What Really Makes You Fat? Should you count calories or carbs? The latest research may surprise you - Well written and balanced article. And in the same issue, a debate between Atkins and Ornish - Low Fat vs. Low Carb The doctors present their dueling diet theories:. Atkins says,

For over 30 years, I've been a lone voice in the wilderness. I am grateful that the National Institutes of Health is now examining controlled-carbohydrate and low-fat nutrition. These studies may end up showing that excessive carbohydrates are the true culprits, not fat. At what point am I allowed to say, "I told you so"?

I have written about that frequently over the past months. Ornish responds,

Here's how you lose weight: burn more calories. Eat fewer calories. That's it.

You can burn more calories by exercising. You can eat fewer calories by consuming less food. You can lose weight on any diet, but it is hard to keep the pounds off because you feel hungry and deprived. An easier way to consume fewer calories is to eat less fat, because there are nine calories in each gram of fat, whereas protein and carbohydrates have only four. So eating less fat allows you to consume fewer calories without eating less food.

I agree with the high-protein advocates that it is wise to eat fewer simple carbohydrates, like sugar, white flour and white rice. They are also low in fiber, so you get a lot of calories that don't fill you up. On top of that, simple carbohydrates get absorbed quickly, causing your blood sugar to zoom up. Your body responds by making more insulin, but too much insulin accelerates conversion of calories into body fat.

The goal, however, is not to go from simple carbohydrates to bacon and brie. Instead you should opt for whole foods with complex carbohydrates such as unrefined whole-wheat bread, brown rice, fruits, vegetables and beans. These are packed with thousands of protective substances. In addition, they are rich in fiber, which slows their absorption, thus preventing a spike in your blood sugar and an excessive insulin response.

They really are not that far apart. This is a good reference.

Spot Reduction? Forget It! Wisdom from a runner.

What should you eat? What should you avoid? Are there 'forbidden foods'? Clearing up nutrition nonsense - Many people mistakenly focus on ‘forbidden’ foods: survey

This new survey suggests that consumers may place an over-emphasis on weight control. Sixty-three percent consider body weight an indicator of healthful eating. Research shows that the increase in obesity in our country reflects an increase in extra-large portion sizes, an excess proportion of high-fat and high-sugar foods in our diets, much too low consumption of fruits and vegetables, and lifestyles that are too often sedentary. But this does not mean that as long as someone’s weight is OK, they must be eating well.

Unfortunately, diet books and advice on the Internet may encourage a variety of food choices quite contrary to what research shows to be healthy eating. If a weight-loss diet results in lost weight — usually because it involves consuming fewer calories — that doesn’t mean it supports overall well-being.

Another misconception is reflected in a statement agreed to by 57 percent of the people surveyed: “I believe there are some foods that I should never eat.” Past surveys showed that increasing numbers of people supported the belief that all foods can fit into a healthful diet, that it’s a matter of the proportion different foods play in our diet rather than being “bad” or good.” But clearly, according to the most current survey, many people still don’t believe that.

Epidemic That Wasn't tells the story of the lack of a Long Island breast cancer epidemic!

For years, it has been widely thought that rates of breast cancer on Long Island are unusually high. But, contrary to popular belief, they are not. The rates on Long Island are not much different from those of the rest of the country — and a number of areas in the Northeast and elsewhere have higher rates.

But the perception of an epidemic has persisted like a suburban legend. Figures that scientists say have no basis in fact, like a breast cancer rate that is 30 percent higher than the national average, have been bandied about at public meetings, and repeated by breast cancer patients, politicians and newspapers, including The New York Times.

So we spent millions of dollars studying this urban myth. Once an activist group believe something, they do no easily accept data.

But Dr. Michael B. Bracken, a professor of epidemiology and public health at Yale University, says the study should never have begun. "It is an example of politicians jumping on the bandwagon and responding to the fears of their local population without really thinking through what is going on in science," he said. Such a study, he added, "is not so much science as a political response."

The study's scientists, in the meantime, find themselves trying to appease two masters, other researchers and breast cancer activists.

Politicians should not make research policy. The squeaky wheel should not make research policy. But I do not live in an ideal world. The NY Times comments today - Breast Cancer Mythology on Long Island

I usually leave malpractice links to medpundit and RangelMD, but this one is so good that I wanted to share it - A plague spread by fee-bitten lawyers. I know the arguments - the patient was injured by the evil medical system. How can we value and limit the financial 'penalty'? Juries do not care, because in their case they believe the insurers, doctors and hospitals have deep pockets. Unfortunately, we need polticians to step up like they did in California. Each suit (even the many unsuccesful suits) damages our health care system - raising costs for patients. Physicians really want to care for patients, that is why we chose medicine. The unintended consquence here is scary.

Maybe we ought to start putting labels on some lawyers, like the kind on the side of cigarette packs: "Warning: Immense jury awards can be dangerous to obstetric care and trauma centers."

...

California's example needs to be emulated, for health's sake. Mississippi's governor, Ronnie Musgrove, is expected to call a special session of that state's legislature to do something about the out-of-sight costs of medical malpractice insurance in his state. Nobody is trying to limit awards for actual damages, but punitive damages are now damaging the public health most of all.

The Bush administration has tried to get Congress' attention as this medical/legal crisis developed. It suggested limiting out-of-control jury awards, but was stymied by the Democrats in the Senate.

When one party has been largely captured by a special interest — in this case, the trial lawyers' lobby — the chances for reform begin to resemble those of a poor patient in urban Philadelphia or rural Mississippi.

Let's hope the Senate gets another chance to cap jury awards beyond actual damages — before more obstetricians take down their shingles, and more hospitals shut down vital services.

In the meantime, the prognosis for reform remains poor. Not every plague, it turns out, is the result of micro-organisms. This one is spread by lawyers.

Well said!

As long time readers know, I worship at the altar of data. I want to know truth not theory. We have preached for years that stretching prevents muscle injuries. Stretching 'fails to stop muscle injury'

These showed that stretching reduces soreness by such a small amount that most athletes would not consider the effect worthwhile. Neither does it significantly help to prevent injuries.

Data from two studies on army recruits in training, whose risk of injury is high, show that muscle stretching prevented on average one injury every 23 years.

...

Researcher Dr Rob Herbert, from the University of Sydney, told BBC News Online the belief that stretching reduced injury first came to prominence in the 1960s.

The theory was that muscles were more likely to spasm, and cause pain, if they were suddenly called into vigorous action.

Dr Herbert said: "It sounded like a good idea, and the timing was perfect - around the time we were learning that physical activity reduced risk of heart disease, so recreational exercise was becoming very popular.

"But like many good ideas, the muscle spasm theory of muscle soreness was wrong and has since been discredited, but the practice of stretching before exercise persists."

Dr Herbert said it was possible that a gentle warm up before strenuous exercise may reduce the risk of injury - but even this was far from certain.

"There is no proven way of preventing muscle soreness associated with unaccustomed exercise apart from repeated performance of that specific type of exercise.

"With unaccustomed exercise, people get sore, but with repeated performance of the exercise they become resistant, for a time, to the muscle damage that causes soreness.

"It appears that the only way to prevent soreness is to get muscle soreness."

For those who like reading the original article - Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review

After writing about the probable benefits of B complex vitamins for heart disease, I find this article from Great Britain - Warning on vitamin use

Taking extra vitamins is unnecessary for most people and may be harmful if taken in large quantities, a health watchdog has decided.

The Food Standards Agency has confirmed that if people eat a healthy, balanced diet, they should not need to take supplements as well.

Recommended upper safety limits:

• Vitamin B6 - 10 milligrammes/day


• Beta-carotene - 7 mg/day


• Vitamin E - 7.27mg/day


• Copper - 5mg/day


• Zinc - 25 mg/day


• Selenium - 0.2 mg/day


• Silicon - 1,500 mg/day


• Nickel - 0.16mg/day


• Boron - 5.93mg/day

The agency has issued recommended safety limits on nine commonly used vitamins and mineral supplements amid concerns that consumers are potentially putting themselves at risk from overuse.

The list includes Vitamins E and B6, zinc, copper, nickel, silicon, beta-carotene, boron and selenium.

We learn early in medicine that when a bit of something helps, more does not necessarily help more. One aspirin a day helps prevent heart attacks. Many aspirins can cause bleeding. Most drugs have "therapeutic windows". I suspect this is true for vitamins.

The good and bad of going over-the-counter Physicians often have mixed feelings about drugs going OTC. This article gives a nice balance and puts the decision into appropriate perspective. I will briefly discuss 2 drug classes.

Women can now self treat for candida vaginitis. Most women know when they have it, and the treatment usually works well. However, other infections can cause vaginitis. Some vaginitis is not infectious. So some women will waste money and time by self treating incorrectly.

Proton pump inihibitors (Prilosec, Prevacid, Aciphex and the hated Nexium) are a class of drugs which inhibit acid secretion in the stomach. The give relief to ulcers, simple gastritis, and most important GERD (gastroesophageal reflux disease - known to most as the disease associated with heartburn). We already have the histamine 2 blockers OTC (Tagament, Pepcid, Zantac) for these conditions. PPIs work better. So what is my concern? Heartburn or abdominal pain may herald a more serious condition. I believe that my history taking would give me some clues to evaluating some patients further. Gastroenterologists see the worse cases of GERD - which often have complications like stricture or even cancer. If patients self treat for years, they may miss the opportunity for better diagnosis and treatment. On the other hand, OTC equals lower prices for PPIs. The article gives the right balance. I do want OTC Prilosec, but I want patients to still talk to me about the problem periodically.

Poor prescriptions for health prospects

But this private American industry of miracle-makers and lifesavers is now under assault from all directions. Many people apparently want the miracle medicines without paying for them, or paying nearly enough to keep them coming.

Charlatans are rushing forward to posture themselves on a high moral pedestal as the champions of the poor, the sick, and the needy in attacking the pharmaceuticals. But all these self-appointed saviors have never produced one drug or medicine that has ever benefited anyone.

This has been reflected in the still pending congressional debate over a Medicare prescription drug plan. The Senate bill would allow unrestricted importation of American-made drugs from Canada, purchased under Canada's price controls. Moreover, even in the U.S., Medicare reimbursement under the pending plans would fall far short of market prices.

Such provisions would drastically reduce the revenue flow to the pharmaceuticals. That would in effect sharply slash the nation's true budget for research and development of miracle drugs.

Solid profits on the drugs that work are necessary for a time to make the whole process of modern biomedical drug development viable. The research and development is highly expensive, an average of $800 million for each new drug, and the investment in it is very long term, for it takes well more than 10 years for a successful research effort to start making any money.

Pardon me while I hyperventilate. The pharmaceutical industry has good features. New drug classes often help patients greatly. I and most physicians greatly appreciate the advances of the last quarter century - statins, ACE inhibitors, ARBs, quinolones, proton pump inhibitors, etc. What this guy ignores is the greed of some companies. They deserved a good return on Prilosec. They have no excuse for Nexium. Likewise Claritin and Clarinex. They do not need to raise prices each year at a greater percentage than the cost of living. I favor the free market, but this is not the free market.

Nightmare of crack nicotine

Drug Cos. Seek Ban on Price Lists.

A coalition of drug makers sued Health and Human Services Secretary Tommy Thompson for approving Michigan's 6-month-old "preferred drug list" program for Medicaid recipients.

Medications can only get on the list if its manufacturer agrees to offer the drug at a steep discount. If doctors want to prescribe a drug not included on the list, they must get prior approval from the state.

"State programs that restrict access, we feel, violate federal law and can result in harmful consequences to the country's most vulnerable patients," said Jan Faiks, a lawyer for the Pharmaceutical Research and Manufacturers of America or PhRMA.

PhRMA wants U.S. District Court Judge John Bates to stop Michigan's program and similar initiatives in other states. Florida and Louisiana also have the preferred drug list programs, while Connecticut, Missouri, Hawaii, Illinois, Minnesota, Mississippi, New Mexico, North Carolina, Ohio, Vermont and West Virginia are in various stages of implementing such programs, according to PhRMA.

'Spokesmen for the Department of Health and Human Services and the Michigan's Department of Community Health declined to comment on the hearing Wednesday. ' And I refuse to comment.

Depression and diabetes often occur together. Data have shown that depression complicates diabetes, and patients with both have worse outcomes than those with diabetes alone. Fighting depression can help diabetics

More aggressively treating depression in diabetics could dramatically improve their physical health, too, research presented to the American Psychological Association's annual gathering here found.

Twenty million Americans have diabetes. That number is on the rise, and about a third of diabetics have significant depression.

Diabetes doubles a person's odds of suffering from depression, and those who have diabetes are more likely to have major depression.

New studies suggest that treating depression could ease the current epidemic of diabetes, said psychologist Patrick Lustman of Washington University School of Medicine in St. Louis, adding that the strong potential for using depression treatment to also improve diabetics' physical health ''has hardly been tapped.''

...

In seven controlled studies by his team, depression treatment worked for a majority of the diabetics. Most important, as depression eased, the glucose in the patients' blood became better controlled. That's a key factor in preventing the effects of diabetes, Lustman said.

Six of the seven studies used antidepressants. But the seventh, employing what's known as cognitive behavioral therapy, showed the highest success rate, 85 percent, and produced the greatest improvement in glucose control, Lustman said.

The therapy seems to work best because it often spurs physical activity, which helps with both the depression and the diabetes, he said.

Now could we possibly convince insurers to pay for depression care. Mental health disorders receive short shrift regualarly from insurance companies. They do not consider that treating depression might be cost saving!

When you study tobacco addiction, you find astonishing features. Animal studies suggest nicotine is more addicting than heroin. When you talk to patients, and really try to understand the effects of that addiction, you should feel empathy, as withdrawal is like leaving your best friend.

Cigs Ensnare Some Teens Quickly. This story reports on evidence that not only is nicotine withdrawal difficult, for some teenagers addiction comes easy. Everything about this addiction drives me nuts. I have seen patiens smoke through tracheostomies (made after there laryngectomy for a smoking related cancer). Patients often smoke while on home oxygen. Patients argue with me about going outside in the winter to smoke - even after a myocardial infarction or during an exacerbation of their chronic lung disease. AAAARRRRRRGGGGGHHHHH!

Norah Vincent (quickly becoming one of my favorites) writes about psychiatry - Norah on psychiatry - today. For both of these links you need to scroll to the correct day. She finishes with this inspiring paragraph

Psychiatry is something of a racket if you ask me. You’re never better. You’re never cured. There’s no discernable, or at least measurable progress, except with pills, which is, to my mind, all psychiatrists are really good for. And if you tell them you want to stop seeing them because you’re going broke on their fees, they always tell you it’s really just that you’re trying to leave them before they leave you. Abandonment issues, don’t you know. If you tell them they’re wrong, you’re simply in denial. If you tell them they’re idiots, that’s projection. It’s endless tail-chasing fit only for the hopelessly narcissistic who get their kicks out of being in a perpetual state of high-toned “sickness.” Crazy, sexy, cool, or something like that. Talk about emblematic of an age. Jesus.

In a completely different vein, the Bloviator addressed the issue of the uninsured yesterday 8/27/02. He writes dispassionately about our health insurance problems. Read what he says, and the political link.

Seven Weight Loss Resolutions That Really Work. I actually see myself in each of these resolutions. Could you transform yourself into using them?

The Other Deadly Threat

Congress has been shoveling the lion's share of new health research dollars into programs to strengthen the nation's bulwarks against biological and chemical terrorism.

In recent weeks, however, the new director of the Centers for Disease Control and Prevention has been rightly trying to drum up support for more funding to fight other ominous public health threats: the rapid rise of infectious diseases and chronic diseases in recent years.

Dr. Gerberding has it right. Physicians and epidemiologists should set priorities, not politicians. We should analyze the data, listen to experts and then set priorities. Our spending reflects sound bites, campaigning and rhetoric - and this is not a new problem!

Exercise tips have interesting twists. This well written review makes two outstanding points. First, the book's author compares (appropriately) the effects of aging to the effects of weighlessness.

The first twist, as intriguing as it is relatively new, is that aging appears to have much in common with space travel. Evans, an adviser to NASA and former head of a special nutrition and physical fitness team for the National Space Biomedical Institution in Houston, is now running a study to figure out what exercises can best protect astronauts' bones and muscles during a Mars mission, likely to occur in 2013 or 2018.

Indeed, writes Evans, prolonged space flight in near-zero gravity results in remarkable physical changes within the body that are astonishingly similar to our journey into old age. In fact, he says, within weeks of blasting off, the astronauts' muscle cells will atrophy, calcium will be leached from their bones, and normal bone growth will be upset to the point where the risk of fracture soars. Recent research, he says, has determined that one month of space flight yields bone loss equivalent to five years of aging. By Evans's calculations, this means that with their muscles and bones weakened by gravity deprivation, even young, healthy astronauts may become as weak as most 80-year-olds.

Second, he focuses on our technique in weight lifting. He champions the eccesntric rather than the concentric (most readers are now wondering what language I'm typing). Let the article explain,

Evans's exercise prescription (for all of us, not just astronauts and research volunteers) focuses on eccentric (which means away from the body, not weird) muscle movements, as opposed to concentric (or toward-the-body) moves. The idea, which is contrary to the way most muscle builders work out, is that it's the away-from-the-body motion that strengthens muscles most quickly.

Take a biceps curl. When you start with a dumbbell at thigh level and raise it to your shoulder, the raising, or upward-bound, part of the motion is considered concentric; the lowering of the weight back down is eccentric, or as Evans prefers, E-centric. Muscles grow in bulk by undergoing microscopic tears during training; it is during the repair of these tears that muscles increase in size.

And it's E-centric motions that produce the most microscopic tears, hence the most muscle growth. The secret, Evans says, is to raise a weight (or move the business end of an exercise machine) quickly, to a count of two, on the concentric motion and lower it slowly, away from the body, to a count of six, in other words, taking three times as long on the eccentric maneuver.

The book is called AstroFit. I just might buy it.

I was working with residents in clinic yesterday afternoon. One of them presented an anxious 41 year old woman, whose sister had a myocardial infarction at age 41. We were discussing how we would screen her, and what prophylaxis to recommend. A cholesterol panel was an easy choice. We decided to add a C-reactive protein measurement, reasoning that if she had an elevated level, we would add a statin even if her cholesterol measurements were unremarkable. An aspirin a day made sense, then I suggested that we consider a multivitamin which included folate. I based this on some suggestive data about homocysteine as a potential risk factor. So this morning in my browsing I find this article - Vitamin regimen shown helpful to heart patients

A six-month regimen of folic acid, vitamin B12 and vitamin B6 can help prevent recurrence of blocked arteries in patients who have undergone coronary angioplasty.

That's the key finding of a new study, being reported in today's Journal of the American Medical Association, that a top cardiologist says offers further evidence that B vitamins are important in maintaining healthy blood vessels.

...

The vitamin regime decreased by 38 percent the need for repeat angioplasties or coronary bypass operations.

The treatment appears to work by lowering levels of homocysteine, an amino acid long implicated in heart attacks.

To read the primary article in JAMA - Effect of Homocysteine-Lowering Therapy With Folic Acid, Vitamin B12, and Vitamin B6 on Clinical Outcome After Percutaneous Coronary Intervention . I believe that this provides a good excuse to recommend a multivitamin which contains folic acid, B12 and B6 to patients at risk for heart disease. Hopefully, more data will emerge over the next few years.

Land of the free, home of the fat and unhappy

It sneaked up on the nation the way it often creeps up on individuals. Its arrival was a surprise, even though it had been a long time coming. We were used to looking in the mirror and seeing a tough, lean country of do-it- yourselfers. Then, seemingly overnight, our image changed. We looked in the mirror and saw that we had become fat. And we've been upset about it ever since.

Of course, people in other countries have been calling us fat for years. In 1990, France's Le Monde published articles about "les Americains obeses" and referred to our kids as "les enfants du Coca-hamburger." The Coke-hamburger kids.

It's easy to ignore a message from the other side of the Atlantic, but when Southwest Airlines told us this summer it would charge those of us whose derrieres don't fit on one 18.75-inch wide seat for two 18.75-inch seats, we finally woke up.

I assume the royal we means the media. Physicians have known this for years. Generally, we do not know how to manage and treat weight problems. This frustrates us, and our patients.

But we haven't gotten where we are today through eating habits alone. We also don't exercise. In fact, we hardly move at all. Less than 20 percent of American adults exercise the federal government's recommended minimum amount -- just 30 minutes a day, five days a week.

Our kids aren't moving any more than we are. Physical Education has been cut so severely in public schools that many youths get no P.E. at all, or it's offered only as an elective. Playtime after school is spent watching television or exercising one digit -- the thumb -- on the GameBoy or PlayStation.

I type the same message constantly. Weight control requires 2 things, eat less and exercise more. The rare patient makes that committment. Our society gives us too many excuses to eat more and exercise less. Few of us resist the easy path.

The American Obesity Association reports that 89 percent of Americans believe that overweight individuals -- not their environment or genetic makeup -- are to blame for their size. Heavy people feel this condemnation at work, in public and in the doctor's office. A study conducted by Rice University's Department of Psychology found that Texas physicians spent less time with heavier patients than with average-weight patients, and "a significant number indicated that it was a greater waste of time to see patients who were heavier. "

For HMOs and health insurers, it's not a question of a waste of time, but of money. Individuals who fall into the obese category have discovered they cannot get independent health insurance, even if they have no other health problems.

When asked if Blue Cross Blue Shield of Florida denied a 26-year-old woman insurance solely because of her weight, spokesperson Rick Curran said yes, that might have happened. "Obesity," he explained, "is considered a health risk factor that can lead to debilitating and chronic diseases." If a person's weight "significantly exceeds recommended guidelines," he said, "that person might receive a rejection letter that states that their weight would need to become more stable and more closely aligned to what is considered healthy."

It's a cruel policy that won't help anyone but the stockholders of Blue Cross Blue Shield, but Curran is right. Obese people often develop such serious health problems as heart disease and Type 2 diabetes. The research institution Rand reported that "obese individuals spend 77 percent more on medications" than non-obese people. Armed with such statistics, health insurers have decided that doing business with fat people is not cost- effective.

Physicians do spend less time with obese patients. I would guess that we respond to our learned futility by giving up on these patiens. We want to help patients, but we rarely fix problems, we just give patients the tools to help themselves! After you try to help obese patients for several years, you rarely if ever have any successes. This learned behavior affects how we treat the obese.

I suspect that obesity will provide this blogger ammunition for a long time. Oh but that were not so! Would that I could influence patients to change their lifestyle. I know that it can be done, I live the proof. But I do work it every day, choosing my diet, even my cheat meals! I exercise 6 days a week on average, and plan that exercise on a weekly basis. Can we get most Americans to do that? And if you read the British press, they have the same problem!

When the Flu Is Taken Lightly. Influenza is a serious disease with a very high mortality. Influenza vaccination decreases the death rate, especially in the very young and those older than 65.

In an interview, Dr. Poland said he thought that the biggest barrier to more widespread inoculation was a false perception about the dangers of influenza.

"We call every respiratory and gastric illness in winter the flu," he said. "People think flu is a minor illness."

In reality, he said, "Influenza has a very distinct set of clinical symptoms, including the sudden onset of high fever and severe fatigue that literally drives people to bed."

Yesterday's piece linking to Norah Vincent brought out some interesting comments. Here is Jane Brody's reporting on the same issue - A Jubilant Barroom Toast to Smoke-Free Air.

A complete ban on smoking in restaurants and bars has proved not just practical, but also good for business.

As Elena Deutsch, director of tobacco control for the American Cancer Society, pointed out, "Revenue has grown in California bars and restaurants every year since this health measure was enacted in 1998." Now, she added, "almost three-quarters of bar patrons in California like their air smoke free."

Likewise, in a survey by a coalition of antismoking advocates more than 70 percent of New Yorkers said they would go out to bars as much or more often if smoking was banned.

We went to see a play last weekend. After the play we went around the corner to check out a new bar. The stench of cigarette smoke was disgusting and even visible. We passed and went to a coffee house instead.

To paraphrase Norah Vincent, your right to smoke ends in my space. Norah's LA Times piece brought out the letter writers - LETTERS TO THE EDITOR: Smoldering Arguments Over Regulations Against Smoking

For those who do not read the comments, the Bloviator has weighed in on the Scarlet Letter Law. He has written a more complete discussion of this madness. Thanks to blogspot, I can only point you to his blog - you can find the discussion listed today.

States Sued For Pushing Cheaper Drugs Via Medicaid . Just when I think about taking it easy on the pharmaceutical industry - there they go again.

The most popular strategy is requiring prior authorization for high-priced medicines. More than a dozen states are developing preferred drug lists, and several demand extra rebates from companies that do not match the lowest price. Michigan's new program saves $800,000 each week -- or $42 million this year, according to Republican Gov. John Engler.

Oregon expects to save $17 million in the first two years, which would result in nearly $40 million in savings for the federal government, said John Santa, administrator of the state health policy office. Massachusetts and Vermont say they could save $10 million.

If the industry suits are successful, "it will throw the country into chaos," Rivers said. "There are too many big states whose budgets would be devastated by it."

Drug manufacturers argue that prescription medication saves lives and money by preventing emergency room visits and more expensive procedures such as surgery.

"The most economic service [states] can provide is adequate access to prescriptions because it gives the most bang for your buck," Faiks said.

"The Medicaid Act does not let them use prior authorization to hold patients hostage because of money," she said. Although PhRMA objects to the state tactics, the industry is suing the federal government in U.S. District Court in the District of Columbia on the grounds it does not have the authority to permit the state programs. In the lawsuits the industry is challenging the state programs, arguing that the government is more concerned with cost than the health of low-income residents.

PhRMA's legal brief contends that "physicians generally respond to the inconvenience and burden imposed by prior authorization requirements by switching their patients" to a drug on the preferred list. Over time, the suit notes, the shift in prescribing patterns results in large swings in the overall market.

If I understand the pharmaceutical industry, I should use the most expensive drugs to save the most money. Sometimes a very expensive drug makes a difference, but often we can treat the same condition with a less expensive alternative. Working with the indigent and working poor, I have learned to use captopril as my ACE inhibitor of choice for hypertension - because it is generic, very inexpensive, and works at a twice a day dosing for hypertenion. Should I switch to a more expensive antihypertensive?

This is a very serious issue. I will try to stay aware of the developments, but if I miss them, and you see them, please let me know.

Doctors Beginning to Test for Bacteria in Stomach. Next year, at Grand Rounds, I will debate a colleague on this issue - Resolved: Patients with dyspepsia who are H. Pylori positive should receive antibiotics. I will take the pro side, as I am concerned about the risk of GI malignancy. He will argue against, and I am interested in what his arguments will be. What do you think?

Both Medpundit and I rant on this issue consistently. Value of herbal supplements is difficult to verify. A few choice quotes from this solid report of the two-day workshop at the National Institutes of Health:

"I still have too many questions," Curt Furberg of Wake Forest University said last week at a conference sponsored by the NIH. "I couldn't recommend any supplements."

Natural garlic, soy and other herbs ingested as part of the diet apparently are healthful, studies suggest, though in most cases experts still haven't pinpointed the beneficial ingredients or how to fashion them into drugs.

...

The lack of standardization of commercially available supplements also makes them difficult to study. "We need to verify that brands contain what they are supposed to contain," Furberg says.

Consultant Stewart Ehrreich, former head of the Food and Drug Administration's division of heart and kidney drugs, adds that the FDA won't "approve a drug with 17 ingredients without knowing what the active ingredient is."

We quickly criticize the medical establishment if we champion a treatment without testing that treatment. Our standard for supplements should not be any less.

My stated philosophy makes the following article even more disturbing - A Supplemental Pitch: More doctors are selling vitamins and herbs even as scientific debate continues over the health benefits of such products..

Last week, cardiologists at a prominent Arizona clinic began advising patients to try a new, untested dietary supplement that has never before been used to treat heart disease. It's not just any supplement, the clinic says; it's a proprietary formula, designed by doctors.

The idea that top medical specialists are offering guidance in the confusing, controversial world of vitamins, herbs and nutritional products is reassuring to many patients. After all, the guidance is coming from graduates of some of our best medical schools, not holistic gurus or health food store clerks.

But there's a catch. The Arizona Heart Institute has struck a deal with the supplement's maker, Vital Living, that gives the clinic a share in profits from sales of the supplement, as well as 1 million shares of stock options in the company.

Read this article, I find it VERY disturbing. But then I am obsessed by data and ethics.

Stepping up the weight loss. This article, which sets up a series of reports from the ninth International Conference on Obesity in Sao Paulo, Brazil, talk about how one loses weight, and how one maintains that weight loss.

Many experts believe that most people today who want to maintain a healthy weight have to be vigilant constantly in countries such as the USA, where high-calorie foods are ubiquitous and exercise has been programmed out of many people's lives.

"It takes a lot of conscious, cognitive effort," says James Hill, director of the Center for Human Nutrition at the University of Colorado Health Sciences Center in Denver. "People who are not devoting substantial effort to managing body weight are probably gaining weight."

Samuel Klein, president of the North American Association for the Study of Obesity, agrees: "It means making weight management a priority in your life."

Statistics reveal how difficult that is to do. Worldwide, more than 1 billion people are overweight, and of those, 300 million are obese, according to the International Obesity Task Force. A startling 61%, or more than 120 million people, in this country are either overweight or obese, according to government statistics. Obesity is roughly 30 pounds or more over a healthy weight.

While not the only theme of this blog, weight control and exercise articles do consistently attract my attention.

"The bottom line for weight loss is you have to eat fewer calories than your body needs," Rolls says.

Brownell says that if people watch portion sizes, eat fruits and vegetables and less junk, "they'd be 90% of the way toward a healthy diet." And "if anything has become clear over the past 10 years, it's the importance of exercise in weight loss and maintaining."

There you go, eat intelligently and exercise. In our society this represents work. One should ask oneself whether that work is worthwhile. I would argue that question has a simple answer. Make rounds with me and you will probably agree.

Over the past several months, we have increasing evidence that we can decrease the probability that patients will develop Type II diabetes mellitus. Weight loss drugs 'limit diabetes'. Certainly, this will become a major prevention movement. Diabetes mellitus costs the patient and society a large amount. The complications include heart disease, kidney failure, amputations, and blindness. We can prevent much diabetes with either lifestyle modifications or medications. This report studied Xenical as a weight loss aid over a 4 year period.

Weight loss drugs could play a role in protecting obese people from the onset of diabetes, according to a study.

It said that those using the drugs alongside diet changes and exercise were 37% less likely to develop type 2 diabetes than those losing weight through lifestyle changes alone.

We should try to influence lifestyle - exercise and healthier diets - and decrease the obesity burden our country. This study comes from GB, where they also have a significant obesity problem. My crusade against obesity comes from a medical perspective (although I admit to having aesthetic problems also - just check out the picture in this article).

Read this wonderful opinion piece on smoking - Smoky View of Libertarianism: They've abused health--now they abuse philosophy. Then visit her web site and read more on this subject Norah on second hand smoke. She includes one of my favorite lines in the LA Times piece

First, by ignoring one of the central tenets of libertarian philosophy; that is, the oft-cited adage that my right to throw my fist ends at the tip of my neighbor's nose. An oldie but goodie. I can do what I like with my own body, true, so long as--and here's the part sophists omit--what I do doesn't harm anyone else.

Mindscapes, Heartstrings & Soul-searching writes today about 'Health, Weight and Happiness'. Her tale is well told and highlights the downsides of weight obsession. We run a fine balance between appropriate diet and exercise and obsession. Read her tale.

20 Questions for President George W. Bush: A Running Conversation . Many readers know that the current issue of Runner's World features President Bush. Maureen Dowd criticizes the President today about this interview and contrasts it with her perception of what he is not telling us about Iraq - Treadmills of His Mind. While I will not comment on the President and Iraq, I am impressed with his role modelling on exercise. We need more stress on healthy lifestyles. If the President helps a few people get off the couch and workout (and he probably will) then he has done well.

I will quote some of his answers and comment .

What’s your response to people who say they are too busy to have enough time to exercise?
I say they don’t have their priorities straight. These are the same people who say they don’t have enough time for their families. I don’t take that as an acceptable answer. I believe anyone can make time. As a matter of fact, I don’t believe it—I know it. If the President of the United States can make time, they can make time

Exercise is so important that corporate America should help their employees make time. Offer flex time. There should be flex time for families and there should be flex time for exercise. A healthy work force is a more productive work force. We have got to do a better job of encouraging that in America.

As I have said often, one should plan one's exercise week consistently. Stephen Covey's book - 7 Habits of Highly Effective People - encouraged me to consider this philosophy. I like his book and was struck by the 7th Habit . A summary of the Habits - Summary of Stephen R. Covey's
The 7 Habits of Highly Effective People. They summarize the 7th habit thus

Habit 7: Sharpen the Saw
Take time out from production to build production capacity through personal renewal of the physical, mental, social/emotional, and spiritual dimensions. Maintain a balance among these dimensions.

I subscribe to maintaining balance in my life, and espouse that philosophy to my residents, medical students and faculty. All work and no play makes Jack a dull boy. It also leads to burnout. The President's exercise philosophy does not just strengthen the body, it also helps the mind. Exercising gives me a time to sort out ideas. It provides respite from the hassles of the day. After exercising, I have more energy to attack problems.

Finally, what do you view as the greatest health issue facing our nation?
Tobacco, bad food and lack of exercise. A lot of disease can be prevented. And I think you’ll see the health-care systems will evolve toward encouraging prevention. Wise business insurers will work with physical fitness folks to encourage reasonable exercise. Statistic after statistic is beginning to sink into the consciousness of the American people that exercise is one of the keys to a healthy lifestyle.

One of my jobs as President is to set examples. I have an opportunity to send the message to the American people that I’m serious about exercising—and you should be too.

Bravo, clap hands, the President has it right. He does understand that the choices we each make about our lifestyle have profound effects on our longetivity and quality of life. I wish that smoking cessation was just a matter of will.

Physicians understand this message. On the VA inpatient wards, I estimate that over half the patients have serious diseases as a result of lifestyle choices - smoking, lack of exercise, obesity, alcohol abuse and former IV drug experimentation. These "choices" all effect insurance rates and contribute to the high cost of health care.

Can we make a difference? Certainly, we can influence one person at a time. We must discuss lifestyle choices regularly with our patients, our friends and our family. We must understand that our challenge never ends. We must search for the buttons to push that will allow people to make healthier choices. We must start by being role models - like the President.

Myth Vs. Fact: Weight Loss Resolutions. The author addresses several myths. The short story:

• Myth: A resolution to lose weight is an empty gesture; hardly anyone succeeds.
• Myth: Only 5% of all dieters keep the weight off - the rest gain it back.
• Myth: Dieters who habitually lose weight and gain it back should just give up making resolutions to lose weight.
• Myth: Forget crash dieting as a way to keep a weight loss resolution; it will only make you fatter.
• Myth: The problem with following through on a weight loss resolution is that it's so painful.

I am currently in my third year of success. I never reached obesity (BMI <30), nonetheless, I have lost 30 pounds and kept it off. As I read this article I recognized several important issues. I have developed my own dietary modifications. My diet is not strict, but I do eat less high calorie stuff. I do exercise very regularly. I do think about when I am going to "cheat", accept the fun of that cheat, but resume my healthier eating immediately thereafter. Read this article, it may help you.

Prescription drugs to have and to have not. Read this nice opinion piece about celebrity interviews and the pharmaceutical industry.

In my 20s and 30s I remember losing my temper much more often. I would get very aggravated playing golf. Basketball referees could incite my flames in seconds.

Now in my 50s, I rarely get upset. More often I'll laugh at a bad golf shot. I seem (to myself) much more even keeled. It turns out that I'm probably not unusual - Relax! Aging Puts Stress in Perspective

In their study, Almeida and his colleagues examined data from a large government survey of over 1,000 American adults known as the National Study of Midlife in the United States. As part of the study, researchers telephoned participants every evening for 8 consecutive evenings, quizzing them on the amount and type of stressors they had faced that day.

"And we found that, in sheer number of stressors that people reported, there was no difference between younger adults and midlife adults," Almeida said. But while these daily hassles tended to really upset those aged 25 to 39, "boomer" types aged 40 to 59 were more likely to shrug them off.

"For example, being stuck in traffic. The younger people in our sample would report that as more disruptive, more upsetting, than older people," Almeida said. The key was "people's own perceptions, how they view their stressors," he said.

But the nature of what stresses us out as we age appears to change as well. In our 20s and 30s, "it was likely to be over some interpersonal tension or disagreement they have with somebody," such as a lover, coworker or friend, Almeida said.

"Whereas midlife adults, their stressors were more related to being overloaded or having too many demands made on them." This makes sense, he said, because midlife is typically our most productive period, with many of us forced to juggle the demands of career, spouse, children and aging parents.

I find this story very interesting, especially since I spend so much time with students, interns and residents. Many have short fuses, and we try to help them learn how to deal with their stressors productively. Maybe I just have an age advantage.

Sometimes expert panels have wisdom - No evidence soy, garlic pills work Experts: Benefits unproven for popular supplements.

But leading botanical researchers, meeting under the auspices of the National Heart, Lung and Blood Institute, said these products vary greatly in what they contain and some may not even be in a form that can be used by the body.

“The available clinical trial results are not adequate to answer important questions about the potential cardiovascular benefits of garlic,” Christopher Gardner of Stanford University in California told the meeting.

But why should we believe that any supplement will help? Why do we rebel from conventional medicine and data, turning instead to herbal gurus? We should not allow the sale of potentially dangerous supplements - which apparently have no standards for ingredients. Should we allow herbal placebos? Are we satisfied if the supplements just do not harm? I am not satisfied with that standard.

Shaming Young Mothers

This new state law requires women — even 14- and 15-year-old girls, even rape victims — to disclose the name and address of the father of a baby offered for adoption, or else to publish these ads for four weeks. Perhaps not since a tribal council in Pakistan ordered a woman to be gang-raped in June has a government treated women with such contempt.

The new Florida law was meant to reduce the risk of a father's emerging years after an adoption and seeking custody. So the law stipulates that the mother must publish her name and description, along with the names and descriptions of men whom she cannot locate but with whom she had sex around the time of conception.

This law is unbelievable. Will they call these ads the "scarlet letters". Why were they not thinking? Are there any lawyers out there? There must be some constitutional problem here.

Doctor, I feel slightly funny.

There's a theory that the real problem with the NHS is not too few doctors, but too many patients. Some politicians like to pin it on the fact that we've become a nation of accident-prone, alcoholic, smoking lard-buckets. If only we could all learn to eat, drink and be merry responsibly, then half the health budget wouldn't be frittered away on potentially preventable diseases. Sociologists prefer to blame the politicians for creating mass involuntary euthanasia in the UK. It's called living in the North of England. The rich live 10 years longer than the poor and the gap is widening under Labour. Until it narrows, no health service will ever cope.

An additional strain on the NHS is that it is full of patients who have little to gain from being there. The beauty of the NHS – that you can be scraped off the pavement without having to check for your Barclaycard – is also its weakness. Any service that is free at the front door encourages life's little problems to become medicalised. A GP friend was phoned at 3am by the relative of a man marching drunk down the high street with his glass eye balanced on the end of his penis. It's a fine trick, and worthy of an audience, but it doesn't have to be a doctor.

Another GP has a T-shirt with "CAMERA" on it; the Campaign for Real Ailments. Much of his workload consists of defusing the anxiety of an increasingly worried well population who don't have any discernible disease, just an awareness of what might, or might not, be "risk factors". Alas, in the doomed pursuit of a risk-free life, their new health awareness makes them pathologically anxious and they end up on anti-depressants. Great for the drug industry, but not great medicine.

Within the humor one can often find wisdom. Our challenge remains sorting out the worried well from the sick. The most dangerous patient is the somaticizer. Sooner or later their complaints are real. Medicine is easier when you know something is wrong - perhaps that is one appeal of doing a subspecialty - someone out screens out all the complaints. But we must remember (after we stop laughing) that the complainers need us also. They need our relationship and validation. We often help patients without a prescription or a test. Unfortunately, we have no outcome measures to document it - and the bureaurcracy probably does not want to pay for that help.

All fast food is not bad. Sometimes that is your only good option. This article gives you some good choices - Nutrition watchdog praises fast food giants

CNN to Reveal When Guests Promote Drugs for Companies

After learning that some celebrities who talked on its news programs about their health problems were being paid by drug companies, CNN has issued a new policy and will tell viewers about the stars' financial ties to corporations.

CNN will ask celebrities who want to talk about a medical issue whether they are being paid by a company, the network said. If so, the financial tie will be disclosed during the interview, CNN said.

Other news programs — including the "Today" show on NBC, "Good Morning America" on ABC and "The Early Show" on CBS — say that they have also become more careful after they learned that some Hollywood celebrities they had interviewed, including stars like Lauren Bacall and Kathleen Turner, had been paid to help promote drugs or other medical products on their programs.

Pharmaceutical companies have one interest in mind - selling their drug. Jane Galt would probably say that is appropriate in a free market. I would say that society has an interest in minimizing influence which does not necessarily correlate with patients' best interests. I like this development. I believe that I can do a better job recommending medical care than celebrities.

Today's NEJM includes many letters about - "Luxury primary care". Since most readers do not have a subscription, I will quote liberally. If you have access - Luxury Primary Care.

The article by Brennan on luxury primary care (April 11 issue)1 was of particular interest to us as patients of a physician who notified us only two weeks in advance that he would eliminate us from his practice unless we joined MDVIP at a fee of $1,500 per person per year.

Our reaction went from surprise to shock to indignation. For the most part, the services being offered were no different from those we have been receiving — that is, prompt responses to our telephone calls, timely appointments, and adequate examinations and consultation times.

We cannot believe that this kind of medical practice is legal. As Medicare patients, we are entitled to access to our physicians with nothing more than a 20 percent copayment. Without a doubt, if this practice is allowed to continue, we will have a two-tiered medical system in our country. How sad.

All threats to the doctor patient relationship are sad. The patients quoted here refer to medical care as an entitlement. Is your choice of physicians an entitlement? Are Medicare's reimbursement and regulations an entitlement? These are very difficult questions. We do not know why the physicians made this decision. It may just be monetary, or it may be more.

As physicians in the center of the controversy over luxury primary care, we were particularly struck by the absence of the patient's voice in the review by Brennan. The current system of primary care is the creation not of doctors and patients, but of those who pay for care — in general, insurance intermediaries acting on behalf of employers or governments. Since this system is not designed by or for the patients we serve, it is not surprising that there has been widespread dissatisfaction with the results it delivers. When those who pay for services are different from those who receive those services, problems arise. Some patients want something different, and we have responded to that desire.

Our practice is not an answer to the problems of the uninsured, nor is it offered as a solution for all patients or all doctors. Our practice is an answer to the needs of specific persons — patients and doctors — who have felt inadequately served by the system as it exists. We have risked our livelihoods and our reputations in an effort to prove that a better and different way of practicing medicine is possible. We believe that free choice and the marketplace of services and ideas are better alternatives than the status quo. Our success will be measured by our ability to deliver on our promises, as determined by the patients who choose our care.

This is a straightforward, honest response from doctors. Do I necessarily agree with them - no, but I emphathize with their point. They do emphasize a better way of practicing medicine.

Brennan sets out to "examine the . . . ethical issues that arise with [luxury primary care] practices." His chief concern is access, and he concludes with the prescriptive (as opposed to descriptive) statement that "as physicians we have a commitment to the equitable distribution of health care." What is the basis for this statement? Certainly, most people believe that food and shelter are more important than medical care, yet there is no expectation that builders have an obligation to provide for the equitable distribution of housing or that supermarket chains have an obligation to provide for the equitable distribution of food. The origin of Brennan's assertion lies in the concept, beloved by certain policy makers and health economists, of medical exceptionalism. Again, however, beyond the assertion that "medicine is different," there is no argument to sustain such a belief. The distribution of resources belongs in the political arena, and ethical physicians of all stripes can advocate for whatever scheme they are committed to, but clearly equitable distribution is not a problem for the individual physician, no matter how guilty he or she can be made to feel.

Very interesting ethical points made in this letter. Is medicine really different? Having chosen medicine, does that give me an unusual responsibility to society, beyond my own sanity, health and financial stability?

I think that the problem that is leading to plans such as "luxury primary care" is the woeful inadequacy of reimbursement for office-based medical care. The current standard for office visits of 15 minutes or less is not a matter of choice, but rather a matter of financial survival. With reimbursement rates as low as they are, a physician has to keep patient turnaround time short in order to keep a practice financially viable. The situation is made worse by the tendency of government to balance its budget at the expense of the medical practitioner. This year, Medicare cut payments to doctors by 5.4 percent, and additional cuts totaling 17 percent are anticipated during the next three years.1 Meanwhile, overhead costs for medical practices continue to climb. For instance, medical-malpractice insurance premiums throughout the country are rising at an average annual rate of 30 percent.2 Where will it all lead? Nowhere good, I'm afraid.

Points very well made. This echoes (and states better) points I have discussed frequently over the past several months.

When I attended medical school, the teachers repeatedly articulated the concept that my fellow students and I acquired a special responsibility to society by attending a state-subsidized medical school. In exchange for life-and-death responsibility and hard work, society would offer us respect and remuneration substantially higher than that afforded the average worker.

My perception is that lawyers and bureaucrats have dismantled the implied social contract that was described to me when I was a medical student. Production pressure has diminished "the calling" of being a physician. It comes as no surprise to me that some physicians have found novel ways to support themselves.

Agreed!

I think that the profession simply cannot tolerate structural inequalities in the ways in which sick people are treated and must resist libertarian, market-driven changes that create such inequities.

The author of the original piece responds. He declares himself anti-libertarian - and implies a need for greater bureaucracy.

If we accept a bureaucratic system, a one class system, will we get the best and brightest to become physicians? Why do expect the medical system to provide one class care? Certainly, one could argue that we should live in a one class world - equal housing, food, clothing, legal advice, etc. But communism does not work. You would not reward me as a basketball player or movie star. What makes physicians so different? Why shouldn't we allow payment for special attention? We are not willing to pay for everyone to get that care.

These are difficult issues. We must keep the debate focused on the problems of adequate care. We should not accept inferior care for all. Perhaps we can use this model to "fix" the entire system.

Making Time to Walk

It's too easy for some of us to create and accept reasons not to exercise. If you find yourself giving in to common excuses for not keeping active, look at this list and counter each hurdle with ideas to stay motivated, weave movement naturally into your day, and stay on the road to a healthier you.

Brilliant, well thought out - just go read it - What’s An Alternative?

The beauty of a hippie chick face-lift: I surrendered to vanity, but I wanted to keep it real. How does one avoid looking like a Beverly Hills real estate agent? - a confession.

Tailoring a diet to fit is the way to keep fit .

Mary Schreiner's take on dieting is direct and to the point: "Diets are dull and boring, and you can't have your favorite foods. You have to come up with an eating plan that works for you and incorporates the foods you love."

...

"People are making this hard, and it's not that hard," she says. "They are eating the same things over and over and not exercising and wondering why they don't lose weight."

She believes that about 80% of what most people are doing is fine, but they need to fine-tune 20% of their habits. For some people, the problem is they eat at fast-food restaurants a lot and that needs to be cut back, she says. And for many people, the problem is they don't do enough physical activity.

Every morning Schreiner walks and jogs for four miles on the treadmill at her house, and then later in the day, she walks for another 30 minutes. "I know I eat at least 2,500 calories a day — that's why I exercise.

"You have to make the diet program or weight-loss program fit you," Schreiner says. 'Don't take somebody else's idea."

The only trick is developing the discipline.

Interesting story on the search for a "high free" cannabis based pain reliever - Cannabis drug 'fights pain without high'

As indicated last month, we will probably soon have our first over the counter proton pump inhibitor - FDA gives conditional OK to nonprescription Prilosec

THE COMPANY said it received a so-called approvable letter from the FDA and now expects to begin commercial nonprescription sales of the drug in the first half of next year.

P&G owns rights to an over-the-counter form of Prilosec, the “purple pill” produced by drug maker AstraZeneca Plc. Prilosec, which generates about $6 billion a year in sales, was the world’s top-selling medicine before its patent protection expired last year.

The approvable letter says final FDA clearance will be granted after a study is conducted to make sure that consumers understand the drug’s labeling, said Dr. Greg Allgood, associate director of the Procter & Gamble Health Sciences Institute.

I have mixed feelings about this announcement. The financial implications are probably very positive. History suggests that patients will pay less for an OTC drug. However, I do worry about patients figuring out when to come in for evaluations - especially with chronic gastroesophageal reflux.

Good advice from the "Lean Plate Club" - The Lean Plate Club: Foraging for Fiber

Two readers have provided important comments on the story about charging for missed appointments (posted yesterday). I have responded. Please consider adding your comments to this issue.

Thanks, db

Many readers remember that I am an addicted golfer. I tell my residents, friends and fellow golfers that I play golf for fun, but I do not delude myself. I work out for fitness. Now golf gets a health warning: Many top players are flabby and have wobbly ankles. But Tiger is leading the gym revolution . Since beginning my more strenous workout program a year ago, I have noticed continued golf improvement. While I do not workout just to improve my golf game, it is certainly a nice benefit.

Advice to all women frustrated by slow weight loss...

Research from East Carolina University shows that African-American women burn less fat during low-intensity exercise (such as walking) than their Caucasian counterparts. Published in the Journal of Applied Physiology, the trial goes some way to explaining the slow weight loss often seen in African-American women.

According to some estimates, 5 out of 10 African-American women are obese. They're also more likely to suffer from high blood pressure or type II diabetes than obese Caucasian women. Although their slow weight loss has been attributed to differences in their diet or lifestyle, researchers also suspect that genetic factors may be to blame.

We must study this phenenomen more carefully. We should understand why people burn fat differently given the same exercise. This research may help us understand obesity in some patients.

Packed With Promise: Blood Test May Predict Heart Attack Risk

"Unfortunately, most heart attacks and most strokes happen in people who have average cholesterol and not severely elevated blood pressure," Libby said.

Studies show that once it is detected, inflammation can be treated effectively by drugs commonly used to treat high cholesterol, like Lipitor and Zocor, as well as aspirin, exercise and weight loss.

There is much logic here. I have been reading the inflammation hypothesis literature recently. The data are very convincing. We have much indirect evidence that we should address inflammation. We do not have, however, good prospective data on efficacy. Should we test everyone and start more statins? And what dose of statins should we use? Do we then recheck the CRP level to show normalization? I have mixed feelings here. Although, I must confess that if I had a strong family history, I would probably get tested and if positive take a statin. But I still think that I'm playing the odds without clear data.

New study a blow to ginkgo's reputation

Researchers at Williams College in Williamstown, Massachusetts, gathered 230 people between the ages of 60 and 82 to help them test ginkgo's ability to improve memory and concentration as advertised. Half the group was given 40 milligrams of ginkgo three times per day for six weeks per the maker's recommendations. The others were given a placebo. Neither group was told what they were taking.

No difference in mental sharpness was seen by study participants or their companions. But the researchers took it a step further with a battery of tests. They looked at verbal and nonverbal learning and memory, attention and concentration.

Their conclusion? "When taken following the manufacturer's instructions, ginkgo provides no measurable benefit in memory or related cognitive function" in generally healthy adults, the researchers write in Tuesday's issue of the Journal of the American Medical Association.

I hope you are not surprised.

Medpundit provides this story - Uneven Accompaniment. This link refers to an article which suggests that a companion may improve the doctor's visit. Medpundit does express the appropriate reservations. I will recount one anecdote which will hopefully drive home her point.

I was caring for a woman with multiple somatic complaints. She was clearly depressed, had interstitial cystitis, and a never ending stream of other complaints. Her husband accompanied her at all times. He would not leave her side, and I was not smart enough to talk to her alone. One day she came in for episodic care and our nurse practitioner saw her alone. The NP found out the real cause of her symptoms - an abusive relationship. We greatly improved her quality of life by helping her withdraw from this relationship. She still had problems, but they decreased dramatically.

As Medpundit says, sometimes you really need to talk to the patient alone. Physicians need to learn when to have the companion present, and when to exclude the companion. This probably represents an art - but isn't much of the doctor patient visit artistry?

Patients turn to private GPs. Patients in GB are increasingly unhappy with the care provided by the National Health Service. Not surprisingly they turn to the private sector for longer same day appointments. Sounds a lot like the retainer medicine movement in this country.

Patients want service. They do not want to feel like another number pushed through the system. As health costs increase, the blind attempt to control costs has decreased the length of the doctor-patient visit. This makes both sides unhappy. I rant about this constantly, but I cannot and will not stop. Health care probably costs more because we can do more. There are a few villians - government regulations, the pharmaceutical industry, the device industry - but the doctor patient visit is not a villian. Maybe we should consider paying for quality. After all you would gladly pay a bit more for a better meal, a better haircut, a better car, a better lawyer. Why should medical care be different? Stop - I do not want to hear that medical care is a right. We should provide basic medical care to everyone, but should we provide the same watered down care to all. Physicians would love to provide "one class" care. Society will not pay for the down trodden to get that care. The GB and Canadian answers do not seem rational either.

Our problems started with the initiation of health care insurance. Insurance rarely covers the outpatient visit. It covers hospitalizations, tests, procedures, but rarely the visit. Medicare does cover the visit, regulates the payment (making the charge moot), and clearly undervalues that visit.

If the physician has increasing overhead (from staff increases prompted by regulations), and decreasing Medicare payments for office visits, what do you think will happen? The system is devaluing the doctor patient relationship, to the great detriment of the patient. Even a committee could not design such a perverse set of incentives. I rant and rant, but I need to compose a coherent discussion of the doctor patient visit - and will try to do that this week. Please comment either here, or send me email with your thoughts. I am very concerned about our health care delivery system. Less good students want to provide frontline care, because it imposes an undesirable life style. This concerns me. Am I alone?

Doctors call for patient 'fines' - from Great Britain,

The majority of GPs favour charging patients who fail to turn up for appointments, a survey suggests.

Most of those questioned believed young people were those most likely not to make the effort.

And many GPs are refusing to take on new patients because of a shortage of doctors, fearing existing patients could suffer a reduced service, it has been reported.

The government is reportedly thinking about introducing non-attendance "fines" as one way of cutting missed appointments, although this has not been confirmed officially.

The survey, carried out on behalf of the Doctor Patient Partnership, questioned doctors at 577 GP practices across the UK.

I suspect that we should consider the same issues in the US. We must reassess how patients pay for services. Charging for the appointment actually makes some sense. How do we charge for phone advice, or email advice? Our model has many flaws.

As a physician I take a flu shot every year. In our clinics, we offer a flu shot to anyone (we actually have a nurse activated protocol). Acording to this study we have acted correctly. Study: Flu vaccine good for all adults. While this study uses a simulation to etimate costs and morbidities, the results have face validity. Now how do I convince patiens that the shot does not make them sick?

This is a major surprise to no one. Scientists say alcohol makes others better-looking: Study finds even small amount of booze boosts sex appeal

Medical records privacy rules finalized The AMAnews summarized nicely the major changes just announced:

Key changes in the final medical records privacy rule:

* Health care professionals must obtain an individual's prior written permission to use protected information for marketing purposes or to sell the information to third parties.
* Health care professionals must disclose their privacy policies and inform patients of their privacy rights; physicians must make a good-faith effort to obtain a patient's written acknowledgement.
* Incidental uses or disclosures are not considered violations if reasonable safeguards are in place.
* The deadline to change existing written contracts to prevent disclosure of protected information by business associates is extended for one year.
* Authorization for use of data for research purposes is streamlined.

Nevada enacts bold tort reforms

The legislation -- which Nevada Gov. Kenny Guinn signed into law Aug. 7 -- calls for many of the reforms that the American Medical Association has said are needed to help change states' medical liability climates. It places a $350,000 cap on noneconomic damages in medical malpractice cases, creates a shorter statute of limitations and establishes a standard that holds physicians liable only for the damages for which they are responsible.

The law also puts a $50,000 limit on damages for hospitals and physicians who treat trauma patients, creates a medical error reporting system, requires more training for judges handling medical malpractice cases and holds lawyers responsible for costs of frivolous lawsuits.

"We have addressed the issues that brought the crisis," said Lawrence P. Matheis, the Nevada State Medical Assn. executive director. "It takes away the unpredictability of awards."

Nevada is one of 12 states the AMA has identified as being in the middle of a medical liability insurance crisis. Another 30 states and the District of Columbia are seeing signs of trouble, the AMA says.

This does not solve the problem. They have a bandaid placed. The plaintiff's lawyer mindset that one can only expect good outcomes from medical care encourages plaintiffs to sue regardless of merit. Physicians make mistakes - sometimes egregious mistakes. If so, then we need a system to help the patient. But we need a jury of our peers, not the plaintiff's peers. We need a jury that can truly understand the evidence.

Male Hormone Therapy Popular but Untested. We talk incessantly about evidence based medicine. Often we have no evidence.

"The only thing we ever learn from medical history is that we never learn," said Dr. John B. McKinlay of the New England Research Institutes in Watertown, Mass. Dr. McKinlay is the director of the Massachusetts Male Aging Study, a federally supported study that follows more than 1,700 men as they age. "On the slimmest of evidence we introduced estrogen to women," he said, "and the public was whipped up to ask for it."

Referring to the large clinical trial of hormone therapy in women that was halted last month, Dr. McKinlay added: "We ended up, finally, after everyone was getting it, with 45 million prescriptions in the U.S. each year. And suddenly we find that not only does it not do what it is supposed to do but there are these untoward consequences.

"We are about to repeat that debacle. We have the slimmest evidence on testosterone replacement. Five men here, 10 men there. Six rats and a partridge in a pear tree. The physiology is not there but the industry, the industry is there."

We have learned too many times that what seems like good logic may be wrong. When will we learn. Nothing replaces good, carefully collected data.

The AMA takes many good positions. This one stretches my common sense. AMA Pans Naming Best ‘Party Schools’. The party school designation was around when I entered college in 1967. Why do we expect different from this generation? Why don't we teach responsible drinking at a younger age? Having a drinking age of 21 makes no sense. It makes almost every college student a law breaker. Stupid, and now the AMA is acting like a Victorian prude. We need a better solution than trying to stop college students from being college students.

Just Saying No to Gifts From Drug Makers. And remember my new motto - just say no to Nexium. Gifts work, that is why they are used. Robert Cialdini has studied the psychology of influence and written widely on the subject - Influence: How And Why People Agree To Things by Robert Cialdini. The link gives a summary of his findings. The first method used in obtaining influence is reciprocity . When we accept gifts from the drug rep, and we are confronted with choosing between 2 or 3 equivalent drugs, we just might use their drug - this represents reciprocity. This factor does not rule our decision making - rather it influences it. That is what the drug companies want. That is why we gain when we say no. The pharmaceutical industry understands it - and their new rules should level the playing field. They will divert their moneys to direct to patient advertising (in my opinion) and try to influence us that way.

My review of Yankee Hotel Foxtrot.

Let me understand this. The pharmaceutical companies, which are highly regulated, sometimes do not give us full disclosure on drug side effects (after FDA approval). So of course we are surprised that a company called Metabolife has withheld information on reported bad health outcomes. Criminal investigation sought for diet supplement seller.

Dr. Sidney Wolfe of the consumer advocacy group Public Citizen, who is pushing the government to ban all ephedra sales, praised the FDA's angry response to Metabolife Thursday.

"The question is, Are they going to follow through and get these dangerous products off the market?" Wolfe said. Metabolife's about-face shows "they are squirming to get out of the dangerous mess they've caused."

Ephedra, a popular herb commonly used for weight loss and body building, has long been controversial. The FDA has reports of 100 deaths among ephedra users, and a report in the New England Journal of Medicine two years ago cited about 1,000 reports of complications linked to the herb since the mid-1990s.

Manufacturers insist that reports of sick patients — instead of a definitive diagnosis from a doctor or a definitive autopsy — don't prove the herb is risky. They contend an industry-commissioned study comparing ephedra to dummy pills shows the herb is safe under the recommended uses with a daily dose of 90 milligrams.

Federal law forbids most regulation of dietary supplements unless the FDA proves danger. Three years ago, the agency attempted to bar certain high doses of the supplement from being sold. Industry protests killed the move, and then a congressional investigative report, while calling ephedra clearly risky to some people, said the statistics FDA used to back its move — partly those voluntary consumer reports — were sloppy.

Folks, this is not rocket science. The weight loss formula is not complicated, the discipline involved is difficult for some. You need to eat less calories than you burn each day. Cardiovascular exercise helps by burning some extra calories. Weight training helps because muscle burns more calories than fat. The equation is simple. There are no magic bullets at the health food store. Do not get your health information from those stores. They are not regulated, the products are not held to any standards.

Many years ago, I worked as an ER doc. I was doing a research fellowship, and moonlit just north of Fort Worth. Texas had no helmet law for motorcycles. I still remember telling two families that their son/husband had died at the age of 21. I remember accompanying another biker with blood coming out of his ear, unconscious to Fort Worth. This is more stupid than smoking cigarettes folks. Costly Ride: Bikers Protest Helmets, But Taxpayers Pay Price.

"The wind in your hair, the freedom you feel," is how Florida biker Jim Vugrich described it to ABCNEWS correspondent Jeffrey Kofman.

Just three states allowed motorcycle riders to go without helmets 25 years ago. Today 30 states do, although almost all say drivers have to be over 18 before they can go helmet-free.

Some say it's not just about comfort, it's about the Constitution as well. "We all like our freedom, and we don't want to lose our freedom," says motorcycle enthusiast Ernie Russo of Florida.

Passions like this help explain why bikers have pushed so hard, and so successfully, to overturn helmet laws in most states.

But there's a big cost, and not just to bikers. After two years without mandatory helmet laws, trauma doctors at hospitals in Florida, for instance, say they are treating more and more patients who hit the road without a helmet.

Stupid, just very stupid!

I am a music critic. The blogcritics bug has hit me. My first effort is with James Taylor.

==============

We could be friends. We are almost the same age. I have listened to him since college. One likes to see one's friends do good work. October Road is good work. James has made db happy.

The new James Taylor CD came out on Tuesday. I had to buy it immediately. I started listening and haven't stopped. The CD feels so familiar despite having new songs.

If you do not like James Taylor already, then this CD will not convert you. Fans will rejoice. October Road has 12 songs (11 new to me - everyone has heard "Have Yourself a Merry Little Christmas"). My favorites (as of this moment) are "Caroline I See You", "September Grass", "October Road", "On the 4th of July" and "Mean Old Man". The production focuses on James' voice and his excellent musicians (including James on guitar). The songs are vehicles for James' expressiveness and storytelling.

At least one review that I read rated this better than any work he has done over the last decade. I will agree with that reviewer, the CD has variety and depth. Each song works, and they are not all alike. Fans will hear songs that they think they've heard before, but they are new songs.

I look forward to continued listening without boredom. Thanks friend for bringing your sweet sounds into my home.

Read this story from Lagniappe (barf bag not included) - Great Moments in Legal Reasoning. No commentary here - just read the link.

Interesting study published in the British Medical Journal - US patients see specialists sooner. Our patients are twice as likely to receive a referral.

Researchers from the Health Services Research and Development Center, at Johns Hopkins University in Baltimore looked at hundreds of thousands of patients both sides of the Atlantic visiting their GP or "primary care physician" - the US equivalent, during 1996 or 1997.

They were matched up for severity of disease symptoms so that research teams could check what happened to similar patients in the US and UK.

In the US, between 30% and 36.8% of patients were referred on to a specialist compared to 13.9% of the UK patients.

...

"Just 1% of US patients wait four months or longer for elective surgery compared with 33% of UK patients."

Which system delivers better care? In which system would you rather receive your care? Our system has problems, but we do not want a system that delivers less satisfactory care. Designing a better system will challenge us greatly.

They must have a very good press release. Researchers laud new antidepressant.

Lexapro becomes the sixth drug in a class of antidepressants that includes the well-known names Prozac, Paxil, Zoloft, Luvox and Celexa.

Lexapro is similar to Celexa, but possibly more powerful and faster-acting, according to researchers who have worked with it.

"These are modest benefits, but they're incremental advances over the other medicines within this class that are available," said Dr. Philip Ninan of Emory University Medical Center.

I will wait for the Medical Letter to evaluate the drug. I will probably wait a year or two before using it. I suspect the Medpundit will wait also. Every new drug has a hype machine behind it. Yawn.

You are in clinic, and have 20 minutes scheduled for a return patient. The patient has diabetes mellitus, known coronary artery disease, hypertension and hyperlipidemia. He is 60 years old, smokes one pack per day, and drinks 3 beers a day (with the occasional six pack or two on the weekend). While the visit represents his routine every 3 month visit, he has a new complaint of abdominal pain. He has lost 10 pounds in the last month. The pain is exacerbated by eating, and he complains of early satiety. You are already 30 minutes behind and it is 2:30 p.m. You :

• Ignore his other problems and focus only on the abdominal pain


• Refer him to a gastroenterologist


• Order some imaging studies


• Reschedule him for a dedicated appointment


• Try to do everything and get further behind on your schedule

If you choose to work on the abdominal pain, you spend time, but get no extra money - BECAUSE NO ONE PAYS US TO THINK!!!!!!! Do you do the right thing, or take the easy way out. This describes our dilemma. Someone has to pay us to think rather than react. Paying us to think might save money, and improve medical care. What a radical idea!

Sunday, both Medpundit and I reflected on the NY Times article about health care costs. Many readers of the Times also reflected and wrote in - The Rising Cost of Health Care

To repeat, we in the US have the best health care system in the world. I would improve it in many ways were I the czar, but it is the best. Some colleagues want us to emulate the Canadian system. I do not think that is such a good idea - Guarantee fast health care, study urges.

The Canada Health Act should be amended to ensure that patients are given quicker treatment, a report to the Romanow commission urges.

Single payor, universal access medicine has a great idealistic feel. However, money gets in the way. Once the government controls things, they start playing with the budget. And money is the issue. We want the highest quality care, we will have to figure out how to pay for it. It really is that simple.

I only became aware that this problem was increasing over that past year or so. I was talking with a medicine-pediatrics resident who mentioned the problem. More adolescents each year develop Type II diabetes mellitus. This saddens me. Adolescents should not have to deal with this disease. More kids get Type 2 diabetes.

Over the last 20 years, Type 2 diabetes has increased approximately tenfold among children and adolescents. Diabetes specialists are calling the increase an epidemic, driven by a rise in childhood obesity. For the one in four children who are now overweight, the extra weight tends to overtax the body's insulin-making machinery. And doctors fear that in 20 years, the Type 2 cases being diagnosed today will produce a generation of young adults with advanced diabetes complications - cardiovascular disease, kidney failure, amputations.

The good news is that weight control and exercise can prevent most cases of Type 2 diabetes, and can stabilize or even cure it in its early stages. But, while young people may have the most to lose, they also face particular hurdles in dealing with Type 2 diabetes.

Hmm, weight control and exercise can prevent ... This is another example of why I'm exercised (intentional pun) about this subject.

Doing inpatient work at a VA hospital, I see many COPD exacerbations. Our government in its infinite wisdom sells cigarettes cheaply to service men. Thus, many veterans still smoke, and some develop chronic lung disease. Since medical school, we have struggled with the proper use of antibiotic therapy for COPD exacerbations. New Bacteria Triggers Lung Ailments. Here the "new" means new to that patient.

The bacteria with new strains most often found during COPD flare-ups were Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae.

Researchers said all three may hit the same inflammation trigger in humans. That could allow treatment which targets a particular molecule on the bacteria, the way some newer painkillers target the enzyme which causes arthritis.

This interesting NEJM article does provide some new clues for researchers. I do not think it will change my practice in the short run.

Now for some news we can all celebrate - Good News For Beer Drinkers

Kaplan says beer in moderation can deliver protection against heart attacks, stroke, hypertension, diabetes and dementia. Red wine gets all the glory because people who drink wine also tend to have healthier lifestyles in general. All forms of alcohol have benefits in moderation, but beer data has been submerged because beer drinkers tend to have unhealthy habits like binge drinking and smoking as well.

Most doctors do not like to recommend moderate drinking because our experience is skewed with sick heavy drinkers. Understanding that risk, I do believe that a beer or two each day (or even some red wine) is a very good idea.

Now is a great time to start your exercise program. Excuses are just excuses. Read these common sense motivational tools - In Your Corner: Motivation

Often I hear that eating healthy just is boring. The Lean Plate Club disagrees. The Lean Plate Club: Eating Right Needn't Mean Eating Dull . This article links many sites with interesting healthy recipes.

Study: Tobacco firms tried to weaken anti-smoking aids. This story stinks so bad, that I may have an anxiety attack.

'Munchies' Study Sparks Diet Drug. There is a lot of money in diet drugs. Thus a lot of research.

Some call me unrealistic. One student even criticized me for smiling all the time. I usually laugh because things are good - and getting better. Dark Outlook on Life Tied, Again, to Worse Health.

This is not the first study to demonstrate the health benefits of abandoning pessimistic opinions: over the past 25 years, researchers have shown that pessimists are more likely than others to have poor physical health, depression, impaired immune systems and to seek medical and mental healthcare services.

The current study is the second in a series, the first of which found that pessimists may have shorter life spans than their more positive peers.

Maruta and his colleagues base their findings on personality evaluations gathered from 447 people between 1962 and 1965, when they visited the Mayo Clinic for general medical care. The investigators re-contacted the patients 30 years later and asked them how healthy they were.

Based on the initial personality evaluations, Maruta and his team report in the August issue of Mayo Clinic Proceedings, 101 of the patients were classified as optimistic, 74 were pessimistic, and 272 had a mix of pessimistic and optimistic outlooks toward life.

Comparing those findings to the patients' perceptions of their health 30 years later, the researchers found that patients who appeared pessimistic had lower ratings in all tested areas of health than both optimistic patients and those who exhibited a mix of attitudes. The test of patients' health included questions about physical functioning, pain, vitality, limitations and mental health.

Federal officials announced yesterday that they have begun a major reassessment of the risks and benefits of all combination hormone products containing estrogen used by post-menopausal women, one month after a large government study found potentially serious side effects from hormone replacement therapy.

The federal effort could change how popular drugs such as Prempro are advertised, prescribed and used, with new recommendations about who should take them, at what dosages and for how long.

The initiative, which will include several public forums this fall sponsored by the National Institutes of Health, the Food and Drug Administration and the Agency for Healthcare Research and Quality, will also try to guide future research on the suddenly more complex and controversial subject.

The move marks the first significant action by the federal government in response to the latest findings about hormone therapy. It is designed to address the widespread confusion that has caused anxious women to inundate doctors with questions about whether they should continue taking the powerful hormones.

The article - Hormone Replacement Gets New Scrutiny: Finding of Increased Risks Prompts Federal Effort

The FDA expects to hold an expert advisory meeting this fall or winter to make recommendations about how hormone therapies should be used. Among the issues to be addressed are whether hormone treatment should be limited to several years, whether all hormone combinations containing estrogen carry the same risks, and whether estrogen-combination products require the kind of more prominent black box warnings that are used for drugs with potentially fatal side effects.

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During the SGIM (Society of General Internal Medicine) meeting which I mentioned yesterday, one of the theme plenary session abstracts discussed the lack of healthy foods in poor neighborhood groceries. Given that background, I love this story - Chicago Neighbors Plot A Way to Healthier Food: With Produce Scarce, Residents Grow Their Own.

On three vacant lots behind their home, the Redmonds have installed two dozen raised garden plots to grow tomatoes, peppers and greens. In a place once overgrown with weeds, and littered with broken concrete and trash, they have created an inviting place where neighbors gather. "You're planting those tomatoes too deep," said one who stopped by to help.

In addition to the garden, the Redmonds have started a Saturday farmers market, where farmers sell fresh, organically grown fruits and vegetables. And as a way to broaden access, they won government approval to accept electronic food stamp cards.

"It's one of the first farmers markets available in low-income neighborhoods that sells the yuppie chow that you tend to associate with wealthier neighborhoods," said Michael Marcus, a senior program officer at the Chicago Community Trust, which has provided $205,000 to the project. "What LaDonna has decided is that poor people deserve a shot at the same kind of food. This is a real breakthrough."

The farmers market, and the gardening project, are part of an improvement plan for Chicago's Austin community that envisions a year-round community grocery cooperative that would sell fresh meats and vegetables and offer cooking classes.

This story suggests a positive model for improving diet and therefore health in disadvantaged neighborhoods. I wish them success and publicity!

I found this article at Med Journal - How to Keep Health Care From Being Sued out of Existence . The article is well researched, summarizing a complex issue. I will not try to summarize this complex and important article - please read it.

Regular readers know how I worry about the pharmaceutical companies. Read this excellent summary by the Blovi8or of the new rules - A CHANGE IN PITCH FOR DRUG REPS. This story bears watching - can they really regulate themselves?

During my college years at the University of Virginia, my favorite eatery was the University Diner. The UD served the famous bacon cheese dog and grills with (or without). You can imagine the bacon cheese dog, but probably have no idea what grills with means. Grills with was a Krispy Kreme doughnut, grilled (with liberal butter) and served with a scoop of vanilla ice cream. Grills without omitted the ice cream.

'What is he talking about?', the curious reader said. Well I read this piece from the Blovi8or - FRIED SNICKERS BARS, FRIED CHEESE CURDS, CORN DOGS, PORK CHOPS ON STICKS ... IT'S FAIR TIME! and thoughts of grills with immediately entered my mind.

I appreciate the recognition of my crusade for a healthy lifestyle. I do want to make clear that I am not the dinner Gestapo. My diet is not pristene - nor do I think anyone elses should be perfect. Rather, I hope to moderate my diet, balancing the occasional meal purely for pleasure, with mostly intelligent eating. Everything in moderation, including moderation. (someone said that - but I know not who).

This past May, I gave the "theme plenary" speech at the SGIM national meeting. Here is my picture and the text of my remarks about academic general internal medicine.

I believe strongly in work-life balance.

Before I start talking, I think it’s very important that I give you some caveats to prevent too many attacks afterwards: These are my personal opinions. I got to choose what issues I included and excluded.

My goal is to stimulate discussion throughout the meeting and throughout the years. I hope to emphasize the hypothesis that general internists desire complexity. We don’t often have time to address this in our out-patient practice; this leads to a lot of discontent. And if we could go back to focusing on complexity, perhaps we could better define ourselves.

I’d like to acknowledge the following, among many other people, who have helped me a great deal in my discussions: Tom Huddle is a medical historian in our division who has tried to put the history in some context for me, and seems to include my thoughts on a regular basis. I’ve had ongoing, long discussions with Gustavo Heudebert at my institution, and this discussion is really the result of probably five, eight years of us wrangling about what general internal medicine really is. Jim Byrd is a long time colleague and friend at East Carolina, and most of our discussions occur on golf courses. Karen DeSalvo, the Division Chief at Tulane, shared some very interesting things about how she redefined her division at Tulane, which really got me thinking about some of the fine points of this talk. And Jack Peirce -- for those of you who don’t know Jack Peirce very well, try to find him, talk to him. He will make you think.

What I’m going to go over in about fifteen minutes is what academic general internal medicine was prior to the ‘70s when I started medical school, how it emerged during the ‘70s while I was in residency, how we expanded our responsibilities in the ‘80s and ‘90s, and then discuss some challenges for this century.

So prior to the ‘70s. General internists were called academic consultants. As a matter of fact, in the early stages of the 20th century, all internists were general internists. The classic is obviously Osler, so how could you give you this talk without an Oslerian quote?

And he said --and I love this -- "There are, in truth, no specialties in medicine, since to know fully many of the most important diseases, a man must be familiar with their manifestations in many organs." And I apologize for the sexist nature of that remark.

I have to have a quote by Tinsley Harrison, since he founded the Department of Medicine at the University of Alabama at Birmingham, and he’s our local hero. "The true physician has a Shakespearean breadth of interest in the wise and the foolish, the proud and the humble, the stoic hero and the whining. He cares for people."

Now, how did general internal medicine first wane? How did subspecialty medicine grow, and then how did we re-emerge? Well, this is a very short story of a complex set of societal issues, but in the 1950s and ‘60s was the first boom in federal research support. Departments over that period of time slowly reorganized along subspecialty lines. Now, this paralleled what had been going on in the community as there were already board-certified subspecialists in practices. And then ACGME gave all this even more standing.

In many departments, and in the department where I went to medical school was a great example, there was no general internal medicine. So when I was a medical student, it was impossible for me to have a role model.

Some issues that occurred in the ‘70s will be familiar to those of us who went to medical school and residency during that era. A lot of key institutions started general internal medicine, and those prominent institutions stimulated other institutions that it really was very important.

There’s a new RRC requirement for continuity clinic, those of you who are residents. When I was a resident, I did not have to have the continuity clinic. That only occurred in about ’77 or ’78, if I recall exactly right. Once you had the requirement for continuity clinic, someone had to run those clinics. The chairs got a little nervous, because they knew they couldn’t run it, and they didn’t have anybody else who could run it, so they had to hire some general internists.

HRSA came through and developed primary care funding, and so these new divisions grabbed on and said, "This is a way for us to build our divisions." Chairs weren’t so sure about this primary care thing that was going on, but it was money, and chairs never turn down money.

We started to develop academic leaders through, for example, the RWJ clinical scholars program, the Kaiser Fellowship, and a lot of other ways that people developed academic focus. Some funding sources started to emerge, NCHSR -- which begat AHCPR, which begat AHRQ -- started to have some funding, and general internists started submitting to that funding source. RWJ was a funding source, and a variety of other foundations. And, most importantly, SREPCIM founded in 1978, which gave us an academic home.

Once divisions were there, a variety of these things -- and not every division does all these things, and this is not a big issue in all these divisions -- but a variety of things occurred. Many institutions did general medicine consultation and found that a very serious issue, and there are some institutions where that became a major focus of research, a major focus of ideas.

At many institutions, the generalists slowly have grown into being the primary ward attendings. More and more subspecialists are uncomfortable being an attending on a general medicine ward. If you’re a rheumatologist -- and I’m picking on them at random -- and someone has lupus, you’re great. But as soon as they have diabetes also, many rheumatoloigsts start to feel uncomfortable, and if they also have to have coronary artery disease, they actually tremble.

This, in some way, began the hospitalist movement, and trying to distinguish between the hospitalist movement and those general internists who do a lot of in-patient care is a very interesting thing to figure out. But it does lead to understanding that general internal medicine represents both in-patient and out-patient medicine.

We have this new phenomenon of out-patient medicine without in-patient medicine. All of the general internists in the ‘70s that I knew did both in-patient and out-patient medicine. But we had this new emergence of people who just do out-patient medicine and don’t do any in-patient medicine.

And then, especially in the ‘90s, we have the influence of managed care on the growth of many divisions, and I’m going to suggest that this has been a very disruptive force.

And finally, we have what -- for lack of the better phrase, we’ll call the cyclic appeal of primary care. We were the kings in the early ‘90s. Everybody wanted to be primary care. I remember an ophthalmologist once telling me he was a primary care ophthalmologist.

I was at a party with a radiologist. He told me he did primary care radiology. That doesn’t seem to be quite in vogue this week.

Our divisions changed a lot in the ‘90s. The research units have benefited from greater funding and more fellowship-trained faculty and just look at this meeting, the increase of research productivity.

Many divisions take a leadership role in the educational activities of their departments, and you can trace the history in many divisions where they start out focusing just on the clinic, but slowly but surely, they take on more and more major responsibilities in the department, and that many institutions are an integral part of the entire teaching program. And this is exactly in line with most of our values.

And at many institutions, the clinical enterprise becomes a large concern. And it becomes a concern because the health system views in the early ‘90s that were going to be the front door to the health system. We need to have a bunch of people out there, doing primary care, bringing patients in, so that the hospital can stay rich.

Now, in my mind, managed care is a very questionable influence, and this explosion was a questionable influence, and I take all of this from articles that were in JJIM earlier this year that really inform how I have thought about the doctor-patient relationship, and thought about the time pressures. And I personally am very concerned about where we’ve gone, and the prime pressure of seeing our patients, the impact that that has had on our career satisfaction, with people who do primarily out-patient medicine, the decreased satisfaction of patients. What is it doing to the doctor-patient relationship.

So let me give you my hypothesis of how we got to where we are. None of my advisors bare any responsibility for my hypothesis. I think that general internal medicine embraced the concept of primary care to emphasize continuity and comprehensive care, and that’s what we meant in the ‘70s and ‘80s. But that embracing of primary care did not mean that we wanted to abandon the complexity of secondary care.

In my opinion, the phrase "primary care" has become distorted to often exclude complexity, and that has led to great display by general internists. I believe many of our subspecialty colleagues look at us as primary care, quote, "simple docs," not complex docs, and I know the insurers view us that way.

We don’t want to abandon complexity. That’s why I chose internal medicine. I chose internal medicine because I liked the clinical complexity. I like the patient with five medical problems and 15 medications to figure out. I like the psychosocial complexity of trying to figure out the interaction between the disease and the underlying psychosocial issues. I like the complexity of trying to figure out how to manage patients in the in-patient and get them back to the out-patient and back to the in-patient, and make all that smooth without error.

So these are my questions for this century. Will research funding continue to grow? Will we be able to support the important research that members of this society do?

How will we pay for education? At many institutions, the educational viability of general internal medicine divisions is threatened because no one will pay them to teach.

We have to decide, is general internal medicine primary care, and/or complex care, and how to define it, and how to present ourselves to the rest of the world.

We’re struggling with can you be both an in-patient and out-patient physician, and how do we balance that, not just in academics, but also out in our practicing communities.

We have to focus on how health care is funded, and how that affects generalists. Right now, it makes generalists depressed. Who’s going to pay for complex continuity care? Who’s going to pay for the patient who has diabetes, hypoepidemia, coronary disease, congestive heart failure and hypertension, and they’re trying to do that in fifteen minutes while they’re depressed. It can’t be done well.

We are doing so much more -- we should do so much more for our patients than we did 25 years ago. We know so much better how to do secondary prevention. But it does take time.

Let me focus on one or two other recent trends. There’s a very good article on the New England Journal recently on concierge primary care. When I was at the APC meeting, going through the exhibits, MDVIP had a booth. MDVIP is one of the concierge care companies.

Now, think what you want of concierge care. Try to remember what the underlying forces were that have caused this to emerge and have attracted both patients and physicians to the concept. A lot of it’s about time, a lot of it’s from the physician wanting to be Marcus Welby, really be able to go visit the patient at home, really go visit the patient and accompany them to the specialist. Now, some of us may not be happy morally with the concept, but try to understand why it has emerged, and it’s not just money.

We have physicians refusing new Medicare patients. Why are they refusing new Medicare patients? Because the overhead is greater than you get for seeing the patient, and you can’t make it up in volume.

We have alternate practice structures, and if you have not read the U.S. News and World Report issue, the web site link will be on the SGIM web page. If you’re interested in trying to get that, you can actually read it on line. But it’s very interesting to see how different people are trying to approach practice in 2002.

I’d like to just preview the four talks for this session. The firsT is about hospital medicine, one of the big issues that I mentioned, and trying to understand how hospital services can lead to efficiency.

Then, an ever-ranging topic at this society and at most of our institutions, and that’s how physicians and pharmaceutical companies interact. One of the big research agendas over the last five to six years has been the specialists trying to prove that they can take care of a disease better than generalists. Now, I would suggest that’s the wrong question. The question is, who can take care of the patient better. But this is an article that contrasts specialists with specialoids, and I think you’ll find it very interesting.

And then a randomized control of primary intensive care. If you do a lot more primary care, you can keep people out of the hospital.

I’d like to close with a quote from my favorite CD. It’s from a song called "Reservations." It’s written by Jeff Tweety of Willco. How many people in the audience -- raise your hand if you’re familiar with Willco? We’ve got about 10 percent. That’s pretty good.

Half of them have heard me talk about it in the last two days.

The name of the CD is "Yankee Hotel Fox Trot," and I’m not going to explain why it’s called that. But this is what he said. "I’ve got reservations about so many things, but not about you."

We report, you decide. I am not the first to point out this story, but it is a huge story. Unfortunately, I am not surprised - Celebrity pill pushers. Does anyone want to defend this?

We anticipated this. The data show that we can decrease the onset of diabetes mellitus. Concerns over 'pre-diabetes' on the rise.

Identifying people at risk for diabetes "is a big task," said Frank Vinicor, diabetes program director for the U.S. Centers for Disease Control and Prevention. "If we don't identify pre-diabetes and stop the development of Type 2 diabetes, the health-care system is going to be completely overwhelmed."

Public health officials have only recently gotten enough ammunition to address pre-diabetes. Experts estimate the number of Americans with the condition to be 16 million. A major study last year showed that many could delay and even prevent diabetes by eating a healthy diet, exercising 30 minutes a day, and losing a little weight.

Just using the word prevention in the same sentence with diabetes is a sea change in thinking. Until a decade ago, health-care providers largely concerned themselves with treating complications of the disease, which can be fatal. A few years later, it became clear that some of the complications could be staved off if patients kept their blood-sugar levels under control.

...

Physicians already have to squeeze quite a bit into a 15- or 20-minute checkup, from breast exams to colon-cancer screenings. To ensure that diabetes screenings are done, he said, he will push for reimbursement from private and government insurers.

I do believe that we can decrease the onset of diabetes. Someone needs to show this skeptic that the pre-diabetes label will make the patient more likely to change their diet and exercise. We will probably resort to drug therapies to decrease the onset. Few patients modify their lifestyle. Before spending dollars on a campaign, why do we not find out that "labelling" patients actually helps them.

I appreciate them noting the 15-20 minute visit. We need to hammer this point over and again. Generalists can address many issues - and would like to address them. It takes time. Recalling off the top of my head, we are now asked to (1) screen for alcohol disorders, (2) ask about tobacco and counsel smokers how to stop, (3) screen for depression, (4) keep up to date on recommended prevention, (5) counsel on diet and exercise - and I probably have left out a few. These considerations are in addition to the increasingly complexity of care. Each year we have more that we can do to help patients - but good care requires time - time for communication, time to ask the patient important questions, time for the patient to present their agenda. Why won't anyone pay for that time? They (the insurers) are telling us that what we do is not that important. While the message is implicit, it is still powerful.

Jane Brody follows up her primer on osteoarthritis from last week (Osteoarthritis - a patient primer) with a nice discussion of surgical options = New Knees May Be in Order When Other Options Fail.

And the answers are money and respect!

This from the AMA News = Senate debate shifts to pay fix: A panel plans to consider reversal of Medicare physician reimbursement cuts next month, but reaching agreement on a prescription drug benefit could be trickier. Perhaps some good news is coming.

Although details of the payment package were not available at press time, the overall spending level of the measure is expected to be close to the $30 billion over 10 years approved by the House in June. The House measure included $21.3 billion over five years to replace the deep cuts in physician reimbursement predicted for the next three years with payment updates of about 2%.

Meanwhile, the body of evidence showing that physician payment cuts are causing an access problem for Medicare services is growing. An annual survey by the American Academy of Family Physicians found that 21.7% of its members can no longer take new Medicare patients, up from 17% in 2001.

"My practice has been forced to quit taking new Medicare patients because the costs associated with treating them are increasing, while our reimbursement continues to go down," said Deborah G. Haynes, MD, a family physician from Wichita, Kan. "It's sad, because these are the patients who need us most."

Amen!

Patients in clinical trials differ from our routine patients. They have greater motivation. They have met exclusion criteria. Therefore, we need studies to help us understand what happens in the "real world". Survival rate after heart failure overstated, researchers say

One in eight people who suffer from heart failure will be dead within a month, and ne in three will succumb within a year, according to a Canadian study.

Such mortality is almost four times as high as that cited in high-profile clinical trials, suggesting that much research grossly overstates survival rates of patients suffering from cardiovascular disease.

"There continues to be a large treatment gap between what is seen in clinical trials and what is observed in the real world," said Philip Jong, a research fellow at the Institute for Clinical Evaluative Studies and lead author of the research.

...

Among patients aged 75 or older, more than 40 per cent died within one year of first experiencing heart failure.

When the patients had other ailments, mortality rose sharply: 61 per cent of men and 56 per cent of women were dead within one year.

In contrast, only 14 per cent of heart-failure patients aged 50 or less were dead within one year of their initial hospitalization.

"This is a wake-up call that we need to treat elderly patients with heart disease as effectively as we do younger patients," said Peter Liu, a cardiologist at Toronto General Hospital and co-author of the study. "We need to conduct additional studies in the elderly population to find safe and effective treatment strategies for this group of patients."

Jack Tu, an internist and a senior scientist at ICES, said that physicians and patients need to recognize the seriousness of heart failure.

"The prognosis for elderly heart-failure patients is worse than many cancers."

Dr. Tu said the research suggests that many older patients need to be treated more aggressively, and that more research is required to find new therapies.

I would submit that younger patients less often have multiple confounding diseases. Our older patients may not respond as well to medical therapies. They may not take their medications as well. Or we may not prescribe as aggressively. Interesting data presented here - the article comes out in the Archives of Internal Medicine today.

Drink 8 glasses of water each day! Everyone knows that now - it is conventional wisdom. Apparently for most of us it really is not that necessary. Is Drinking Lots Of Water All Wet? The comments come from a very well respected researcher.

The journal asked him to review all the scientific studies he could find and he concluded that someone misinformed has been telling people to drink large amounts of water when most do not need to.

“I am referring to healthy adults in a temperate climate leading a largely sedentary existence,” Valtin said. “Persons with certain diseases must have large volumes of water — kidney stones are probably the most common example.”

The rest can just drink enough to slake thirst — and this includes coffee, tea, and even beer — despite their diuretic effects, Valtin said.

He hopes people will be relieved of the guilt of not getting enough water, and of the expense of buying bottled water to drink throughout the day.

“There is also the possibility that if you drink a lot of water that happens to be polluted then of course you get more pollutants,” Valtin said.

“Then there is the inconvenience of constant urination, the embarrassment of having to go to the bathroom all the time,” he added.

Patients sometimes ask us about supplements. Creatine has become very popular with the weight lifting set - studies show that it does help increase the amount of work one can do in the gym (by about 10-15%). No one has yet found a major documentable side effect. Here is a good summary for your archives - The Power of Creatine: It's Real but Subtle.

Sometimes Medpundit and I gravitate to the same issue. Today is such a day. The NY Times article is a must read . - Decade After Health Care Crisis, Soaring Costs Bring New Strains. I will excerpt from this long article and provide my own commentary. Then read Medpundit's view.

If the cost of coverage keeps going up, experts warn, even more Americans will join the ranks of the uninsured because they will be priced out of the market. Many health care analysts, their faith shaken in managed care, see no easy fixes.

Politicians in both parties are beginning to respond, but they are profoundly divided on the issue, a deadlock underscored last month by the Senate's inability to pass a prescription drug benefit for Medicare. As a result, the issue is expected to bubble throughout the fall elections.

The last decade saw a squeezing of health care costs. Every drop of easy decrease was accomplished. The next cuts will require a major change in thinking. Politics cannot solve this problem, because politicians do not address issues, they address constituencies.

The soaring costs are driven, in part, by the biomedical revolution of the past decade, which has produced an array of expensive new treatments for an aging population, from drugs to fight osteoporosis to high-tech heart pumps. The result is a health care system filled with great promise and inequity — such as wonder drugs that many of the nation's elderly must struggle to afford.

Dr. Janelle Walhout sees the paradox every day at the community clinic in Seattle where she works. "I've been thinking lately about the mismatch," Dr. Walhout said, "between how very high-tech medicine has become, with all these genetic tests for everything, mixing your medications like fine cocktails, and our patients, who can't afford them, can't understand it, can't get interpreters to explain it and are just not accessing those things."

These paragraphs outline the problem well. We can do so much more than we could. And we will be able to do even more. What is this progress worth? Should we set limits on health care expenditures? No one has good answers to these questions. Our society accepts inequities in legal care, automobiles, housing, but wants to deny those inequities in health care. If health care is special, if it is a right, then society must pay. If it is not a right, then we cannot be hypocritical about that decision. Declare it, and accept a multi-tiered system. But I do not think we really want to do that.

Spending on health care rose faster in 2000 than at any time since 1993, federal researchers reported this year. Spending on prescription drugs and hospital stays grew particularly fast, largely because of advances in technology and "the retreat from tightly managed care," said Paul Ginsberg, president of the Center for Studying Health System Change, a research organization.

That quote about retreating from tightly managed care really bothers me. The cost problems come from our ability to do more, with drugs and with procedures. No one was happy with tightly managed care - and medical care was worse.

Not surprisingly, doctors disagree. Dr. Richard Corlin, a former president of the American Medical Association, cited "advancing technology and an aging population," along with the rapid increases in the cost of malpractice insurance, as the primary reasons for the rising cost of care. The A.M.A. also notes that insurance companies are reaping higher profits.

And the AMA is correct. Physicians are making less money and health care costs are increasing. We have increased regulations (all of which cost much money), increased malpractice, more expensive drugs, more excellent technological advances - it has to cost more money.

Many health policy experts argue that tackling health care inflation will require a fundamental cultural shift in the American approach to medicine. They say doctors and patients must begin taking cost into account when making treatment decisions. They say Americans must limit themselves to treatments that are proven to work and accept the premise that more care does not necessarily mean better care.

"As a society, sooner or later we will have to determine whether there are some benefits that are too plain small to justify the cost," said David Eddy, an independent analyst who advises health care organizations, including the managed care industry. Americans, he said, "have an enormous tendency to use treatments if we think they work or if we hope work, even if there is no evidence that they do work."

In the 1990's, for instance, bone marrow transplants were widely used to treat aggressive breast cancer. Then studies showed it was no better than standard therapy. Hormone replacement therapy, prescribed to millions of American women, has now been discredited as a way to prevent heart disease and stroke.

Dr. Eddy says he believes a new government agency should be set up to take this kind of scientific literature into account, and then make recommendations about whether new treatments are worth the cost. But while health experts agree there is a critical need for independent evaluations of new technologies, they doubt such an agency will ever come into existence.

"It would be killed by all the lobbying groups," said Uwe Reinhardt, a health economist at Princeton University.

First, we have a such an agency - the Agency for Health Care and Quality (AHRQ), which receives a meager budget (relative to NIH), and which cannot do the studies needed because of lobbying groups. We do need more efficacy studies of many treatments. I have previously called for device manufacturers and pharmaceutical companies to fund these studies but not have any control over their design or execution . Such studies such be the litmus test for adoption of new treatments or diagnostic tests. We can do the studies. Unlike Medpundit I think we will have to involve subspecialists to do the studies properly. However, each study panel should have a heavy representation from generalists. Patients will only take cost into consideration when they share in the costs. Our health insurance system makes health care an entitlement. If it is - then let's pay, if it isn't let the patient participate in the costs.

Finally, let me suggest that the doctor patient relationship might actually help here. Physicians who have the appropriate amount of time with patients can take a more complete history, provide better prevention, more carefully select diagnostic tests, refer more appropriately. Our system has evolved over the past 10 years to shorter visits - and I believe the visit length leads to more expenses. We need to test this hypothesis. The system is trying to save money in the wrong places. The generalists should not be squeezed. They control much care, many expenses and can do a great job if given the tools and the time. This topic will recur often. And I will probably sound like a broken record.

I have studiously avoided blogging about the West Nile virus. My gut feeling told me that this was not really a big issue. Not surprisingly, the press wants to make it a big issue. Thus we need some common sense - Misplaced Fear of a Viral Epidemic.

How dangerous is it? Two studies were conducted during the first outbreak in New York in areas where the disease was most prevalent. One found that 25 people per 1,000 had been infected by the virus. The other found far less infection: it tested 2,436 people and found only five who were infected. And infection does not mean sickness. The vast majority of those infected do not have symptoms, and the vast majority of those who do become ill recover fully. According to the Centers for Disease Control and Prevention, less than 1 percent of those who get infected will become severely ill, and of those between 3 percent and 15 percent will die. Other studies indicate far lower mortality rates.

...

West Nile disease will likely conform to the epidemiological model of St. Louis encephalitis. It will be with us for the foreseeable future. When an outbreak does occur locally, the elderly and people with compromised immune systems should take precautions. It is likely to kill a handful of people each year. But it should not cause panic. Other more lethal mosquito-borne diseases occur in this country. We survive them — and without hysteria.

Read this nicely written opinion piece from an expert. And try not to worry to much.

Bush Rolls Back Rules on Privacy of Medical Data.

The administration decided to abandon the core of the Clinton rules, a requirement that doctors, hospitals and other health care providers obtain written consent from patients before using or disclosing personal medical information for treatment or paying claims. Instead, providers will have to notify patients of their remaining rights and have to make "a good-faith effort to obtain a written acknowledgment of receipt of the notice."

...

The rules appear to set strict standards on using personal data from patients for marketing. They prohibit drugstores from selling personal medical information to a drug company or other business that wants to sell products or services.

In the last few years, some drug companies have paid pharmacies for customer health information and used it to try to sell products to individuals with conditions like osteoporosis, diabetes or depression.

Mary R. Grealy, president of the Health Care Leadership Council, which represents large health care corporations, said the new rules were "stronger and tougher" than the Clinton rules on marketing.

Representative Edward J. Markey, Democrat of Massachusetts, said the Bush administration had made some improvement in the marketing rules, but left some loopholes.

"The final regulations appear to shut down some of the existing avenues of commercial exploitation of personal medical data by third parties without the knowledge or consent of the patient," said Mr. Markey, who is co-chairman of the Congressional Privacy Caucus. "But the regulations still allow a drug company to pay a pharmacy to act as its agent and allow the pharmacy to do the marketing without disclosing the financial arrangement."

At first blush, the new rules seems better than the original rules proposed by the Clinton administration.

Thanks to SciTech Daily Review, I found this interesting essay from last year - Brain and Mouth Disease.

The person describing the health benefits of the Mediterranean Diet was Dimitrios Trichopoulos, Professor of epidemiology and public health at Harvard University. When we completed our respective talks we shared a cab to Washington’s National Airport en route back to our home bases. On the way I asked Dr Trichopoulos "If I faithfully follow the Mediterranean Diet, how much longer will I live?" He seemed taken aback by the remark and said something like "That’s a very interesting question. Perhaps we should put a graduate student on the problem."

I don’t know if he ever did. But a lengthy article by Gary Taubes in the March 30 issue of SCIENCE, the premier American scientific publication, suggests that the answer to my question "How much longer will I live?" is — not much. And if the analysis is correct, it will have an explosive impact on the vast industry in this country and in fact the world which is based on the notion that fat is bad and that consuming it will kill you. But as Taubes points out, 50 years of mainstream nutritional research and hundreds of millions of research dollars have not proved that if you eat a low-fat diet you will live longer. Certainly your cholesterol levels will be lower. But the link between diet and longevity it has been argued remains undemonstrated.

...

Since the beginning of the 70's Americans have dropped their consumption of fat to about 34% of their calories from fat, down from over 40% beforehand. The incidence of heart disease does not seem to have declined, as a 10-year study reported in the New England Journal of Medicine in 1998. Nonetheless, the treatment of heart disease has improved enormously - with more than 5.4 million heart-related procedures compared with 1.2 million in l979. This may provide the questionable impression that it is dietary change which is responsible for improved coronary experience.

Furthermore, the replacement of fat-containing foods by carbohydrates may have contributed to an epidemic of obesity and then diabetes among Americans. The term "fat-free" on a product appears to provide permission to consume large portions of it, producing an intake well beyond what appears to be necessary to balance energy consumed and energy used. ...

...

Nevertheless, humans evolved as omnivores and we seem well-equipped to eat well-balanced and moderate diets of the foods which were in our environment as we evolved - animals, fish, legumes fruits, vegetables, nuts, berries, and honey when we could get it. Ample fruits, vegetables, and nuts may deliver protective impacts and are obviously one sign of the current good gastronomic fortune of North Americans - our temperate climate provides us with a good cross-section of an ideal grocery store. And it would be irresponsible to avoid stressing exercise as a factor in healthy nutrition - we were born to run, for our dinner.

It appears that people who are committed to low-fat diets almost invariably turn to high-carbohydrate regimes, many components of which provide physiological stimuli to increased hunger. Perhaps a dab of fat will do you, to provide a satisfying experience with food and transform it from battle rations into a calmly sensible aspect of the pursuit of pleasure.

© New York Press, April 18, 2001

This well written essay balances a quest for data with common sense. I like that!

That is if anything about lawyers can be funny.

Do we need lawyers or government to protect us? R. Emmett Tyrell says no - and points to President Bush - Fat food foibles.

The vigorous president has taken personal responsibility for his diet and his lifestyle. He did not need the Prohibitionists' remonstrances. He once drank too much. Without benefit of the Prohibitionists, he cut out the booze and picked up the personal training regimen. The consequence is that he is fit, beyond the dreams of any Prohibitionist or trial lawyer ever heard of.

...

Allow me to recommend to Mr. Barber the splendid figure of Our President. He is precisely Mr. Barber's age, 56. He took stock of his health a decade or so back and did not need lawyers or Prohibitionists to tell him what was necessary. He demonstrated personal responsibility and he is now in the pink. He did not need more government regulation and higher excise taxes to direct him toward a better diet and toward exercise. Yet more government regulation and taxation are what the Prohibitionists demand. Ironically, the result will not be a leaner but a more corrupt America, if the tobacco scenario taught us anything.

Regulated industries are always subject to the corrupt practices of pressure groups. Substances burdened with high excise taxes are always subject to bootleggers. Given the disparity of onerous taxes on tobacco among the states and municipalities, organized crime is now extending its grip on tobacco sales. Just as the Prohibitionists of the 1920s were the Mafia's best friend, history is repeating itself today as the Prohibitionists' taxes on tobacco widen the opportunities for Mafia bootleggers to take over tobacco distribution. When the states start imposing more regulation and taxes on junk food the opportunities for corruption will multiply.

Yet, as the robust George W. Bush demonstrates, if we take personal responsibility for our diet we will not need the Prohibitionists, the trial lawyers, and now — as I hope I have demonstrated — another of their allies, the Mafia.

Michael Connelly writes mystery thrillers which I love. I will see the first movie based on one of his books Saturday night. The book, Blood Work, combines a health issue (cardiac transplantation) with a disturbing mystery. If you like movie reviews - BLOOD WORK - the review by Roger Ebert.

Read this poignant confession - Hollywood's Responsibility for Smoking Deaths.

I've written 14 movies. My characters smoke in many of them, and they look cool and glamorous doing it. Smoking was an integral part of many of my screenplays because I was a militant smoker. It was part of a bad-boy image I'd cultivated for a long time — smoking, drinking, partying, rock 'n' roll.

Smoking, I once believed, was every person's right. Efforts to stop it were politically correct, a Big Brother assault on personal freedoms. Secondhand smoke was a nonexistent problem invented by professional do-gooders. I put all these views into my scripts.

...

Eighteen months ago I was diagnosed with throat cancer, the result of a lifetime of smoking. I am alive but maimed. Much of my larynx is gone. I have some difficulty speaking; others have some difficulty understanding me. I no longer have the excruciating difficulty swallowing or breathing that I experienced in the first months after my surgery.

I haven't smoked or drank for 18 months now, though I still take it day-to-day and pray for help. I believe in prayer and exercise. I have walked five miles a day for a year, without missing even one day. Quitting smoking and drinking has taught me the hardest lesson I've ever learned about my own weakness; it has also given me the greatest affection and empathy for those still addicted.

Why can't I convince them before this happens?

Health care in rural areas remains spotty. Some areas have thriving medical communities, while others are virtually doctorless. There are many barriers to rural practice, but Medicare shoud not be one. Rural doctors plead for equal pay: Lawmakers from underserved areas also push for an easing of the geographic disparity in Medicare physician payment.

Thousands of family physicians in rural areas are facing similar crises, and many believe Medicare payment policy is to blame. A 5.4% cut in Medicare rates in 2002 has only exacerbated previous funding shortfalls that are driving primary care doctors from rural areas.

"If our reimbursement rates continue to go down and our expenses continue to go up, you will see an exodus of physicians out of rural areas like Moses out of Egypt," Dr. Casey said. "The practice of medicine is like any other business. If you can't pay your bills, you can't survive."

As long as the government controls reimbursement and sets requirements which increase overhead, we will have this problem. We have bureaucracy run amok. Reading about the Canadian and British health systems only supports my distrust of bureaucracy - they are in worse shape than we are. Bureaucrats and insurers do not care about patient care - they care about statistics and finances. That is the problem.

Legislatures need to remember that each problem fix has unintended consequences. These unintended consequences usually cost money. Each sanctimonious congressman and senator needs to understand the implications of their rules on health care costs. Where did common sense go?

In a July speech, President Bush echoed what some physicians have been saying about the medical liability climate for years. Here are excerpts:

"Sometimes the lawyers take up to 40% of the verdict -- 40%. And while patients injured by a doctor's malpractice deserve fair compensation, there are too many cases of grossly excessive jury awards."

"People say, well, is it a federal responsibility? Should the federal government act on this problem? And the answer is yes. ... The federal government uses taxpayers' money to fund health care programs -- Medicare, Medicaid, children's health care, veterans' health care, military health care. And any time a frivolous lawsuit drives up the cost of health care, it affects taxpayers."

"Higher and higher insurance premiums make it nearly impossible for a lot of doctors to practice medicine. And if docs don't practice medicine, it's hard to have good health care."

Bush decries "junk lawsuits," calls for federal tort reform: Physicians praise the president's proposal, which is similar to AMA-backed legislation aimed at easing the medical liability crisis. This well researched article from the AMAnews summarizes the issue well. The trial lawyers (and hence the Democrats) disagree. Posted by at 05:42 AM | Comments (0) | TrackBack (0)

We remain in a battle with microbes. Each time we use an antibiotic, we have a chance of selecting a mutation which can resist the antibiotic. Use the antibiotic enough times, and natural selection yields a resistant strain. The resistant strain can then start to spread. This is evolution. With the recent discovery of Vancomycin resistant Staphlococcus aureus (VRSA) , scientists are working on rebuttals - Chemical combat foils superbugs: Chemistry trick restores antibiotic potency.

When sharks circle, they smell for blood in the water. Battle Of The Widening Bulge.

The same lawyers who took on Big Tobacco met this summer in Washington to explore whether similar tactics can be used against the food industry.

"The lawyers smell the blood in the water," says John Banzhaf, a law professor at George Washington University. "It seems to be an issue at the moment.

"Maybe it's a movement."

Banzhaf, a brazen crusader against the cigarette, says "don't laugh," because that's what the tobacco industry did 20 years ago.

I will not laugh at these lawyers, but I hope that they cannot dupe jurists with their sophistry. Food is not addictive like nicotine. It is a habit - and we can break habits. My eating habits have changed as a result of setting goals. We can change our preferences. Too many lawyers lead to looking for issues. Why does everything end up in court? Is that what the founding fathers wanted?

While I try to blog on a wide variety of medical issues, I am consistently attracted to fitness and diet articles. Hopefully, I will help at least one person's motivation. If so - this article is for you - Fitting fitness back in your life

But you have plenty of company. You've joined the 4-in-10 adult Americans of all ages who admit they are not physically active at all, according to the President's Council on Physical Fitness and Sports.

Exercise experts like Richard Cotton and Cedric Bryant have heard it all before — busy boomers complaining that, between carpools and van pools and making ends meet, they barely have time for a movie, much less a regular exercise routine.

Cotton is an exercise physiologist and also a spokesman for the American Council on Exercise in San Diego, Calif., an organization that certifies instructors and oversees exercise research. Bryant is the chief exercise physiologist for the council.

They both specialize in motivating inactive people to become involved in exercise programs. They inspire woefully out-of-shape, middle age lapsed exercisers or never-exercisers to consider the benefits of incorporating workouts into their however-hectic-or-sedentary routine, convincing them that the stress-reduction and disease-risk reduction benefits are worth the effort.

Check out their tips - very commonsense yet perhaps uncommon advice.

Into our stomachs, out of our minds: Are we gluttons for diet nonsense?. I recommend reading this link. Sally Squires has summarized the issues very well.

While most overweight people could resolve their problems through more intelligent diet and exercise, some cannot. Why do so many of us eat too much most days? Researchers are addressing the basic science of appetite and the underlying hormones. Hormone That Causes Full Feeling Is Found. Interesting story about PYY

The hormone, Peptide YY3-36 or PYY, is made by cells in the small intestine in response to food and then circulates to the brain, where it switches off the urge to eat.

"It stops you feeling hungry," said Dr. Stephen R. Bloom, a professor of endocrinology at Hammersmith Hospital at Imperial College School of Medicine in London, who led a study of the hormone that was being published today in the journal Nature. "It controls you and me after every meal we eat."

...

Like many other scientists, Dr. Bloom attributed the rise in obesity to the increased availability of fattening foods. Humans had evolved to survive famine, not feast, he said, and people today are the descendants of ancestors who had withstood starvation because they had genes that enabled them to store fat as a reserve.

"We didn't evolve for this environment of supermarkets at every street corner," Dr. Bloom said. "So what we do is, we find out how appetite is regulated and we work to readjust that regulation to make us more fitted to the environment we're in. We interfere with nature to alter the bad effects of this environment for which we haven't evolved."

Currently, PYY remains experimental and will only work parenterally. It is unlikely to be "ready for prime time" for many years.

MSNBC also has a good story on this research, putting several recent discoveries about appetite hormones into perspective - Hunger hormone may fight obesity: Natural chemical shown to make people feel full in buffet experiment

I am not surprised. I tell patients, interns and students that the only dietary intervention that I see work for hyperlipidemia is significant weight loss. Standard Lifestyle Recommendations Have Little Effect on Cholesterol Levels. I like this article (registration required), because it reports on data. At follow-up, the researchers observed no significant changes in any of the measures among patients randomized to the standard lifestyle recommendations.

However, patients in the other groups experienced weight loss (from 1.7 kg to 3.7 kg), reductions in total cholesterol (by 4% to 6%), reduction in LDL cholesterol (6%) and a lowering of mean systolic blood pressure (from 7.3 mm Hg to 8.8 mm Hg), the researchers found.

Patients in the supervised exercise program also significantly improved their exercise capacity, they add. These patients also reported a significantly greater improvement in health-related quality of life compared with other patients, according to the report in the July issue of Preventive Medicine.

"These improvements in cardiovascular disease risk factors in the more intense groups translates into a 3% to 6% absolute reduction of the estimated 10-year cardiovascular disease risk, whereas this risk remained stable in the step 1 group," the researchers note. "This represents a relative risk reduction varying from 15% to 27% over baseline for the more intensive interventions, compared with only 6% for the step 1 diet group."

Dr. Lalonde and colleagues conclude that "more intensive lifestyle interventions may be associated with improvement in cardiovascular health and quality of life. Further studies should be done to identify interventions that are both effective and attractive for the majority."

This is an interesting story. We are probably years away from understanding which patients will benefit from this knowledge. Hormone breakthrough in obesity

The treatment is based on injections of leptin, a hormone that appears to play a central role in suppressing appetite by informing the brain when the stomach is full.

Doctors believe its use could form the basis of a new and highly effective way to treat severe obesity.

...

Dr Ian Campbell, chairman of the UK National Obesity Forum, told BBC News Online that the treatment sounded promising.

But he warned that only a small proportion of severely obese people were deficient in leptin.

"This shows that replacing leptin can have a profound effect in achieving weight loss, but what remains to be seen is the effect leptin would have on people who are not deficient in the hormone in the first place."

We still have a lot to learn about obesity. This does not obviate the benefits of diet and exercise for the great majority of patients. Nonetheless, I find such research very interesting.

The Atkins diet sure get a lot of attention - Researchers chew the fat on merits of the Atkins diet

Some of the nation's leading obesity researchers and nutritionists are outraged by the diet, arguing that it runs contrary to the advice of most major health organizations, which advocate a diet relatively low in saturated (animal) fat and high in complex carbohydrates (grains, vegetables). Those recommendations are based on scientific evidence that a diet rich in fruits and veggies and low in saturated fat reduces the risk of heart disease, some types of cancer and other health problems.

Still, many dieters swear by the Atkins diet. And until recently, there haven't been many studies investigating its safety and effectiveness.

As a skeptical physician, I am always happy to question the "advice of most major health organization'. I worship at the altar of data. We need to see the data - 'show me the money'.

In one new study, conducted at Duke University Medical Center and funded by a grant from the Robert C. Atkins Foundation, participants ate a very low carbohydrate diet of 25 grams a day for six months. They could eat an unlimited amount of meat and eggs, two cups of salad and one cup of low-carbohydrate vegetables such as broccoli and cauliflower a day. Of the 50 patients enrolled, 80% adhered to the diet for the entire study, losing an average of 10% of their original body weight. The average weight lost was approximately 20 pounds, says Eric Westman, associate professor of medicine at Duke University Medical Center.

...

In another pilot study, obesity researchers at three universities recruited 63 people who were 30 or more pounds overweight and assigned them to one of two programs. One group was given a copy of Dr. Atkins' New Diet Revolution. The other group was put on a conventional diet with about 30% of calories from fat, 55% from carbohydrates and 15% from protein.

At the end of six months, those following the Atkins diet lost about 10% of their starting weight and those on the conventional diet lost about 5%. Atkins dieters also were more likely to stick with the plan than conventional dieters.

...

Foster and fellow researchers are going to continue to investigate the Atkins diet with a longer-term study sponsored by the National Institutes of Health. They will look at several different aspects, including whether the diet may be more useful for some people than others and how much people are able to exercise while eating a low-carb diet. They also want to investigate why some dieters seem more likely to stick with the Atkins program than a more conventional diet.

The data speak. At least in the short run Atkins works for dramatic weight loss. I am glad the the NIH is studying the diet in a longer-term study. That seems a good use of federal funds.

I hate typing this. FDA Rebukes Maker Of Diet Drug Meridia

The Food and Drug Administration has told the maker of the diet drug Meridia that it violated federal regulations by failing to properly report the deaths of patients taking the drug.

In a letter to Abbott Laboratories made public yesterday, the FDA said that information about seven deaths associated with Meridia was not reported properly to the agency, that one death was not reported at all, and that reports on three other deaths were incompletely reported.

Why are they not thinking? What are they trying to hide? This makes me very unhappy.

Jane Brody (one of my favorites) wrote this week on osteoarthritis. First Step in Treating Arthritis: Keep Moving. While we know from good studies that physical therapy helps osteoarthritic patients, I am dismayed by how few of our patients will devote themselves to a program. They assume that we have a magic pill that will fix them. The article discusses the wide variety of therapies. She discusses the increasingly popular supplements:

So-called dietary supplements offer another option that may be taken alone or along with other arthritis drugs. Most popular among them are glucosamine and chondroitin sulfate, often sold in combination tablets or capsules with instructions to take three a day.

Other than a possibility of somewhat loose stools in the first few weeks of therapy, they have no known side effects. Several clinical studies, not always pristinely conducted, have indicated that glucosamine alone or the two in combination can relieve arthritic discomfort and may delay or halt its progression.

The National Institutes of Health is conducting a proper study of their effectiveness.

Some evidence also supports another dietary supplement, SAM-e, for arthritis pain, as well as mild depression. For arthritis, 200 to 400 milligrams of SAM-e are taken three times a day. With all supplements, do not expect noticeable pain relief for three or four weeks.

Dietary supplements can be quite costly and are not covered by medical insurance. Neither are their quality and potency regulated by the Food and Drug Administration. So bargain hunting may be a bad idea. It is best to choose products made by reputable companies like Nutramax and Schiff.

This is a good reference for the web searching patient. The information is sound, well balanced and obviously researched.

Diabetes mellitus (especially type II diabetes) is a disease of epidemic proportions. Medical care makes a major difference in patient outcomes. But many patients do not take ownership of their care. Getting diabetics better care.

Now a growing number of frustrated specialists say it's time to shake up diabetes care, telling patients in stark terms that early, aggressive treatment is all that stands in the way of a nasty death. They also want to persuade doctors to push stronger therapies sooner.

"People are still in denial about diabetes," says Dr. Alan J. Garber of Baylor College of Medicine, who is gathering specialists to develop such a campaign.

Indeed, research suggests that patients should wait only three months to see if a prescribed treatment — first diet and exercise, then varying types and amounts of medication — controls their diabetes before changing or adding therapies. One recently published study found patients need a combination of diabetes pills plus insulin far sooner than many doctors advise.

This disease frustrates me for several reasons. First, many patients can avoid diabetes with lifestyle changes. Diet and exercise decrease the probability of developing diabetes. Thus, we have another major benefit of a healthy lifestyle. Second, the complications of diabetes are devastating. We know how to decrease the probability of all the complications. Patients need to treat themselves compulsively. Medications help. Frequent eye exams help. Attention to detail helps. And I am frustrated because I cannot figure out which button to push to help patients adhere to a good regimen.

One must admire marketers. They find buzz words and capitalize on our beliefs. Such a word relating to food is 'natural'. ‘Natural’ not always better: But nutrition experts urge eating less processed foods.

According to a recent survey by the National Consumers League, three-quarters of Americans believe products labeled “natural” contain at least 90 percent natural ingredients, and even more people believe that “natural” means a product is safe. Actually, neither assumption is true. The California Department of Human Services, for example, found that 32 percent of “natural” remedies sampled from herbal stores contained heavy metals, like lead or arsenic, or unlisted pharmaceutical ingredients.

...

With grain products like bread, cereal, rice and pasta, choosing less refined versions means choosing whole grains. In refining grains, as in milling wheat to make white flour, much of the fiber, vitamins, minerals and health-promoting phytochemicals is removed along with the bran and germ. Whole-grain foods like whole-wheat bread, oatmeal and brown rice are nutritionally superior to refined products. More than five major studies link regular consumption of whole grains to a 30 percent drop in the risk of heart disease risk. Other studies show a 10 to 50 percent lowered risk of various cancers among those who eat more whole grains.

I think that understanding carbohydrates will help us greatly. How To Tell Good Carbs From Bad We all need to learn what foods we really need to buy.

Medpundit sited a Boston Globe piece yesterday - Boutique Medicine. As long time readers know, I prefer the name retainer medicine as more descriptive and less perjorative. Maybe someone can develop a better solution to first contact care, but we really should examine the forces driving the retainer medicine movement. I understand that health care costs continue to increase, but underpaying physicians will not help. Physicians need the right amount of time with patients. Current fee schedules do not permit the proper length visit. Insurers (especially the government) have onerous documentation requirements which increase overhead. We need a better solution. This may be the solution, although we will need to modify our current understanding of health insurance. Maybe we could develop an option which allows for a retainer fee (giving unlimited access - visits, email, phone) but no visit fees. We could decrease overhead by not filing for insurance claims and not having to fill out so many forms. Such a system will require refinements, but I really believe it could work. Of course, some will argue that unlimited visits will encourage abuse of the privilege. We should consider that and start to study the options. A scientific approach to redesigning medical practice should start now. The current system is broken beyond repair.

The pharmaceutical industry refers to sales calls as detailing. I hate being detailed. However, detailing works. Research has also shown that one can counteract detailing by using this weapon to clarify drug information. Now insurers and prescription drug benefit organizations are taking the academic research and using counterdetailing to decrease drug costs -
Doctors Hear Alternatives To Drug-Firm Sales Pitches

Drummond is a "counterdetailer" -- a paid consultant for a prescription benefit company whose job is to question those sales pitches, to counsel doctors to look at cheaper and generic drugs whenever appropriate. And the rise of this figure in the health care landscape has opened another front in the battle to control prescription drug costs, which have been rising more than 17 percent yearly since 1997.

...

Then there are counterdetailers, targeting doctors. The states of West Virginia and Michigan have hired their own counterdetailers to visit doctors and encourage them to prescribe generics whenever possible. Legislators in other states, including Vermont, Massachusetts and Washington, have proposed or passed similar programs. First Health Group Corp., which manages prescription benefit plans in 14 states, reports that the states' interest in counterdetailing is growing fast.

...

Persuading doctors to prescribe generics -- and patients to use them -- can bring enormous savings. As explained by Tom Susman of the West Virginia Public Employees Insurance Agency, 43 percent of prescriptions paid by the plan are now generics. If that number grew to 45 percent, he said, the state would save $1 million. That's why he is beginning the state's counterdetailing program, and why the work of people like Marcia Drummond is drawing increased interest.

She works for the prescription benefit company AdvancePCS, which has its own financial reasons for wanting to control drug costs but whose goal is shared by many others, including some generally critical of managed care. New York doctor Robert Goodman, for instance, who runs a program that highlights improper drug-company promotions to doctors, applauds private counterdetailing efforts because "it's essential that doctors get drug information from sources other than just drug company reps."

The AdvancePCS program began several years ago, and now sends out 150 counterdetailers to visit 20,000 of the nation's top prescription-writing doctors each year. The goal, as Drummond described it, is to discuss with doctors the drugs they're prescribing to make sure the patients are getting the most appropriate -- and least expensive -- medications.

All I can say to the pharmaceutical industry is ' Take that!!!'. This is constructive, and I hope the government figures out the benefits of this approach. I only worry that costs do not bias the information given to physicians. I suspect we will read more about this approach over time.

Yesterday (seems weeks ago) morning I commented at length on the duodenal ulcer story over the past 25 years. The acute coronary syndrome story also should intrigue us. Over the past several years, much literature has focused on inflammation as a precursor to acute coronary events. A variety of inflammation markers show up in these studies, but the most ubiquitous is CRP (C-reactive protein). Now the American Heart Association is preparing a guideline relative to screening for inflammation - Surprising discovery: Inflammation May Be Worse For the Heart Than Cholesterol. While the data do not yet reach the level to entirely convince me, I am impressed by the ongoing accumulation of evidence.

In the past year or two, experts say, the evidence has become overwhelming that inflammation hidden deep in the body is a common trigger of heart attacks, even when clogging in the arteries is minimal. Now the main question is: How aggressively should otherwise healthy people be tested to find and treat it?

The new recommendations are still being drawn up, but they will offer the first formal blueprint to answer this, probably sometime in the fall. Doctors writing them say they will almost certainly recommend broad testing.

Inflammation can be measured with a generic $10 test that looks for high levels of a chemical called C-reactive protein, one of many that increase during inflammation. Experts expect it to quickly become a standard part of physical exams. As a result, many people ordinarily considered at low risk will probably be put on statin drugs, which lower inflammation as well as cholesterol.

No one disputes the importance of cholesterol. Yet half of all heart attack victims have levels that are normal or even low. Clearly, something big was missing from the equation, and that appears to be inflammation.

As time passes, I become more cautious about new ideas in medicine. All physicians see ideas come and go. This idea seems to "have legs".

CRP probably will not matter much for heart attack survivors and others who already know they have heart disease, since presumably doctors are already doing everything they can to keep their condition from getting worse.

"We believe the niche for C-reactive protein - and it is a large niche - is the healthy population who want to do what they can to lower their risk of cardiovascular disease," says Dr. Richard Cannon of the National Heart, Lung and Blood Institute.

Screening is important because inflammation can be readily lowered in several ways. One of the most powerful is losing weight. Exercise also helps, as does moderate alcohol intake, giving up smoking and lowering blood pressure.

Of course, this amounts to the same healthy living advice that doctors have long dispensed. But now they have a much better understanding of why it works so well. Furthermore, they are likely to urge these habits on people with bad CRP readings who until now would have seemed to be at no special risk of heart problems.

Medpundit urges caution about this story today -

Why not wait until the studies are finished before putting out guidelines? I don’t have access to all of the journals that come up in a PubMed search of C-reactive protein and coronary artery disease, but I do have access to the New England Journal of Medicine article that started it all. The results in the abstract state that treating someone with normal cholesterol but a high C-reactive protein with a cholesterol lowering drug, specifically a statin, prevented heart disease. In truth, the people with high C-reactive protein values and normal cholesterol who took a statin had a 3% incidence of heart attacks compared to a 5% incidence in people who took placebo. That’s not much of a difference. Especially when you’re recommending that someone take a drug for the rest of their lives to achieve it. Furthermore, an aspirin a day could prove just as effective, or more so, in preventing heart disease in people with elevated inflammation markers alone. We don't know. No studies have been done to compare the two.

While I am not as skeptical as she is, her points do provide some balance. I am giving a talk on acute coronary syndromes later this year, and had already planned to include a section on the inflammation hypothesis. If you want to read more about the inflammation hypothesis I recommend an article in the July 2, 2002 issue of Circulation - 'Need to Test the Arterial Inflammation Hypothesis', Deepak L. Bhatt and Eric J. Topol; Circulation 2002 106: 136 - 140. This article develops the question very nicely, and proposes

It is vital that the "inflammation hypothesis" be tested in a large-scale clinical trial, which has the potential to change radically the approach used with patients with cardiovascular disease. Patients with a history of cardiovascular events and an elevated baseline CRP could be randomized to either usual-care or a CRP-guided strategy. All patients would be treated with aspirin at a moderate dose of 81 to 162 mg.41 Patients with an LDL cholesterol level greater than 100 mg/dL would be treated with a statin. ACE-Is would be prescribed to patients with left ventricular dysfunction. Further therapy in the group randomized to the CRP-guided strategy would be based on a prespecified algorithm of tiered therapy and response of CRP levels to initiation of a particular medication ...

The inflammation story is fascinating and makes much sense. I am not against the enthusiasm for using the available data, however, we should always strive to refine our knowledge and continue our quest for understanding.

For those who check in each morning, sorry for the late blogging today. I had a wonderful weekend - my daughter got married last night! The weekend exhausted me, and I'm just starting to recuperate. I'll be catching up on blogging over the next couple of days, but there are a few interesting stories today.

Today's entry is my 300th. That accomplishment tells me that I look forward to blogging about medicine each day. As a medicine blogger, I do not expect to run out of topics. As a physician I never run out of wonder.

While I understand the frustration that many physicians have with the current health non-system, I am still very happy that I decided to become a physician (and would do it again were I in college). I will rant daily about the problems we face - politically, legally, and socially. Nonetheless, we have a wonderful profession.

As I consider being a doctor, I marvel in the balance between the science of medicine and the art of medicine. Let me first comment on the science.

As an intellectually curious human being, I desire knowledge. As knowledge advances, we can often use that knowledge to help our patients. An example picked from my 30 years since starting medical school will illustrate my thoughts.

As a medical student we were taught about the acid hypothesis for ulcer disease. We treated patients with frequent small feedings and antacids. The most common surgery in the country was a Bilroth II (a vagotomy and gastrojejeunostomy). Over the next decade, the histamine 2 receptor was discovered and blockers developed. The introduction of cimetidine (Tagamet) had a marked impact, decreasing dramatically the need for ulcer surgery. After a few more years, the first proton pump inhibitor (omeprazole - Prilosec) was introduced, advancing our care even more. Meanwhile, a renegade researcher, Barry Marshall began pushing the hypothesis that a bacteria caused most ulcer disease. We now treat ulcer disease with an antibiotics concoction. The story all makes sense now, but who could have imagined it when I started medical school.

That story is not an isolated example. As I teach internal medicine on the wards, I draw from new findings daily. Medicine brings intellectual excitement daily.

Medicine also brings an emotional high. The art of medicine is fascinating. Although I have not done other jobs, I cannot imagine any other vocation where you meet someone (the patient) and they respect you and will tell you almost anything. Patients like physicians and physicians like patients. Our job is difficult, including delivering bad news, discussing end of life issues, and trying to steer patients to help themselves. The challenge of combining our need to maintain our knowledge base with the opportunity to effect patients in the manner we talk to them makes what I do a constant wonder. As I reflect on this past ward month, I remember several patient discussions about end of life care and dignity. The patients (and their families) showed such gratitude that we cared to insure their humanity, even when their medical condition was trying to rob them of that same humanity. We had to deliver the news of undesirable diagnoses. We saw the ravages of severe dpression, and learned how our caring and understanding allows the patient to start climbing out of the abyss. And we were fortunate enough to deliver some good news. This art of medicine makes our profession special.

The politicians will never understand. The insurers look at our patients as numbers not humans. The lawyers see the unfortunate as opportunities to sue (and gain contingency fees). But I see patients and want to help them. Sometimes my knowledge of science can make a dramatic difference. Sometimes I can use technology to make a diagnosis and get the right specialist to help the patient. But regardless, I can help the patient by bringing my humanity to the bedside and respecting the patient's humanity at all times. I really love my profession and feel fortunate that I found this way those many years ago.

Michael Kinsley makes sense (my fingers deceive me). He has analyzed the debate over prescription drug benefits rationally. Congress on Drugs: The bizarre debate about a prescription drug benefit. He asks

Government benefit programs are sometimes called "social insurance," but what exactly is being insured against? Look at the prescription drug benefit that died—for this year—in the Senate on Wednesday. Differences between this proposal and the one that passed the House in June do not loom large to the naked eye. Both parties claim to favor drug coverage for the elderly, and what they are quarreling about is as unclear as the philosophical basis for the plans they have come up with.

Hey Michael - they are quarreling about politics. Just thought you would want to know.

When Congress takes up a drug benefit again, it should keep things simple and concentrate on the risk, approaching a certainty, that it wishes to prevent: people doing without drugs—or without food—because of the cost. That means concentrating on poor people. The risk that drug prices will move you down a notch in the middle class is not something an entire society can insure itself against anyway.

Amen!

Read this wonderful essay - Fads and Big Fat: Diet plans, lawsuits. What happened to the human will? .

There are no rigorous medical studies to prove that any of these diets really work, but that has not stopped them from becoming bread-and-butter issues. In California, "Fat Liberation Activists" want to classify obesity as a disease and give weight-loss treatments and diet plans special tax benefits. If they have their way, Dr. Atkins's book, and food deliveries from the Zone, will be tax deductible.

By codifying obesity this way, the fat activists have taken the individual out of the equation, making weight gain another one of the "it's not my fault" maladies and Krispy Kreme a kind of disease transmitter. That litigious New York man is taking aim at fast food, but it is conceivable that one day someone will file suit against a diet plan that fails to deliver on its promises. After all, a weak human will is not to be blamed.

There are of course nongimmicky diets, such as Weight Watchers, that preach sensible eating and exercise, and these seem to work. But the bottom line remains self-discipline--e.g., eating less. For those who follow the fads and fail, a faith in easy fixes remains, as the rising number of weight-loss surgeries attest. This year alone, nearly 60,000 Americans will undergo stomach stapling, at a cost of $5,000 per operation. That's 50% more surgeries than in 2000.

The author, an internist, writes well about this complex topic. We will continue to read and write about overweight and obesity. It is a big deal.

Medpundit has me pegged. I am a statistics geek. She reads gobbledygook and claims innumeracy, while I revel in the beauty of the numbers. Sweep On You Greasy Statistics.

Thus, we have an unresolvable disagreement. I read the article and love it. They used sound statistical analyses, straightforward and seemingly controlled for confounding variables. I find the attributable risk an important concept, one which helps me understand the percentage of the pie to which obesity contributes. Medpundit reads - too complex, must not be that important.

Obesity does danger one's health. It increases the risk of diabetes mellitus, osteoarthritis, hypertension, cancer, heart failure, etc. We all know that, but what can we do? This NEJM article adds to the data. Now the medical community needs proactivity. How can we influence our society to make the necessary changes to decrease obesity - BMI 25-29 (not to mention overweight - BMI > 29?

Some modest proposals:

• Start measuring body fat - knowing your body fat has more drama and immediacy than your BMI
• Supporting healthy food alternatives
• Giving exercise prescription
• Being role models of fitness and good diet

Medpundit also criticized the Senate movement to support these ideas

“...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 better nutrition and more 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.

At first glance, this seems innocuous. Nothing wrong with encouraging nutrition and exercise, or with making sure government sponsored food assistance programs offer healthy foods (shouldn’t they be doing that anyway?). But, do we really need the government this involved in our lives? That money would be better spent on, say, beefing up local health departments to deal with the threat of bioterrorism, or helping to finance immunizations for the poor.

I favor the expenditure. While I do not want the government more involved in my life, I do understand that we need a concerted effort over years to improve this insidious situation. Rather than super-size it, we need to learn to right size it.

I hope you read both sides of this debate, and let me know your opinions. As I walk through the wards, I see too much obesity. When I go to clinic, I see too much fat. I believe that while each individual should take responsibility for their health, society can help - and should.

CBS has this story on 4 decades of weight watchers - The Four-Decade-Old Diet

Read this nice summary of the "movement" behind the fast foods suit - Fat suits: Who’s
to blame for flab? The battle of the bulge takes on fast food

As a physician, we must all learn the lesson. Knowing what to do is just the first step to treating a patient. Next one needs the patient to want to participate in their care. Many patients just do not want to take the medication, either because I did not explain it properly, or because they do not accept our medical model. Finally, the patient must have the resources to obtain the medication. Increasingly, that is the problem. Danger of Unaffordable Drugs: Older Americans Risking Their Lives to Save Money on Medicine. All physicians who have asked know this problem. The reporters did not have to search long to find this example.

Some will say that the pharmaceutical industry provides drugs to the needy. Cold Fury pointed out a web page devoted to those programs - Needymeds.com ...because everyone should take their medicine. Unfortunately, these programs are a pain in the butt for physicians and their staff. Each company has its own form, and criteria for inclusion. They generally mail the drugs to the physician's office, turning us into a dispensary. Read the article - it describes the problem well. It does not give a solution. That is realistic.

Bloviator took a cue from my piece on Medicare vaccine reimbursement, and wrote a beautiful piece about the underfunding of immunizations. MEDICARE VACCINE REIMBURSEMENT POLICY MAY AFFECT VACCINATION OF CHILDREN

Instead of linking to the news story, just read with Rangel says Does AM Exercise suppress the immune system!? He has a nice summary and opinion. The data present a theory rather than an observation. He analyzed the problem well.

Just when I thought I understood all the pharmaceutical industry tricks, bingo, they have a new one. First, you market the disease... then you push the pills to treat it

The modus operandi of GlaxoSmithKline - marketing a disease rather than selling a drug - is typical of the post-Prozac era. "The strategy [companies] use - it's almost mechanised by now," says Dr Loren Mosher, a San Diego psychiatrist and former official at the national institute of mental health. Typically, a corporate-sponsored "disease awareness" campaign focuses on a mild psychiatric condition with a large pool of potential sufferers. Companies fund studies that prove the drug's efficacy in treating the afiction, a necessary step in obtaining FDA approval for a new use, or "indication". Prominent doctors are enlisted to publicly affirm the malady's ubiquity, then public-relations firms launch campaigns to promote the new disease, using dramatic statistics from corporate-sponsored studies. Finally, patient groups are recruited to serve as the "public face" for the condition, supplying quotes and compelling stories for the media; many of the groups are heavily subsidised by drugmakers, and some operate directly out of the offices of drug companies' PR firms.

I generally respect and like this administration. They have this one wrong. I generally dislike the trial lawyers, but they may have this one right. White House and Senate Hit Impasse on Patients' Rights

In June last year, by a vote of 59 to 36, the Senate passed a bill that would establish a wide variety of patients' rights for more than 200 million Americans. Patients could file suit, in federal or state court, to enforce their rights and could win damages for certain injuries. President Bush had threatened to veto the Senate measure, but supported a bill passed by the House last August. The House bill would provide patients with a much more limited right to sue.

We do not always agree. Hopefully, we are civil. Medpundit criticized the effect size in the obesity and risk of heart failure study - Sweep on, you fat and greasy citizens: -Shakespeare, As You Like It..

Or so says the result section of the not-so-helpful abstract of the paper, a statement which was duly copied in CNN’s report of the study. That sounds pretty impressive, but the abstract doesn’t tell us how many overweight subjects had heart failure compared to the non-obese. It only talks of rates of risk which can be misleading. In fact, the paper itself isn’t much clearer. It, too, never gives out the absolute numbers, preferring instead to deal with “person-year of follow-up” compared to numbers of heart failure cases. Even using these gymnastics, the final results aren’t all that impressive. For women of normal weight there was a 10-year cumulative age-adjusted incidence of heart failure of 3.4%. For overweight women (BMI 25.0- 29.9) it was 3.7%. For the obese (BMI > 30), it was 6.8%. Yes, it doubled, but the percentages are still pretty small. The figures for men are similar. Normal weight men had an incidence of 4.9% over ten years, overweight men had an incidence of 6.1% and the obese had an incidence of 10%.

Epidemiologic papers are tricky to interpret. I spent some time reading the article, and will give my interpretation.

Over a 10 year period, each BMI increase of 1 increases the heart failure risk by 5% (men) or 7% (women). Thus, having a BMI of 30 increases the heart failure risk by 30%. This makes sense (the more overweight the greater the risk), but the implication is difficult to understand. A better way to consider the data comes from the population attributable risk. This calculation estimates the percentage of heart failure that weight control would eliminate, or what percent of heart failure can we blame on weight alone (controlling for all other known variables). In this study,

The population attributable risk of heart failure due to overweight was 14.0 percent in women and 8.8 percent in men. The corresponding population attributable risks due to obesity were 13.9 percent in women and 10.9 percent in men.

These are impressive attributable risks. Given around 500,000 new patients with heart failure each year, over 50,000 are attributed to overweight and obesity. I do not believe the NEJM got this one wrong.

I got this link from a comment at The Safety Valve. Cold Fury started a stir Those Greedy Pharms. He discusses (amongst other things) free drug programs for the needy, the cost of clinical trials, and the problems of big government. I found it worth reading.

This piece from the National Review Online - Wasted Resources: John Stossel takes on the drug war.

Associations in medicine are dangerous. Estrogen usage is associated with less heart disease, but we now assume that estrogen users generally had better health habits. Wine drinking is associated less heart disease. Is it the wine? Dining, not wining, is healthy

A study of 4,500 Americans found that wine drinkers lived longer, healthier lives because they also followed a diet richer in fruit and vegetables and higher in fibre than that of teetotallers.

Surprisingly, they also smoked less and exercised more than their non-drinking counterparts.

The findings, to be published in the forthcoming issue of the American Journal of Clinical Nutrition, suggests that wine lovers could be deluding themselves about the advantages of imbibing.

Hmm, I still think that red wine is good for me.

Rounds at the VA hospital for the past 35 days ended yesterday morning. I had several personal goals this month. First, I wanted to help my team test the new ACGME guidelines for hours worked. Second, I wanted to focus on the doctor-patient relationship, particularly how to have difficult conversations. Finally, I wanted to provide a strong framework for the new interns and third year medical students in internal medicine.

The new ACGME guidelines are both easy and difficult. We had no problem with the 80 hour work week nor the 4 days off per month. The interns and resident probably worked around 60-70 hours per week. They each had 4 or 5 days off during the month. I did not think this would challenge us, and it did not. The 24 + 6 rule is a problem. At our institution, the on-call team starts at 8 a.m. If we can get the team to arrive at 8 (they generally come in around 7 a.m. to "pre-round") then by the new guidelines, they should be leaving by 2 p.m. Using this liberal definition, we need to dissect their morning post-call.

We started post-call rounds at 7 a.m. on weekdays (week-ends are a very different and easier situation). After rounding for an hour, we broke for an hour, allowing the resident to go to morning report and the interns to call consults, order tests and prepare discharges. We then reconvened around 9 a.m. and tried to finish presenting and seeing the new patients by 10:30 a.m. This required keeping presentations short, and teaching minimal on post-call days. The housestaff have a daily required educqtional noon conference. The problems revolve around getting test results back, getting patients discharged and talking with consultants, social workers and case managers. Those things take time, and one cannot "hand off" those tasks to another team. Often a test result changes the patients management plan. Waiting until the next morning for the result probably will increase length of stay. I am still struggling with what the ACGME is thinking, and our residents and interns are not happy with that provision.

We did a great job with the doctor patient relationship. We made our intellectual rounds behind closed doors. We joked, asked the tough questions, and got to know each other as people. This social aspect of rounds is very important in the growth of young physicians. When we went to the bedside, we went to talk to the patient and examine the patient. Patients helped our teaching by allowing us (with permission) to demonstrate physical findings. I also had serious discussions about depression, end of life issues, alcoholism, cigarette smoking, and our difficulties in making a firm diagnosis. After these discussions with patients, we would debrief the team to better understand the principles used in those interactions. The team enjoyed these discussions and told me it helped them in their own interactions.

Teaching internal medicine was my easiest job. I was first a ward attending in 1980. I have done this many times, and have a variety of "canned talks" to add to the teaching about specific patients. This went well for me and them.

Finishing a ward month is bittersweet. I love the stimulation of the learners - they induce me to learn more about medicine and refine my teaching. But 35 days at the hospital making rounds without a break is a long time. I'll enjoy not driving there on weekends this month.

The data speak loudly. Weighing too much decreases your quantity and quality of life. Study Links Excess Weight to Risk of Heart Failure

Previously, researchers were aware that severe obesity was an independent risk factor for heart failure, but the new data show that being even moderately overweight increases one's chances of developing the condition -- and the more overweight someone is, the greater the risk. Obesity alone accounts for 14 percent of cases of heart failure in women and 11 percent in men, according to estimates in the study, which appears in today's issue of the New England Journal of Medicine.

...

BMI can be approximated by multiplying weight in pounds by 703, then dividing by height in inches squared. A normal BMI is 18.5 to 24.9. Among study participants, overweight women (BMI between 25.0 and 29.9) had a 50 percent greater risk of heart failure than women of normal weight, and overweight men had a 20 percent greater risk than men of normal weight. In obese people of either sex (BMI of 30 or greater), heart failure risk was nearly twice that of normal-weight individuals.

...

"If you really want to have a public health impact, you have to intervene on obesity" before heart failure or other conditions develop, Lenfant said. But "it's pretty darn hard," he added. "Because . . . in most instances, it is the result of things that people enjoy. It's part of the culture."

Americans love to eat. We have plentiful food. We can more easily eat the wrong foods than the right foods. Exercise does not fit into most Americans daily plans. Can our society correct itself like it has with a major decrease in cigarette smoking?

When you keep expectations low, your do not get as disappointed. Senate Kills Plan for Drug Benefits Through Medicare

Senators of both parties said they would have to answer to voters this fall for their failure to deliver Medicare drug benefits. Each party blamed the other today.

They continue to posture, spin and not address issues. Blecchh!