, as it is practiced today, is very different from the way ethicists envisioned it. It was supposed to protect patients from doctors. Instead, it is used to protect doctors from patients or, rather, from the hard decisions that patient care demands. Doctors today sometimes use informed consent as a crutch to abdicate responsibility, as I probably did that afternoon.

I do not advocate a return to the paternalistic ways of the past, but patients need doctors to guide them through the tough decisions and, sometimes, tell them what to do. The father of a friend of mine died two years ago from lung cancer. My friend told me that when he asked the doctors about chemotherapy, they gave him numbers and statistics but assiduously avoided giving advice, which was what he really needed.

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

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.

Dr Bogle told the BMA's annual conference in Harrogate: "Doctors are not working on a production line.

"Do we want this new money to help us deliver a sausage factory service based on productivity targets, which ignore the needs of individuals and the importance of time with patients?

"Or do we want it to help us deliver a quality service that is truly patient-focused and patient-centred?"

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.

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.

It turns out that the more severely depressed people are, the less likely they are to respond to a placebo. And people with more mild depressions get better with just about all treatments, including placebos. Since most clinical trials enroll less severely depressed patients, the observed difference between the response to an antidepressant and a placebo can be misleadingly small.

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