Insurance companies do not fund programs for weight loss. Wrestling With Weight Issues: Insurance: Health plans can be stingy in their coverage of obesity and diet treatments.

Given obesity's role in triggering heart disease, high blood pressure, diabetes and other ailments, it's no surprise that people would expect their health insurance to pick up the tab for treatment. But getting your health insurance to pay for weight-loss treatments is a big "if," depending on which type of insurance coverage you have and where you live. Coverage is spotty, and many insurers still seem to take the attitude that being overweight is a personal failure of will.

Attitudes are changing--but slowly. In California, one of the most common disputes between consumers and health insurers involves an operation known as gastric bypass surgery, used to treat morbid obesity. The California Department of Managed Health Care, which regulates health plans, reports 86 cases in which patients appealed a health insurer's decision involving treatment for morbid obesity, a condition defined as someone who weighs at least 100 pounds more than his or her ideal weight. When those 86 cases were sent to an external review board, a panel of independent doctors hired by the state, the patients won 49 of the appeals, an unusually high success rate.

Despite the rulings, insurers are skeptical about the value of some obesity treatments. Aetna-US Healthcare, one of the nation's largest insurers, largely excludes coverage for obesity surgery, said Jill Griffiths, a company spokeswoman. Employers who provide health insurance for their workers have the option of including obesity surgery as a benefit, she noted.

"There is a fair amount of disagreement in the medical community about when [gastric bypass surgery] is appropriate and when it is not," said Jim Anderson, a spokesman for Kaiser Permanente. Anderson said that the surgery can be risky and that Kaiser wants to make sure patients have tried all other alternatives. Even so, Kaiser approves hundreds of gastric bypass procedures a year, he said. In at least one case, however, state medical reviewers overturned Kaiser's denial of a patient's request for obesity surgery, ruling that the operation was appropriate.

Insurers are more likely to approve obesity treatments today than five years ago, said Dr. Gary Anthone, director of the bariatric surgery program at USC's Keck School of Medicine. Attitudes have begun to change as the medical community has begun to consider that obesity is a disease itself, not just a contributing risk factor to other diseases.

Anthone says gastric bypass surgery is appropriate for people who have tried diet and exercise unsuccessfully and who are threatened by the other ailments that can come from obesity, including diabetes, heart disease and sleep apnea. But only as a last resort. The operation has a 1% death rate within 30 days of the surgery. And it means a permanent lifestyle change for patients who will be taking special vitamins and nutrients for the rest of their lives and eating tiny meals.

We need support for treating the obese. This disease is endemic and causes great morbidity.

I believe that criminalizing drug use harms society. The users can go to jail, and we all know the effect of a long jail stay. Making drugs illegal, increases their worth, leading to much crime, including violent crime. Today's USA today has a debate on this issue. Time to revisit costly policy of locking up drug offenders versus Incarceration aids drug fight

Say healthy fast food - you think oxymoron. Apparently this is changing - Can fast-food titans thrive on healthful fare? This interesting article suggests that we are looking for healthier food, but do like to get our food quickly.

Flu vaccine is plentiful this season

No smoke and mirrors here - this article reports on a carefully done study. Cannabis kills pain in medical trials

Its latest work focused on 34 patients with multiple sclerosis, spinal cord injury and other conditions causing severe pain.

None of the patients had responded well to current medications, but 28 said that using cannabis-based treatments reduced their pain and helped them to sleep more soundly.

Each patient was given three different types of medication which contained different levels of the active ingredients of cannabis. All out-performed a dummy medication.

The research was conducted by Dr Willy Notcutt, at his pain clinic at the James Paget Hospital, Great Yarmouth.

He said: "Patients in this trial are suffering from severe pain - it dominates their lives.

"Given the previously intractable nature of their pain symptoms, the improvements provided by cannabis-based medicines are all the more remarkable.

"Many of those with chronic pain also suffer from a poor quality of sleep, which - over time - can have profoundly negative effects on them and their families.

"By bringing about improvements in their sleep regime, as well their pain, we can have a major positive impact on their quality of life."

Chronic pain requires attention. We need another option in our armamentarium. We should have no moral objection to using marijuana. I that as the data are collected, the government will understand this important point.

Physicians know this - the data confirm it. After Decline, the Number of Uninsured Rose in 2001

I am currently on the road. I will be driving all day Monday, and will not have a chance to blog in the morning. I do plan to resume sometime Monday afternoon or evening. Sorry for any inconvenience.

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We (health care workers) are the carriers. We carry organism between patients. Infections spread. We all know to wash our hands, but washing your hands takes time. When I make rounds, not only does hand washing take time, but I have to find the sink, hope there is soap and even hope to find a towel. We may have a breakthrough - Hospitals Abandoning Soap and Water. I like this very much.

Soap and water may be all washed up. Many hospitals are switching to quick-drying alcohol gels to keep hands clean as evidence builds they stop dangerous germs faster and better.

...

"One of the real barriers to hand hygiene is how busy health care workers are," said Dr. David Hooper of Massachusetts General Hospital. "The ability to very rapidly kill bacteria on your hands is a great advantage."

Researchers at the Veterans Administration Medical Center in Washington D.C. measured the effects of switching to the alcohol rinses two years ago. Dispensers were put in all patient rooms and outpatient clinics.

New cases of drug-resistant staph infections decreased 21 percent, while resistant enterococcus dropped 43 percent. Both of these are serious, hospital-acquired infections.

Among the first to study the gel's advantages was Dr. Didier Pittet of the University of Geneva Hospitals in Switzerland. Four years of use there cut hospital-spread infections in half.

Some hospitals have been reluctant to adopt the new cleaners because they cost more than soap. However, a new analysis by Pittet suggests they actually save money because they reduce infections, which are expensive to treat.

At his hospital, he found the gels cost an extra $1.62 for each patient admitted, or $82,000 per year. But between 1999 and 2001, they save more than $12 million in treatment costs.

Many brands are available. The solutions contain between 60 percent and 90 percent alcohol and are thought to be equally effective in killing viruses and bacteria. They are also being tested in school bathrooms and child care centers, among other places.

Buying Your Pills Online May Save You Money, But Who's Selling Them?

Because of growing scrutiny by both federal and state authorities, some online pharmacies have gone out of business. But some regulators say they continue to have serious concerns about the ways some companies operate. And they are worried about a large number of Web sites that still list only an e-mail address, as well as a rapidly growing number of online pharmacies that are based in Canada, beyond United States regulatory control, that cater to Americans seeking cheaper prices outside their own country.

Pricing continues to be an issue as well. Some studies have found that Internet shoppers can save 25 percent on the cost of prescription drugs, but the California State Board of Pharmacy, in a recent online shopping trip, found that some drugs cost up to five times as much on the Internet as they did at the local pharmacy.

Some regulators say they have also noticed a new slickness in the online pharmacy industry. They point to Web sites that now require a customer to release them from liability before they mail prescription drugs, as well as those that make a customer agree not to consume any prescription drug without first consulting a local physician. Some Web sites describe themselves as unbiased "information exchanges" for consumers who want to share tips about particular pharmacies, but the sites have no information about where they are based or whom they represent.

"Online pharmacies have gotten much more sophisticated than they were in 1999," said Richard Cleland, assistant director of the division of advertising practices for the Federal Trade Commission.

Carmen A. Catizone, the executive director of the National Association of Boards of Pharmacy, a professional group that represents pharmacy licensing boards in the 50 states, said his organization was receiving about two dozen consumer complaints a month about online pharmacies, with most of the complaints directed at roughly three dozen companies that have blanketed the Internet with hundreds, if not thousands, of Web sites.

Caveat emptor. But I do understand the buyer's motivation. Medications can cost a lot of money!

While I have never diagnosed celiac disease, I have always considered it. Our first month in medical school, we had a case to decipher. The case was non-tropical sprue. As you can imagine, that case has remained etched in my memory. So obviously I was attracted to this report - Cause of dietary disorder uncovered. Basic science really does help. This finding looks very promising.

Governor, Sign Laura's Law: Interest groups are bringing pressure to bear against an important mental health bill.

By press time Friday night, Gov. Gray Davis still had not signed "Laura's law," an important bill that would let judges order outpatient treatment for seriously mentally ill people who can't fathom the gravity of their condition.

The deadline is midnight Monday.

Davis had pledged to do everything in his power to protect Californians from crime, so supporters of the bill had expected him to embrace the measure. It would enable some of California's most vulnerable people, including many who live on sidewalks or alongside freeways, to get help before they harm themselves or others. But opponents of the legislation have grown particularly vocal in recent weeks.

Two weeks ago, for instance, a subgroup of the Church of Scientology, which opposes virtually all psychiatric treatments, sponsored a rally at the Capitol against Laura's law--named after a 19-year-old killed by a man whose mental illness had been left untreated.

Davis also might be concerned about a recent report from the Judicial Council, a rule-making body for California's courts, which concluded that the bill could be a financial drain on the state.

But the council's analysis overlooks a broad array of information. For instance, it does not consider that the bill's implementation would result in fewer criminal prosecutions of nuisance crimes and more serious offenses, fewer probation violation hearings and fewer sentences of persons with severe mental illness to jails and prisons.

I believe this law is needed - not just in California, but elsewhere. We do see patients who need treatment. When we emptied the 'mental institutions', we did not do everyone a favor. Too many schizophrenics become homeless and even a danger to society. The challenge for medicine and government is balancing individual rights with society needs. This law makes sense.

Loudoun Mosquitoes Show Malaria: Pools Test Positive Several Miles From Where 2 Became Sick . Mosquitoes do carry disease. We need to think of malaria as a future possibility for disease in this country.

I assume I sound like a broken record - harping on the time constraints in medicine. Patients understand this - and it may hamper their care. Patients' perceptions of entitlement to time in general practice consultations for depression: qualitative study

An intense sense of time pressure and a self imposed rationing of time in consultations were key concerns among the interviewees. Anxiety about time affected patients' freedom to talk about their problems. Patients took upon themselves part of the responsibility for managing time in the consultation to relieve the burden they perceived their doctors to be working under. Respondents' accounts often showed a mismatch between their own sense of time entitlement and the doctors' capacity to respond flexibly and constructively in offering extended consultation time when this was necessary. Patients valued time to talk and would often have liked more, but they did not necessarily associate length of consultation with quality. The impression doctors gave in handling time in consultations sent strong messages about legitimising the patients' illness and their decision to consult.

I do not know the answer - I can only identify the problem. And make no mistake it is an important problem.

What's a good doctor, and how can you make one? By marrying the applied scientist to the medical humanist Read this interesting editorial from the British Medical Journal. We need to consider these issues. The entire issue has important articles about quality of medical care.

10 Weight Loss Promises That Spell F-R-A-U-D

Syphilis is not a simple or benign infection. One can easily avoid syphilis - safe sex works. Obviously safe sex is no longer chic in some communities - Syphilis Rises Among N.Y. Gay Men: Experts Fear Data Point to Increase in Risky Sexual Activity. This report disturbs me.

Power of a Kind Word and a Cup of Tea - a story.

Read this well written column - Unnecessary Tests . The author defines the problem clearly. I personally do not understand the radiology community on this one (and maybe some radiology readers will comment). They are pushing (yes the are advertising these tests) technology which has no proof of efficacy. They generally get cash for these tests, and if they find something abnormal, refer the patient back to his/her generalist. Does anyone know what is going on here?

New warning with Viagra This is simple, patients should not take their alpha blocker (used for hypertension or BPH) within 4 hours prior to taking Viagra. To do so increases the risk for syncope. Another warning to give those men who have a 20 minute visit and then as you are getting ready to leave the room say 'Oh by the way ... '

The Rising Cost of Care

Hospital services account for 51 percent of the increase last year, according to the report by the Center for Studying Health System Change or HSC. Prescription drugs accounted for another 21 percent and doctors' fees 28 percent.

"Spending on hospital care is increasing because people are getting more tests and more treatments and are being hospitalized more often," HSC President Paul Ginsberg told ABCNEWS' Jackie Judd.

...

For many experts, the rising costs of health care are to be expected.

"The combination of the American appetite for more of everything, especially things that might help us cheat death/aging/disability, the enormous amount of 'service' available on the health market and the relentless promotion of health services and drugs by manufacturers, providers and the popular media, makes increased utilization and increased costs inevitable," says Dr. M. David Low, Rockwell chair and director of the Center for Society and Population Health in Houston.

As I write repeatedly, we will not find an easy answer to this problem. We should ask whether we are getting our money's worth. Increased health care costs are not necessarily bad, if we get great value for our expenditures. Clearly when one looks from an individual perspective the problem focuses on outcomes. Only when one aggregates the costs does society get excited.

Drug combo stops hepatitis C: Therapy cures more patients with fewer side effects. Hepatitis C can cause cirrhosis and hepatocellular carcinoma. This insidious infection can smolder for over 20 years, with no outward sign of infection. As we learn more about the virus, we also learn more about the number of infected patients - millions in the US alone. Since we cannot predict with certainty which patients will progress to significant liver disease, we hope to find a treatment which removes the virus from the patient.

Over the last decade we have seen great progress in antiviral therapy. In Hepatitis C, we have had a regimen that works in around 2 of 5 patients. Today's NEJM has an important, though expected, report on the newest medication as part of combination therapy. Peginterferon Alfa-2a plus Ribavirin for Chronic Hepatitis C Virus Infection. We should look carefully at two issues - the entry criteria (which patients did they study) and the response rate.

The study was conducted by the Pegasys International Study Group. Eligible subjects were adult patients who had never received interferon and who had at least 2000 copies of HCV RNA per milliliter of serum according to a polymerase-chain-reaction (PCR) assay (Cobas Amplicor HCV Monitor Test, version 2.0; Roche Diagnostics), serum alanine aminotransferase activity above the upper limit of normal within six months before entry into the study, and a liver-biopsy result consistent with the diagnosis of chronic hepatitis C. Serum HCV RNA levels above the linear range of the PCR (more than 1 million copies per milliliter) were diluted to within the linear range. Patients were excluded from participation if they had neutropenia (fewer than 1500 neutrophils per cubic millimeter), thrombocytopenia (fewer than 90,000 platelets per cubic millimeter), anemia (less than 12 g of hemoglobin per deciliter in women and less than 13 g of hemoglobin per deciliter in men), human immunodeficiency virus (HIV) infection, decompensated liver disease, a serum creatinine level more than 1.5 times the upper limit of normal, poorly controlled psychiatric disease, alcohol or drug dependence within one year before entry into the study, or substantial coexisting medical conditions.

Now let us decipher that paragraph. The patients had blood test evidence of on going hepatitis. They had significant amounts of hepatitis C virus in their serum. Exclusion criteria included a variety of blood abnormalities, HIV infection, significant liver disease, chronic kidney disease, poorly controlled psychiatric disease or ongoing substance abuse (drug or other). Many patients get excluded from these criteria. These therapies are not benign, but in the well selected patient they do help. How much do they help?

Significantly more patients treated with peginterferon alfa-2a plus ribavirin had end-of-treatment virologic responses than patients treated with interferon alfa-2b plus ribavirin (69 percent vs. 52 percent, P<0.001) or peginterferon alfa-2a plus placebo (69 percent vs. 59 percent, P=0.01). Significantly more patients treated with peginterferon alfa-2a plus ribavirin had a sustained virologic response (i.e., no detectable HCV RNA 24 weeks after cessation of therapy) than those treated with interferon alfa-2b plus ribavirin (56 percent vs. 44 percent, P<0.001) or peginterferon alfa-2a plus placebo (56 percent vs. 29 percent, P<0.001)

So the punch line is that 56% of patients treated with the new combination had no evidence of virus 24 weeks after the end of the study, while only 44% of patients treated with the old combination had the same response. For those who like the NNT approach (number need to treat), a quick calculation shows that you need to treat approximately 8 patients in order to help 1 patient who would not otherwise be helped.

Most medical progress occurs with baby steps. I would call this a baby step, nonetheless an important step. In 2002, we (the general internists with whom I work) refer all eligible patients to a liver expert. These treatments are not benign, and require (in my opinion) experience.

Amongst a variety of responsibilities, I serve as the Associate Dean for Continuing Medical Education. A couple of weeks ago I was talking with my professional staff and mentioned this blog. They asked for the URL and liked what they saw. So they approached me about offering CME credits for my daily rants. It sounded like an interesting concept - so we will do that for a while and see what happens. You can get 0.25 hours each day for reading this blog! You have to go through our CME site - UAB CME or Medrants for CME credit. We will experiment with this and see what response it generates. I am certainly surprised that we are trying this, but it just might introduce some new physicians to the world of blog.

Pot Got You Confused? You Must Be the DEA: Raids on medical marijuana are reefer madness.

Outpatient Care Spending Soars - this somewhat misleading headline actually refers to outpatient hospital costs, like outpatient surgery.

Spending on outpatient hospital care soared 16.3 percent last year, the fastest growing component of overall health care spending, according to one of the new studies released by the Center For Studying Health System Change (HSC).

Overall health care spending grew 10 percent -- the first double-digit increase in more than a decade, and outpatient spending accounted for 37 percent of that increase.

It was the first time since 1995 that drug costs didn't represent the biggest chunk of the increase, according to the HSC study. According to the Washington, D.C.-based nonprofit research and policy institute, spending on prescription drugs rose 13.8 percent last year, making it the second biggest cost driver. It was the second year in a row that the increase in prescription drug costs shrank from the previous year.

Spending on inpatient hospital care jumped 7.1 percent. Driven by higher prices and increased use, inpatient and outpatient hospital care spending climbed an average of 12 percent, accounting for 51 percent of the overall health care spending increase.

...

Annual health spending starts rising rapidly when someone hits age 50 -- increasing about $152 a year between 50 and 64. Ginsburg notes this isn't insignificant.

However, he says factors such as new technology and mandated coverage for certain conditions play a bigger role in driving up costs, and need to be considered more seriously in the debate on curbing health spending.

The assumption that Ginsburg makes is that we must curb health spending. If we can provide better health and quality of life for patients, what value does it have. Why must we curb health spending? Where in the equation do we find value? I fear that politicians and economists simplify this complex problem. They must start to understand what truly drives costs, and not just complain about percentages.

I like this opinion piece - The dirt on dirt . The author starts with the dirt hypothesis (relating to asthma) and extends her thoughts to how we interact with the world generally. She writes with sense and proportion.

GP shortage 'critical'. I write about this problem often. As bad as we moan about our primary care problems, Great Britain has the same or worse problems.

Dr Ian Winterton, a Newcastle GP and chairman of the regional general practices committee said it was sad to see good GPs retiring early.

"The job is far more stressful than it used to be because we have to deliver on numerous targets," he told BBC News Online.

"If we had enough staff and enough support we could deliver it," he added.

If you have not already read my rant - On Burnout. We are burning out primary care physicians in the US and in GB (I suspect many other countries). Primary care is much more complex than most physicians, patients or administrators understand. To do it properly takes time. One needs time to think and reflect and time with the patient. Time costs money. Our societies do not understand that you get care proportionate to your investment. We must change how we invest in primary care. Our nations' health demands it.

Patients lack info on depression drugs

Patients with depression would like to be given more advice about their medication.

Too little information on side effects and the recovery process was of particular concern to about 50 people questioned by the London School of Pharmacy.

About half of people given anti-depressants stop taking their pills after three months.

According to medical guidelines, a course should be taken for at least four to six months.

Most people surveyed were happy with the service they received from their GP.

But many found it hard to take in information given at the time of diagnosis.

One common feature of depression is lack of concentration. So even if one carefully discusses the depression and the treatment, the patient's retention of that information may be suboptimal. I do not really understand the survey's purpose or the point of the article.

Doctors 'ration dietary advice' - As I point out repeatedly, every medical interest group has another task which they expect the primary care physician to perform perfectly.

Most doctors spend less than a minute discussing nutrition with their patients, says a report in the American Journal of Preventative Medicine.

A survey of 138 primary care physicians in Ohio found that only a quarter of patients were given information about food intake and nutrition.

Every year, in the US alone, hundreds of thousands of people die from diseases linked to a poor diet.

"The need for nutrition counselling is pressing in light of the epidemic of chronic diseases such as hypertension, diabetes mellitus, obesity and hyperlipidemia [excessive fat content in the blood]", says team leader Dr Charles Eaton of Brown Medical School.

He hopes the research will be used by medical educators to develop tools to help doctors give advice about nutrition within the time constraints of primary care practice.

I doubt that Dr. Eaton or his team truly understand the time constraints of a primary care practice. Will they lobby for higher fees to pay the primary care physician for his/her time? Nutrition is important, and perhaps we can make a difference when we give advice. This will require additional training and take time which we do not have. Great goals and pronouncements which do not recognize the true plight of primary care only worsen the frustration of our frontline warriors in medicine.

Stressed Out? Just Forget About It.

Ignoring trauma may be healthier than pouring out your heart about it, Israeli researchers reported on Tuesday.

Report after report has detailed the post-traumatic stress suffered by the US population after the September 11 attacks on New York and Washington, DC, but a study published in the journal Psychosomatic Medicine suggests it may be better to suppress those feelings.

"The findings of this study suggest that a repressive coping style may promote adjustment to traumatic stress, both in the short and longer term," Karni Ginzburg of the Bob Shapell School of Social Work at Tel Aviv University in Israel, who led the study, said in a statement.

Ginzburg and colleagues studied 116 patients who were hospitalized for a heart attack and suffering from anxiety over their near-miss with death. The researchers compared the patients with 72 people who had not had heart attacks.

"The damage to the heart, with its symbolic meaning as the essence of the human being, may shatter the patient's sense of wholeness and safety," Ginzburg said.

The patients took standardized tests for acute stress disorder, which check for symptoms such as distress, trauma flashbacks, difficulty carrying out everyday tasks, insomnia, and poor concentration.

This syndrome is called post-traumatic stress disorder if the symptoms last or occur more than a month later, and the patients were re-tested after 7 months.

They were also asked questions about coping style--whether they ignored their anxiety or tended to dwell on it.

People who tended to repress their anxiety had the lowest levels of post-traumatic stress, the researchers reported.

I find this interesting, and suspect it will be controversial. It actually makes sense to me. How can it help to keep reliving the trauma in our minds?

The Safety Valve has an excellent summary of the malpractice crisis today - "First, do no harm" or in Latin - Primum non nocere. Toren does a nice job lecturing the trial lawyers about the harm they are doing. He references a nicely written article by our own Medpundit - Law and Orderlies.

Toren found this article from another site - The Real Healthcare Crisis . So it has been a big day for considering the true health care crisis. For a slightly askew position, check out the Bloviator today at the bottom of his article about health care costs.

I would love to see the malpractice crisis garner major attention in the blogverse. We need many thoughts and comments. I am pleased to see non-medical blogs noticing the problem.

First, thanks to Overlawyered.com: chronicling the high cost of our legal system for the kind link. I was perusing the site and found this unbelievable article Woman is suing VA doctors: Kathleen Ann McCormick says she wasn't told to stop smoking or lose weight, factors she alleges caused her to have a heart attack.

A Wilkes-Barre woman is suing several doctors at the Department of Veterans Affairs Medical Center, saying the physicians did not do enough to assist her in making life changes - including quitting smoking and losing weight - that might have prevented a debilitating heart attack she suffered.

Kathleen Ann McCormick of North Empire Court says the physicians knew she had multiple risk factors to develop heart disease, but they failed to aggressively treat her, leading to a heart attack on Jan. 17, 2000, that left her a "cardiac invalid," according to the suit filed Friday in the U.S. District Court for the Middle District of Pennsylvania.

A logical person would wonder which alternate universe she occupied. She needed aggressive interventions from physicians to convince her to quit smoking and lose weight. Of course, if one uses logic, we would assume that physicians know the magic words that help patients make lifestyle changes.

Physicians recommend these lifestyle changes with virtually every patient they see. I work on VA inpatient wards, and many patients fit her description. We try, we coax, we offer programs, and we rarely have success. One would suspect that she received appropriate advice which she ignored. Now she has 'buyer's remorse', but would rather sue someone. I just do not understand her or her lawyer.

The Lean Plate Club: Diet Ads That Are Hard to Swallow .

The FTC said that these types of diet ads are proliferating and generated $35 billion in sales in 2000. The deceptive ads bombard consumers on television, on the radio, the Internet, in magazines and, yes, even in this very newspaper. Last week, the FTC also announced that on Sept. 3 it had charged a Canadian corporation operating in the United States under the name Bio Lab with deceiving consumers through ads and sales of Quick Slim and Cellu-Fight. Quick Slim is a dietary supplement sold as a "fat blocker" that appeared in free-standing inserts that were distributed through the Phildelphia Inquirer, the Dallas Morning News, the San Francisco Examiner, the Los Angeles Times and The Washington Post.

So why do so many otherwise savvy consumers continue to reach for the quick fix when it comes to weight loss? "We are told we can buy our weight out with the right product," explained Lynn McAfee, medical advocacy project director with the Council on Size and Weight Discrimination, who described her lifelong struggle with obesity at the FTC press conference last week.

McAfee said she "lived in a hopeless world when I constantly felt out of control of my body and my life," until she discovered the ads for various weight loss products in her mother's women's magazines. "Suddenly," McAfee said, "it was not that my body or my will was in error, but that I could buy a secret. . . . Is there anyone in this room who would not choose to do something the easy way?"

Some Retirees Look Abroad for Prescription Drugs. This article discusses how some patients decrease their drug costs. The pharmaceutical industry deserves to make a profit, but at whose expense. Read and think about the problem from the patients' perspective.

Fast food gets healthy too - very nice story about a new fast food chain.

The fries aren't fried, the chicken is farm-raised and the burgers are made of lean buffalo meat. For the more adventurous diners, there's tofu sandwiches, veggie pockets with soy cheese and one-ounce cups of wheat grass juice.

The Healthy Bites Grill opened this summer about the same time a New York man sued four fast-food restaurants for making him fat and unhealthy. The restaurant, owned by Health Express USA, is hoping to capitalize on that bad publicity and target the more health-conscious among those who spend $100 billion annually on burgers, fried chicken and other fast-food nationwide.

Interesting concept - and since we do live in a capitalistic country (for which I am grateful) we will see how this concept fares in the marketplace.

Most physicians know this, but do not know how to proceed. Unhealthy Illiteracy: Functionally Illiterate Can Be Overwhelmed by Medication Directions. This article gives some background on the problems the functionally illiterate have when sick. The data are impressive. The illiterate do much worse with taking meds, following diet, and have worse health outcomes.

Government Proposing Cuts in Many Medicare Payments

The proposed cuts are part of a new system of paying hospitals for outpatient services. With advances in medical technology, hospitals report explosive growth in the number and kinds of procedures that can be performed in outpatient clinics, without the need for an overnight stay. Outpatient care accounts for nearly half the revenue at some hospitals.

The cuts would affect many drugs, devices and high-technology procedures, including cancer drugs and cardiac defibrillators like the one implanted in the chest of Vice President Dick Cheney to prevent an irregular heartbeat.

Medicare would also pay less for blood products given to people who receive transfusions but do not need overnight hospitalization. The Medicare payment for a unit of red blood cells — about a pint — would be cut 39 percent, to $83 next year, from $137 this year.

Federal health officials said Medicare had been overcharged for many outpatient services. But patients have joined health care providers in protesting the proposed cuts, saying that at the new prices hospitals will be unable to provide treatment to patients who need it.

"We were shocked when we saw the payment rates," said Christopher T. Mancill, director of reimbursement policy at the American Red Cross.

The payment for inserting a battery-operated pacemaker and defibrillator would be cut 59 percent, to $12,102, from $29,360.

Doctors and patients' advocates expressed concern that hospitals would stop providing services on which they consistently lose money. This could make it more difficult for Medicare patients to obtain life-saving drugs, devices and treatments.

The health care industry has become so dependent on Medicare that when Medicare makes its unilateral decisions, the entire industry suffers. This article points out the problem of government health support. Health care costs keep rising (and here I mean real costs, not charges which are also rising) yet the moneys available to pay for that care are shrinking. I keep pointing out our health care crisis. This will convince a few more readers. We must either increase the moneys we designate for health care, or start to ration health care. That always sounds fine for the other fellow, but totally unacceptable when I am affected. We will not easily address this problem as the solution will not be popular.

2 years ago I was asked to address the new first year students at their white coat ceremony.

The White Coat Ceremony is a rite of passage for first-year medical students that symbolizes a psychological contract in which the student strives to become a competent and caring professional. The activities of the ceremony are designed to emphasize the importance of both scientific excellence and compassionate care for the patient.

The White Coat Ceremony, as conducted at medical schools across America, is the result of a vision by Arnold P. Gold, M.D., a professor of surgery at the College of Physicians and Surgeons at Columbia University. Dr. Gold believes that medical students should be introduced to the white coat and what it represents as they enter medical school rather than as they exit, which had been the case historically.

I recently reviewed my comments and feel that they hold up well. I hope you find them interesting.

25 Years Of Medicine – Advances in Science and Art

Recently I went to Richmond, Virginia to attend my 25th Medical School reunion. As I anticipated that reunion, I reflected on how medicine has changed during my quarter of a century as a physician. I shared some of these thoughts with students and residents here at UAB. In verbalizing my thoughts, I began to appreciate in amazement these medical advances.

These reflections remind me very explicitly why I love being a physician. My excitement over advances in science, technology and the art in medicine over these 25 years clarified my sense of the privilege of my chosen profession.

My remarks will feature some advances in our knowledge of science, technology and how the art of medicine has progressed. I hope that these reflections will stimulate you to have as much excitement about medicine as I continue to have to this day.

In 1975, when I started my internship, the most common surgery in this country was ulcer surgery. At that time we were convinced that ulcers were caused by stress and acid. In the 80’s a lone voice started trying to convince everyone that bacteria caused ulcers. This was initially greeted with derision but over time, with persistence, the case for a bacteria causing ulcers grew and grew. We now know that ulcers are caused by the bacteria helicobacter pylori.

Several things happened prior to that discovery. First, we learned that we could control acid with a class of drugs called H-2 Blockers. Everyone in the audience is familiar with H-2 blockers because they are advertised widely on TV; these include Tagamet, Zantac, and Pepcid. These drugs while not perfect at inhibiting acid in the stomach do an excellent job and replaced the need for ulcer surgery in most patients. However, ulcers would recur if patients did not stay on these medications indefinitely. In the year 2000, when someone is diagnosed with an ulcer we demonstrate that they are infected, we then treat them with antibiotics and cure their ulcer. To take this in context of living in 1975, would have seemed like science fiction.

Severe congestive heart failure is a disease with a horrible prognosis. In 1975 when we diagnosed someone with severe congestive heart failure, the average life expectancy was six months. Over the course of the past 25 years we have had a variety of studies which have taught us how to better care for these patients and extend their useful life. Life expectancy has increased dramatically for this disease despite the fact that many people who develop congestive heart failure are elderly and have many complicating medical diseases. We also do much now to prevent congestive heart failure in patients.

If you came to the emergency room in 1975 with a heart attack we would put you in intensive care, put you to rest, give you some medicine to try to decrease the chance that you would have sudden death and then see what happens. We talked about, but were unable, to decrease the amount of heart muscle damage. We really didn’t really understand the details of why heart attacks occurred or how to prevent future heart attacks or at least decrease the chance of future heart attacks.

If you have a heart attack today, and you come in early enough you get thrombolytic therapy (therapy to break up blood clots). You’ve seen and heard about patients getting such therapy. We have a variety of medications that are given in the acute phase of a heart attack, you’ve seen advertisements of the importance of aspirin for heart attacks and those are accurate advertisements. We treat people with a class of drugs called beta-blockers, which were not released when I started my internship.

Moreover, we do a much better job of secondary prevention. That is prevention of the progression of the underlying of coronary artery disease that causes heart attacks. We can do an excellent job of treating with medications the elevated cholesterol a major risk factor for heart attacks. We are much better at helping people stop smoking. We have a variety of other medications that lead to increased life expectancy as well as quality of life.

In 1975 if you had gallstones and needed surgery, you were out for 6 weeks. There was a large incision under your ribs in the right upper side of the abdomen. The surgery was successful but was short term debilitating. We now know that people get laporoscopic cholecytectomy and return to work in a week or so. This laporoscope can be used for a variety of other surgeries. This technology has revolutionized surgery so that complications are decreased and recovery time is greatly decreased.

The mid 1970’s started coronary artery bypass-grafting era. This operation is so common now as to be one that we are all familiar with. At that time that was really the only treatment of blockages of the coronary arteries. Over the next decade we learned about balloon angioplasty, where physicians put a catheter into the coronary artery and open the artery up. This was followed by a variety other procedures and the current often used procedure to put a stent into the artery to keep it open. This management of coronary artery disease compliments all of the things that we are doing to treat heart attack patients aggressively with medications.

The diagnostic technology of medicine advances rapidly. My career has seen the introduction of ultrasound, CT scanning and MRI. It is rare to watch ESPN Sports Center and not hear that someone has an injury in a sporting event that will require an MRI in the morning. This is a common part of our language and we all understand that the MRI does a wonderful job of showing us damage to soft tissues and even cartilege.

But MRI was not even introduced until the 1980's. Our ability to diagnosis a variety of disease is greatly enhanced by these radiological techniques.

When a football player injuries his knee, we see on Sports Center that he is going to have his MRI. The next day we hear that the MRI showed disc damage and he is scheduled for surgery the next day. Within ten days he is playing football again. In the 1970's, knee surgery was always major and reconstructive and was months of rehabilitation. Now athletes often are back on the field shortly.

These scientific advances are exciting and noteworthy. I have only briefly described the extent of the scientific advances that I have seen thus far in my career. Just as interesting in many ways is the evolution of doctor patient relationship.

The art of medicine has advanced greatly as has the science. Over the past 25 years we have seen the growth of the hospice movement - the understanding that the dying patient deserves dignity and respect is much more explicit than it was in 1975.

Most medicine was paternalistic in the 1970’s. What do I mean by paternalistic? Paternalistic refers to the physician telling the patient what to do and the patient saying yes sir. In my class less than 10% of the students were women. Today we balance paternalism with a desire for patient autonomy. Patients are much more involved in deciding about their care and gaining knowledge of their care. The Internet has given patients the opportunity to research their illnesses. We now offer our patients a great deal of individualism in how they choose to care for themselves.

We have championed informed consent and now very much want our patients to understand the decisions they are making, why they are making the decisions and what the various options are. These changes occur slowly, but when one reflects they do represent major advances in the doctor patient relationship. Even the idea of discussing the doctor patient relationship as an important relationship is new to the last two decades. This concept was rarely discussed during my training and really became popularized in the 80’s and 90’s.

So what does all this mean? Are these just the ramblings of an OLD MAN, I don’t think so. I don’t think that there is anything different about my 25 years in medicine than your first 25 years in medicine or my teachers first 25 years in medicine. For me medicine remains the most exciting profession. I wake up every morning and I am grateful that I am allowed to be a physician in this country during this era.

Medicine remains exciting, it remains vital because of the advances in science & technology, because of our ability to better care for our patients every year then we could the previous year. Medicine grows with times, the act of being a physician and interacting with patients changes constantly so that one need not ever get bored of doing exactly the same thing day after day.

The greatest gift is the doctor side of the doctor patient relationship. When you first enter the room, the patient assumes you to be a good person. The patient respects you and starts out liking you. Patients in this country expect the best from their physicians and generally get it. The pleasure of the doctor’s side of the doctor-patient relationship is a pleasure and privilege, which you will soon understand. We are very fortunate to be physicians, we are very excited that you will join our profession, and I personally hope that your first 25 years as a physician will be as exciting as my first 25 years as a physician.

I found this entry a 'must read'. Medpundit quotes and comments on a radiologists perspective on the mammography problem. An Inside View. Why would a radiologist specialize in a field with unrealistic expectations and a high probability of law suit? While I love to blame the trial lawyers (and they are not innocent here), I believe we have a societal problem. We 'sell' screening so aggressively that patients believe it perfect. Few physicians, and almost no patients, really understand sensitivity and specificity of diagnostic tests. All screening tests have false positives and false negatives. And both are costly (here I use the term cost in more than a monetary meaning). We (the medical profession) must learn how to explain screening to patients so that expectations are realistic. Maybe that is an unreasonable goal, but therein lies the problem.

As the reader can tell, I am obsessed with this issue this week. I dislike passion in place of reason when it negatively affects so many lives. The Right to Inhale.

The fundamental issue involved is personal freedom from government coercion. As long as you don’t violate the rights of others, as a free individual you should have the right to do with your life—and your body—whatever you think is best, without government interference. This means, for example, that you should have the right to get drunk—as long as you pay for your beer; and the right to get drowsy—as long as you don’t drive out of control; and also the right to get stoned—as long as you don’t stone somebody else.

Many people who believe in personal freedom are nevertheless against decriminalizing drug use because they believe it would increase crime. To support their belief they point to a strong correlation between drug use and violent behavior.

While it is undeniable that such correlation exists, it does not by itself demonstrate that drug use causes crime. In fact, a Bureau of Justice Statistics (BJS) survey of prisons found that the opposite was true for half the inmates, who started their criminal careers before they had ever used a major drug. Moreover, if it were true that drug use caused crime, how would one account for the twelve million drug users who commit no crimes?

A much more likely explanation for the correlation observed is that criminals often act self-destructively. It should be no surprise that they abuse drugs and alcohol. It should also be no surprise that a great number of parents capable of neglect and violence against their children are also drug users. If they have no concern for themselves, is it any wonder that they have no concern for their children?

The fact we must face up to is that no causal connection between drug taking and violent behavior was ever identified. Certainly no such connection exists for marijuana. The theory that drugs cause crime basically misses the point that violence is an act of choice. Criminals use force against others because they think it is a valid and desirable means of gaining values. Drugs do not cause crime—criminals cause crime.

It makes no sense for government to punish all drug users because some of them are criminals. Government’s job should be to protect rights, not to trample on them.

I guess all this logic does not apply. The arguments make sense, thus I will continue to harp on this issue. We are wasting money, damaging lives and creating a criminal culture. We should not allow that.

Read this and think about it. It will not work, as it makes too much sense - Should We Re-Legalize Drugs? Let me quote the preamble:

Libertarians, like most Americans, demand to be safe at home and on the streets. Libertarians would like all Americans to be healthy and free of drug dependence. But drug laws don't help, they make things worse.

The professional politicians scramble to make names for themselves as tough anti-drug warriors, while the experts agree that the "war on drugs" has been lost, and could never be won. The tragic victims of that war are your personal liberty and its companion, responsibility. It's time to consider the re-legalization of drugs.

Waist Girth Predicts Cardiovascular Risk Better Than BMI (article from Medscape - registration required).

Waist circumference is a better indicator of cardiovascular (CV) risk than is body mass index (BMI), according to results from the National Health and Nutrition Examination Survey (NHANES) III published in the September issue of the American Journal of Clinical Nutrition.

"Body fat distribution is a more powerful predictor than is BMI for risk factors, diseases, and mortality," write ShanKuan Zhu, from Columbia University in New York, N.Y., and colleagues. "Measurements that are more sensitive to individual differences in abdominal fat might be more useful than BMI for identifying obesity-associated risk factors."

...

Waist circumference correlated more directly than did BMI with overall CV risk. Using receiver operating characteristic curves, the authors identified "cutoffs" of 90 cm (35 inches) for men and 83 cm (33 inches) for women. To minimize CV risk, they recommend advising patients with waist circumference at least as large as the cutoff value to lose weight.

"Waist circumference is more closely linked to CV disease risk factors than is BMI [so] it is inappropriate to base waist circumference thresholds on their association with BMI thresholds," the authors write. "Rather, thresholds for each should be based on their relation to risk factors."

In an accompanying editorial, Michael J. Lean and Thang S. Han discuss practical problems involved in clinical measurement of waist circumference. They recommend that future studies develop similar correlations for subjects of other races and for those who have other chronic diseases.

I hope we see more such studies. Waist circumference is easier for everyone to understand - it makes an excellent goal for patients.

Lagniappe has an important article this week. He talks about patent law and the pharmaceutical industry.