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. As Others See Us.

But let's be real. These days, when big-selling drugs go generic, their sales don't just slowly fade out like they used to: they drop off a cliff. HMOs aren't stupid, at least not when it comes to obvious cost-cutting measures. When Claritin goes off-patent, it's not going to matter whether or not the word "loratadine" is on everyone's lips; its sales are going to tank anyway.

Every drug company realizes this. So why is Pfizer (and the other companies that may be cheering them on) making such a request at all? It's not going to help; all it does is make the compan(ies) involved look slick and greedy. This is most definitely not the time to be looking slick and greedy.

He focuses here on a key point. The pharmaceutical industry feels slick and greasy (oops greedy). They have created that perception, especially amongst physicians .

He then bemoans the lack of recognition that the industry gets for major advances in patient care. The pharmaceutical industry has made an enormous contribution to treating many diseases and improving quality of life. But they still feel slick and greedy. They need a new approach. They need a bit less short term outlook and a more measured long term outlook.

Please read the entire article, it does provide some balance for my rantings.

This article discusses the ubiquitous problem - burnout. Perhaps some people need burnout before they can address their problems. No way out but burnout . This article refers to a new book apparently available only in Great Britain.

As an academic physician, I have often seen burnout in colleagues and even residents. As a physician, I have often seen burnout in patients. I struggle with how to prevent burnout, which requires recognizing the early warning signs.

I believe this is a very important problem for physicians. Physicians, especially primary care physicians, are showing signs of burnout.

Professor Andrew Kakabadse, of Cranfield School of Management, believes some people still refuse to acknowledge burnout because of its association with mental breakdown. 'But burnout isn't like that,' says Kakabadse, who sees it not as a crisis point, but as a state of being. 'People can be burnt out for two or three years and they just carry on working. Most don't leave their jobs but their relationships and health suffer.' For Kakabadse burnout is essentially overwork, and is 'a social not a mental-health problem'. He says stress is worse in countries with Anglo-American business models where rationalisation and redundancy mean far too few people doing far too much work. 'If you go to Germany, Scandinavia or parts of France, there is less burnout,' he says. 'The UK has the longest working hours in Europe. Around 80-90 per cent of executives experience some kind of burnout in their career, and most have two.'

Despite figures that suggest a near epidemic, some still see burnout as nature way's of weeding out the weak. Glouberman insists, however, that burnout is likely to hit the most creative, hard-working and committed people. And psychology professor Christina Maslach, from the University of California, Berkeley, one of the world's leading burnout experts, argues that companies ought not to scapegoat employees but look to the environment they expect people to work in.

...

Signs of burnout

· You are exhausted all the time, no matter how many hours you spend in bed

· A sense of isolation from other people, and even from yourself, to the extent of becoming a virtual recluse

· Ineffectual, no matter how much work you put in

· A feeling of emotional deadness

· Chronic anger even in the previously mild mannered

· Loss of empathy for other people's problems even when it is your job to be empathetic

· Feeling of being trapped

· Increase in cynicism

· Loss of sense of humour

· Loss of sex drive in a relationship but increased interest in casual sex and other activities that can become addictive such as drinking, shopping and internet chatting

· Increase in physical problems including back and heart pain, headaches, frozen shoulder, chronic fatigue, adrenal and thyroid problems, irritable bowel syndrome, post-viral illnesses, viral meningitis and even heart attacks

· Rising dislike for yourself and others

This sounds like many physicians I know. We must restructure the delivery of generalist care. The current style of seeing too many patients each day quickly becomes a catalyst for burnout. As physicians we must demand a better work situation. This is serious business.

Jonah Lomu is fat ... according to the official method of measuring obesity, the body mass index. There must be a better way, says Michael Hann So who is Jonah Lomu.

There are not many sportsmen in the world who have made an impact on their sport as great as Jonah Lomu has.

He burst onto the scene during the 1995 World Cup in South Africa aged 19, scoring eight tries, helping New Zealand to reach the final.

Since then, Jonah has become the most famous rugby player in the world.

He has become a role model for young rugby players in New Zealand and across the world.

Ah, there, Jonah Lomu is apparently the Michael Jordan of rugby. In this country one would substitute Michael Jordan in the headline and get the same effect. Many world class athletes have high BMI (body mass index). The body mass index does work for most patients. This article makes some interesting points about when we should not use BMI and discusses a better indicator of disease risk - body fat.

Well, that shudder may have been a little premature, because in individual cases the formula is not as helpful as you might believe. The BMI, a method used worldwide to determine how healthy a person's weight is, is based on the relationship between an individual's height and weight. At a reading of 25 or above, you are overweight. But so, according to the calculations, is Mel Gibson. And at 30, you become obese; but so are Arnold Schwarzenegger, Jonah Lomu and Sylvester Stallone.

The simplicity of the BMI makes it a godsend for looking at trends. But it is also something of a broad-brush tool. It takes no account of age, sex or race; it makes no allowance for your fitness. Most importantly, it does not measure how much fat you are carrying or how that fat is distributed.

Professor Ian Macdonald, co-editor of the International Journal of Obesity, explains that the fat you need to worry about is abdominal fat. Fat above the hips puts a strain on your heart, putting you at risk. Below the hips, it is not such a problem.

The system also fails to take into account the amount of fat you are carrying - hence the reason for the "obesity" of Jonah, Arnie and Sly. Dense, muscled physiques can weigh more than flabby, unfit ones, with the result that the superfit can end up being categorised as obese.

...

He says that too many health professionals in this country do not understand that a healthy weight is about more than a BMI reading. "I've been on a personal crusade about it," he says. "But it's what doctors in this country have always been taught."

Campbell, Macdonald and others say there is an easy and simple alternative: look at your waist size. For men, a waist size of more than 91cm (36in) should give you cause for concern. More than 101cm (40in) and you need to lose weight urgently. The equivalent figures for women are 80cm (32.5in) and 88cm (34.5in). By this criterion, Lomu, with his 27in waist, kicks the obesity tag into touch.

Macdonald, though, offers a word of caution to those who think this gives them an excuse to avoid that trip to the gym: "You can't get away with saying, 'I've got a big frame, so this doesn't apply to me.' It does."

This editorial addresses a bill concerning making clean needles and syringes available for drug addicts. The author makes a persuasive argument

In a bipartisan vote, the California Legislature passed SB1785, which permits pharmacists to sell up to 30 needles to an adult without a prescription. The bill requires participating pharmacists to provide information about disease prevention and drug treatment to consumers (including a number to call where they can get help) and it mandates pharmacists to participate in syringe-disposal programs.

Some fear that SB1785 condones drug use. But the facts demonstrate the contrary. Numerous studies show that expanding access to sterile syringes reduces disease transmission without increasing drug use, drug injection or crime. This legislation is not about enabling or encouraging drug use -- it is about preserving the lives of Californians.

While I do not personally know the data, I would argue that if the data support this editorial, then the legislature is right and the Governor should sign the bill. Needles next phase in fight against HIV/AIDS This is a public health, not a moral issue.

As I read this opinion piece, I kept asking if it was really satire. I think though that the author is probably serious. It does come from a California paper. Die, McDonald's Stock, Die: Is it possible to own shares in noxious, proto-American corporate monsters and still sleep well at night? I personally have greater ethical dilemmas to face each day.

Why I'm Fighting Federal Drug Laws From City Hall. This opinion piece from the mayor of Santa Cruz highlights an issue I addressed earlier this week.

Before the morning raid, Santa Cruz had a good relationship with drug enforcement officials. Santa Cruz, like many communities, has a problem with illegal drugs, most notably heroin and methamphetamine. In the last 15 months, the D.E.A. has conducted two operations here; working with the sheriff's office and the Santa Cruz Police Department, the agency has caught hundreds of drug dealers and users. According to our police chief, "the D.E.A. did an excellent job" in these operations.

That was not the case on Sept. 5. The D.E.A. came to town unannounced and under cover of darkness.

I'm worried that the agency is going to be coming to other towns, too. Since 1996, eight other states — Alaska, Washington, Oregon, Nevada, Arizona, Hawaii, Colorado and Maine — have passed laws allowing for the use of medical marijuana. At the same time, the Department of Justice has made it clear that it opposes the use of marijuana under any circumstances.

Clearly, state law and federal law are on a collision course. I would not be surprised if there are more raids.

The problem with the DEA and marijuana comes from a federal government agency and their laws being at odds with the people. Few citizens object to the use of marijuana for medical purposes.

The government is fighting a losing battle. In the states where medical marijuana has been on the ballot, it has received overwhelming approval from voters. Canada and Great Britain recently approved the medical use of marijuana and plan to have the government grow and distribute it.

As medical costs skyrocket, medical marijuana is a cost-effective way to treat people with chronic pain. Most of all, making medical marijuana available is an act of common sense and compassion. The Corrals' collective lost 40 members this year; many of them left this world with Ms. Corral holding their hand.

As a society we have an obligation to weigh the risks and benefits of our marijuana laws. Most opposition to medical marijuana comes from a moral view. The data do not, in my opinion, support this opposition. Unfortunately, we rarely have a dispassionate discussion about this issue. The DEA raid only raises passions. Perhaps this ludicrous act will focus more attention and allow some courageous politicians (an oxymoron if I ever typed one) to start the discussion in Congress.

U.S. Inquiry on Pricing of Prostate Drug

Bloviator has written a thesis on malpractice premiums. I highly recommend it to those who want the meat, potatoes, gravy and dessert. THE BIG MEDICAL MALPRACTICE INSURANCE POST.

The abridged version - awards do matter as does 'return on investment' of the insurance companies. Laws can keep the first under control. We cannot change the second.

Jack La Lanne’s fitness formula: Father of modern fitness gives tips on living longer — and stronger. He is a bit "over the top" but the message has some validity.

Making Medicine Political: A London Times article describes how two American physicians who printed their views on prostate cancer screening in their local newspaper were treated: Political correctness rears its ugly head in medicine. Dare I doubt prostate cancer surgery, or screening mammography below the age of 50. Damn the data, full speed ahead. Physicians have to think and interpret scientific data. We cannot alter our opinions so mollify lobbies. That is why most of us avoid politics. We are trained from the beginning of medical school to be honest with patients and ourselves.

I suspect that many readers read the other medical blogs I have listed on the left. If you have not checked Rangel this week, you should. I particularly like these stories - Using your patients as "guinea pigs" - a rant about why he does not jump to the newest, latest greatest medication - Diet products: False claims and snake oil - a nice summary of the FTC concerns over weight loss ads - and A national cap on malpractice awards? - in which he castigates the opposition to a cap on non-economic damages. Nice writing and therefore good reading Chris!

I have mixed feelings about this one. On our VA wards, we have many patients with sleep apnea. The government has purchased equipment for them to use at home. Anecdotally, a high percentage of patients do not use this expensive equipment. However, many patients do benefit, so here goes - Sleep Apnea, a Noisy but Often Invisible Threat

What Is Sleep Apnea?

The word apnea is Greek and means "with no breath." As the name of the condition implies, sleep apnea occurs only while a person sleeps. With obstructive sleep apnea, by far the most common type, the airway repeatedly becomes blocked, usually by soft tissue at the back of the throat. With central sleep apnea, no blockage occurs, but the brain fails to signal the respiratory muscles to breathe. A third type, mixed sleep apnea, is a combination of the two.

In most cases of obstructive sleep apnea, the muscles of the soft palate relax at the base of the tongue and the small fleshy piece hanging at the back of the throat, or the uvula, causing the tissue to sag and block the airway.

This is most likely to occur when sleeping on one's back, but it can also happen in other positions. These involuntary breathing pauses may occur as many as 20 or 30 times an hour all night long.

Breathing resumes when the blood oxygen level falls low enough and the carbon dioxide level rises high enough to stimulate the brain into action. Although the afflicted person is unaware of what is happening, with each apnea episode, the brain arouses from deep, restful sleep, resulting in a night's sleep that is fragmented and of poor quality.

After spending up to 10 hours in bed, the sufferers may think they got enough sleep, only to feel groggy in the morning and sleepy for much of the day.

Sleep apnea is very common, as common as adult-onset diabetes. It is most common among middle-aged men who are overweight, especially those with fat necks. But it spares no age group or body size. Even some children have sleep apnea, which is a suspected cause of some cases of sudden unexplained infant death. It has been estimated that as many as 40 percent of elderly residents in nursing homes have sleep apnea.

Sleep apnea is common and important - but not everyone who snores has the disorder. Testing does identify those who would benefit from treatment.

If you are looking for a punch line to a joke, I will reluctantly refrain. Rather I will just provide this link - Study: More susceptible to parasites, males live shorter lives

Physicians all know this - unfortunately many patients and potential patients do not know this. Warnings Sought for Popular Painkiller.

Citing evidence that thousands of Americans unwittingly take toxic — and potentially fatal — doses of acetaminophen, a panel of expert scientists today urged stronger warning labels for the painkiller, the main ingredient in nearly 200 over-the-counter cold and headache remedies, including Tylenol.

The committee voted nearly unanimously, 21 to 1, to advise the Food and Drug Administration to adopt the stronger warnings, and the agency typically follows such advice. The vote came after F.D.A. officials presented evidence that 100 people die and more than 2,000 are hospitalized each year as a result of liver damage from unintentional overdoses of acetaminophen.

Those numbers are relatively small compared with the billions of doses of acetaminophen taken each year, and manufacturers insist that the drug, which is also in prescription painkillers like Percocet and Vicodin, is safe when taken as directed.

But the committee's chairman, Dr. Louis Cantilena, said the panel was convinced of the need to reduce the risk further. Committee members were "particularly disturbed," Dr. Cantilena said, to hear that many consumers mistakenly mixed more than one acetaminophen product because they failed to realize, for instance, that their prescription painkiller and cold medicine both contained the drug.

I have a simple rule of thumb - try not to take multiple OTC drugs. If your pain is that bothersome, you need a professional to evalute the pain. Colds make one miserable, and no OTC drug will make you feel good, only a bit less miserable. I am not sure how I would resolve this problem, but I will follow the FDA decision.

Yesterday was a frustrating day. I could not blog! It took a while for Hosting Matters to track down the problem (which as always ended up being simple). I had used too much space - apparently I have bloggorrhea. So I am increasing my space, and am back in action. I'll try to catch up over the next 3 days with my ranting! Boy, it is nice to be posting again.

Dilemma on Prostate Cancer Treatment Splits Experts - an article in the NY Times, does a very nice job of laying out our dilemma.

The dilemma is not just medical sophistry. Instead, it touches on a fundamental debate among doctors and researchers. What should be the bottom line? Is it enough to show that you can reduce the likelihood that a person will die of a particular disease? Or must you insist that the overall mortality rate is reduced?

The prostate cancer study reveals splits among medical experts. Some, like Dr. Patrick Walsh, a urologic surgeon at Johns Hopkins Hospital, say it is enough to prevent deaths from that disease.

"Have you ever seen anyone die from prostate cancer?" he asks. "It's a terrible death." The cancer, he said, moves into the bones. "Bones break and disintegrate. You linger for a year of a painful death. I have three uncles who died of it. One was a favorite uncle, and I was a child watching him die. It was a horrible thing."

Dr. Albert Mulley, a specialist in internal medicine at Massachusetts General Hospital, has a different perspective. "I see people who die of esophageal cancer or liver cancer or lung cancer," he said. "There is nothing uniquely terrible about prostate cancer."

"Is it worse than Alzheimer's?" he asked. "I don't think so. Is it worse than a debilitating stroke? I don't think so?"

The problem with demanding that treatments or screening tests reduce the total death rate, however, is that it is a high hurdle, sometimes an impossible one, researchers say.

This long article delineates the arguments for and against surgery. I do not think the decision is any easier today than it was last month.

As physicians we have biases. Surgeons see the world through a different prism than internists. The old saw 'a chance to cut is a chance to cure' in many ways describes the surgical mindset. And that is not bad at all. One needs to believe that one is doing the right thing for ones patients.

How do we adjudicate such a controversy? As an internist I believe that my job is to help the patient gain the facts so that he can make a decision about prostate surgery. The urologist worries about the prostate cancer more than everything else.

An orthopedic surgeon I once knew used to say 'Dead is dead'. The patient does not really care about the cause of death. When I review these articles I see comparable death rates (throughout the followup of the study) and comparable quality of life scores.

As some have pointed out, several other very interesting options are not included in the studies - local radiotherapy being one. I do not think that I would opt for radical prostatectomy. But one never knows until one has to make that choice.

In the case of prostate cancer, Dr. Wilt is directing a study that is designed to find a decrease in the overall death rate, if it exists. The study involves 731 men whose cancers were found early, with a P.S.A. screening test and who were randomly assigned to have their prostates removed or not. After 12 years, the researchers expect to see an effect if there is one.

"We felt that if we haven't been able to show an increase in survival, then you have to wonder about the importance of the treatment," Dr. Wilt said.

Dr. Wilt's study, of course, is the ideal. "Everyone would say, boy, that's what I really wish I had," Dr. Goodman said. "The greater debate is, What do you do in the absence of such data?"

At the very least, Dr. Welch said, "if it's such a small difference that you can't see it in the overall mortality, then patients ought to know that. If it's that close a call, maybe they will make a different decision."

Or maybe not.

As usual the story is not over. We will learn more as time goes on, and hopefully we will provide better care as time goes on.

FTC Assails Deception In Weight-Loss Ads

I am working out in my mind a longer rant on this general issue. Read this article iand you will understand the illogical pursuit of the war on drugs - Pot raid angers state, patients . Where is the common sense?

When it comes to marijuana, the government totally lacks common sense. The great majority of college students know this. Now the government is going to use a tactic which just will increase government distrust - New Drug War: Will The New Batch of Anti-Drug Ads Work?

Some young adults say they find the ads offensive. Elisa Roupenian, a college sophomore, told Good Morning America that her peers objected to linking the violence of the drug trade in other countries to drug use here.

"It made people mad because they pointed the finger at teenagers," Roupenian said. "Some people think that if the government didn't create the war against drugs that made it such a huge black market, the terrorists and drug cartel wouldn't be able to make such a tremendous profit," she said.

Roupenian's comments reveal a troublesome side to the anti-drug movement. When it comes to marijuana, young Americans often blame the government for the problems that result from the high demand for it.

When will our country and our government understand that prohibition only helps the drug cartels. England and Canada are taking a more enlightened view on marijuana. Why do we criminalize this drug (or any drug for that matter)? We are not helping society or patients with our laws. Please let us change them.

Osteoporosis occurs with increasing frequency as we age - especially in women. A new recommendation suggests that the government pay for screening - because early diagnosis can lead to successful prevention. Experts recommend routine osteoporosis screening. The article refers to the recommendation and background published in the Annals of Internal Medicine - Screening for Osteoporosis in Postmenopausal Women: Recommendations and Rationale and Screening for Postmenopausal Osteoporosis: A Review of the Evidence for the U.S. Preventive Services Task Force.

Many physicians already screen these patients regularly. Given the complications of fractures in these patients, an aggressive preventive strategy makes sense.

Everyone must remember that this adds one more item to the ever growing check list for generalists. Ordering a test, obtaining results, and explaining the results takes time. Everything good that we ask generalists to do takes time.

I love this article. When `Health' Supplements May Do Harm

Conventional medical education and treatment guidelines discourage the use of vitamins and supplements as therapeutics for heart disease, largely because they have not been shown to have any benefit. Interestingly, while diets emphasizing foods rich in certain vitamins correlate with improved cardiovascular and cancer risks, the pill forms of these same nutrients have proved to be no more effective than placebos.

...

n promoting a product as a "supplement," manufacturers often rely on a combination of factors: vague claims made by sellers, word of mouth, and the distrust by many of organized medicine and the pharmaceutical industry. Supplement manufacturers are permitted to use advertisements and testimonials claiming that their products are "all natural" and "completely safe, without side effects."

The manufacturers of prescription drugs are allowed to make claims only about efficacy and safety that are based on results from controlled clinical trials approved by the F.D.A.

When Congress passed the Dietary Supplement and Health Education Act of 1994, it created this inequity between the marketing of medicines and supplements. This legislation places the burden on the F.D.A. to prove that a "supplement" is harmful before it can be removed from the market. In stark contrast, medicine approved by the agency must satisfy many safety and efficacy requirements before it can be sold.

The absence of a prospective review process may very well have contributed to the late discovery of harm associated with supplements like ephedra, the contamination of another supplement with a prescription blood thinner warfarin and an anxiety medication, and the fatal effects of an amino acid product.

Read the entire article. You may want to make copies to hand out to patients - it is that good.

Nice article, reprinted from the Wall Street Journal - States, Insurers Find Solutions for Drug Costs describes succesful strategies for decreasing drug costs.

After a heart-attack scare, Ms. Hummel, 55 years old, visited her Kaiser Permanente clinic in Santa Clara, Calif., for a cholesterol check. Her readings weren't good: Her LDL, or bad cholesterol, was 195, nearly twice her recommended level. She got a prescription for a type of drug called a statin. Within a month, her LDL had fallen to 104.

It's the kind of outcome you'd expect from Pfizer Inc.'s Lipitor or Merck & Co.'s Zocor, two heavily advertised pills that are the top-selling statins. But Ms. Hummel took lovastatin, a generic version of a drug called Mevacor that Merck introduced in 1987. It's less potent than the others and has been largely ignored by company marketers since Zocor came out a decade ago.

But Mevacor, which went off patent last year, is plenty powerful for most patients. It is now the linchpin to an ambitious cholesterol-management program in Kaiser's Northern California Division. More than 80 percent of the division's 130,000 high-risk heart patients have reached federally recommended cholesterol goals, up from 22 percent five years ago. And, thanks to the drug's lower price and Kaiser's discount-generating purchasing power, the HMO can treat five patients with lovastatin for what it costs to treat just one with Lipitor.

Point well made! This is not an isolated example in the article. The problem remains educating physicians (including myself) on clinically proven alternatives. We hear more about the newer medications, and often forget the older ones. Where are the studies showing equivalence?

In the U.S., the FDA scrutinizes drugs for safety and clinical effectiveness, but no federal agency offers a comprehensive assessment of the economic value of drugs. Many private health plans attempt such research while creating their lists of approved drugs, but those data largely remain secret.

The National Institutes of Health, which conducts and finances basic research, sponsors occasional clinical trials comparing the performance of drugs. In 1994, the NIH's National Heart, Lung and Blood Institute launched a 44,000-patient trial to compare, among other things, four hypertension medications. The institute wanted to know which was more likely to prevent heart attacks and deaths.

Results of the study aren't expected until late this year, but already it has yielded an important finding. Patients taking a blood-pressure medication called doxazosin were more likely than those on a cheaper diuretic to have heart problems and be hospitalized for congestive heart failure. That prompted a call by the Heart, Lung and Blood Institute for one million Americans taking doxazosin to see their doctors about using an alternative.

But the NIH sponsors relatively few such studies, which are complex and costly. Increasingly, experts argue that the government should play a more active role in exploring the cost-effectiveness of drugs. ``We have a national institutute for heart disease, a national institute for diabetes, a national institute for allergies,'' says Harris Berman, chief executive of Tufts Health Plan in Waltham, Mass. ``Maybe we need a national institute for pharmacy.''

I have previously decried the lack of these practical and important studies. As long as we rely on pharmaceutical companies to fund research on their drugs, we will not get the studies that we need!

Last week, I wrote about the Swedish prostate cancer trial. Both Medpundit and RangelMD weighed in with similar takes. Today's Boston Globe has a well written and thought out editorial - Prostate prospects.

It speaks volumes about the nature of prostate cancer that a major study could show that surgical treatment reduces the risk of dying from the disease but does not reduce a patient's risk of dying within the study period.

Those two conclusions came from a Swedish study conducted from 1989 to 1999 and reported in last week's New England Journal of Medicine. The findings are not contradictory because prostate cancer has traditionally been diagnosed in men old enough so other diseases often kill them before their cancerous prostate does, especially since so many prostate tumors grow very slowly.

This puts patients and their doctors in a quandary: Should they aggressively treat the malignancy, running a high risk of impotence and incontinence, or should they engage in watchful waiting to see whether the cancer will show itself over time to be one of the fast-growing ones that will lethally metastasize if left untreated?

Contrast this well reasoned approach with the headlines in the popular press. I worry about the sensationalizing of medical findings. How does medical 'news' affect doctors and patients? I suspect that these stories can cause anxiety in many. They also can impede decision making, as good decision making requires a balanced review of the data. The 'popular press' is not interested in a balanced review, they are interested in attracting attention and viewers or readers. Kudos to the Boston Globe for understanding this major issue.

I find being a physician a great privilege. As a physician, I strive daily to help patients, either directly while they are under my care, or in the future by studying, teaching medical students and residents, or doing research. My profession challenges me intellectually, and often rewards me on a personal level. Most times when I enter a room and meet a patient for the first time, he/she looks at me kindly, with trust, and assumes that I care. Patients like their physicians.

While our jobs are usually challenging, yet pleasing, sometimes we must deliver bad news. I would like to present a couple of patient scenarios for your consideration, then refer you to a well written article about bad news.

Once, in the 1990s, I got a call from the pathology lab. The pathologist called and said she wanted to discuss a laboratory result on one of my patients. The patient was newly HIV positive. The problem was I did not recognize the patient's name. So I called my secretary and asked if the patient was scheduled to see me. In fact he was scheduled the next week as a new patient. So I asked who referred him, and found out that a general surgeon had made the referral. "Call the surgeon," I thought. Our discussion revealed that this 29 year old man had come to him for evaluation of posterior cervical adenopathy. The surgeon biopsied the nodes with the pathology suggesting AIDS. He sent off an HIV test and referred the patient.

I thought about the situation, and decided that I could probably do a better job breaking the bad news to the patient than could the surgeon (knowing his style, and the circumstances of the referral). I remember telling the patient the diagnosis, and having a productive long discussion with him that day. He did well during the 2 years that I followed him, eventually referring him to an HIV specialty clinic.

Recently, a 61 year old man was referred to our inpatient service to 'confirm his non-Hodgkin's lymphoma'. The patient had become sick a couple months previously. After a month of routine outpatient antibiotics and symptomatic treatments, a chest X-ray showed bilateral hilar adenopathy. A CT of the chest and abdomen showed many nodes and splenomegaly. The patient had a hemolytic anemia and thrombocytopenia. We had pulmonary and oncology consults, both of who suspected lymphoma, both of whom wanted a definitive diagnosis.

At the other hospital, he had had a peripheral node biopsy which showed reactive lymph tissue. A bone marrow biopsy was 'abnormal, but non-specific'. The referring physician had told the patient and his wife that he had lymphoma, and that she was referring him to us to confirm the diagnosis.

We sat down with the patient and his wife to understand their comprehension, their fears and try to understand their interactive style. As the data mounted, it became more likely that the patient did no have a lymphoma. Several days into the hospitalization, we sat down (I as the attending did most of the talking, but the resident, interns and students were present in the room) to discuss what we knew and what we did not know. Our previous discussion had made it clear that the wife especially was not ready for uncertain news. She did not want to know that he probably had lymphoma; she wanted a more certain diagnosis. The bad news (on incomplete data) had shocked the patient, his wife, and the children.

Our evaluation proceed slowly. After peripheral biopsies, another bone marrow biopsy, a mediastinoscopy with biopsies, a bronchoscopy with biopsies and many serologies we determined that in fact he did not have lymphoma. We believe that he has a rheumatologic diagnosis (in fact the precise diagnosis remains a bit uncertain). He has responded beautifully to oral prednisone. We did not discuss his presumed diagnosis until we had successfully eliminated lymphoma from our differential diagnosis.

What principles do I derive from these two patients? First, breaking bad news is a primary responsibility of generalist physicians (whether family physician, pediatrician, internist or hospitalists). We probably have more opportunities, and therefore we must learn how to help patients work through these difficult situations. Second, we should not break bad news until we are certain of the bad news. My patient with the hilar adenopathy is not unique. A colleague had a similar patient with a large lung mass and brain mass recently, which turned out to be an infection despite everyone thinking cancer. Prior to shepherding the patient through an emotional rollercoaster, we must have as much certainty as one can get in medicine.

I always have to emotionally prepare for these conversations. I usually decompress by discussing the conversation with the housestaff and students. This decompression helps and supports my feelings, and hopefully provides some role modeling for their future encounters.

Browsing the web today, I found this article - Breaking Bad News. I highly recommend reading this nicely written exposition on the skills of breaking bad news. I plan to hand the article out to my housestaff and students, and then discuss the details. Hopefully, by focusing on this issue, we can improve, to the benefit of our patients and their families.

The painful truth

'That the sexes handle pain differently won't arrive as news to any woman who has nursed a man through a mild respiratory infection, while feeling pain, from say, multiple fractures.' MARNI JACKSON reports on an emerging new science -- men, it seems, can't even begin to 'feel your pain'

Men and women are different. We respond differently to stimuli. We rate pain differently. This article lays out the differences in pain perception and explores possible reasons.

Anita Unruh began her talk at the congress with an anecdote. "I had left my purse back in class and when I went back to get it, there were two men in the office. As I overheard them talking, a third man joined them, and he was limping. 'Still limping there, eh Joe,' one of them said. 'Well, I just had surgery two weeks ago,' Joe replied. 'Two weeks!' they said, 'bit of a wuss then, aren't you?' The two men chuckled, and a slightly chagrined Joe joined the laughter. It was all very good-natured."

Nevertheless, Ms. Unruh thought the story revealed a number of things about the way we think about other people's pain. "It implies a kind of intolerance of pain, a behaviourial inhibition of pain, and an appraisal of pain as a challenge -- as something to be overcome."

She added, "I can't really think of a situation in which women would speak in this way to another woman in pain.

"Girls appear to feel free to express their pain, and boys may receive more negative consequences if they do. Girls also anticipate more pain when it comes to needles or other painful procedures. If you think about that, it could be a problem of girls being more afraid," she said, "but it could also be that if you anticipate more pain, you prepare yourself to cope better with pain when it occurs to you."

I think this is a very interesting observation. The article's author has a very interesting web site - Pain: The Fifth Vital Sign by Marni Jackson.

Feeling Under Par? Ask Your Doctor for Golf

Doctors will be able to refer unfit patients to the town's municipal golf course for an eight-week session.

"The golf professional will go round with them and give them a few tips on how to improve, to make sure they don't get frustrated if they can't hit the ball," Chapman said.

Patients will pay 36 pounds ($56) for the treatment, with local government picking up the rest of the 200-pound bill.

"Our golf course is quite short so it won't be a long old hike," Chapman told Reuters. "It's not overstrenuous and it's not hilly. It's quite a sedate course."

I love this story!

I knew this, but the data confirm it. Specialties see higher pay; primary care not so much

AMGA's latest Medical Group Compensation & Productivity Survey reports that median physician compensation rose most steeply for diagnostic radiologists, dermatologists and anesthesiologists, all up more than 9%.

Interventional diagnostic radiology led the survey with a $356,000 median and topped the chart with a 16.3% increase from $306,000.

The survey is based on data from 242 medical groups representing 31,000 physicians. AMGA's members tend to be from large physician groups.

The big increases in compensation for those specialties are driven by supply and demand, said Shawn Schwartz, manager at Minneapolis-based RSM McGladrey Inc., the consulting firm that conducted the survey for AGMA.

What specialties do you think medical students are choosing?

They do not work! This entertaining article discusses the scam - Once Upon A Magnetic Mattress. Whether you care about magnets and arthritis or not, you probably will enjoy the clever way the author makes a point.

Read this very nice piece from the Sunday Times (London) about heart failure and its treament (note that in the US the tradename for carvedilol is Coreg) - Kick-start the heart. The article covers known ground, but discusses some important new data.

The treatment of chronic heart failure was one of the principal points of interest in the Berlin conference. This interest had been excited by the presentation of the results of Carmen, a trans-European trial involving patients from 65 heart units in 13 countries. Carmen was designed to evaluate and compare the effects of the use of an Ace inhibitor, Innovace enalapril, and/or a sophisticated beta blocker, Eucardic carvedilol, manufactured by Roche, in the treatment of heart failure.

Eucardic, unlike most beta blockers, not only blocks the beta 1 andrenergic receptors but also comprehensively blocks the beta 2 and alpha 1 adrenergic receptors. Blocking the alpha 1 receptors gives Eucardic a vasodilatory effect of benefit in the control of heart failure, ischaemic (coronary) heart disease and high blood pressure.

There was a time when doctors did not prescribe beta blockers in the presence of heart failure. Now beta blockers such as Eucardic have been confirmed as being an important part of the trinity of drugs — Ace inhibitors, appropriate beta blocker and, when there is fluid retention a diuretic such as bendrofluazide — which should be the standard regime for those with heart failure. Evidence from an earlier trial showed that patients taking Eucardic demonstrated a 35 per cent reduction in mortality, and with it an accompanying improvement in the quality of life.

Carmen has shown the value of combining an Ace inhibitor with Eucardic — most patients were already receiving diuretics. The research also demonstrated that the combination of Eucardic with an Ace inhibitor resulted in reversal of the changes in the heart’s shape and structure that are characteristic of heart failure.

The article does not mention that we really do not know whether carvedilol works better than metoprolol or other beta blockers. "The Carvedilol or Metoprolol European Trial (COMET) is comparing the use of carvedilol or metoprolol in heart failure patients and the effects of the therapies on all-cause mortality." Until we get the results of the COMET study, I am using metoprolol (FDA approved) for my heart failure patients (much lower cost). When the patient has class III or IV CHF, I often start with carvedilol for the first few low doses (carvedilol's marketing includes very low dose pills for gradual titration). Once I get to 12.5 mg b.i.d. of carvedilol, I then switch to 25 mg b.i.d. of metoprolol (those are equivalent doses), and continue titrating upwards. The data for beta blockers are clear and compelling. If you feel uncomfortable using beta blockers in CHF patients, please find a consultant to help you care for the first few patients.

Report outlines diet-cancer link: Experts offer bottom line from decades of confusing research

Wading through 30 years of confusing and sometimes contradictory studies on cancer and diet, experts have summarized the state of scientific knowledge: alcohol is bad, obesity is bad and lots of fruits and vegetables are good.

Well that introduction provided no surprises. One can read the original article here - The effect of diet on risk of cancer (Lancet - free but registration required).

Riboli said emerging evidence suggests many of the factors that contribute to heart disease are also involved in cancer, such as lack of exercise, being even moderately overweight and problems with insulin, the hormone that goes wrong in diabetes.

“I think it’s possible that we will realize that some of the benefits which were in the past attributed to the diet in itself should actually be attributed to the global balance between how we eat, how we move and our body shape, where we are actually pointing more to the energy balance,” Riboli said.

...

Experts are also starting to advocate a tougher strategy. “The individual awareness approach has been shown repeatedly to have failed,” experts said in a report presented Wednesday at a European Union summit on obesity.

In its report, the International Obesity Task Force called for European restrictions on the advertising of junk food.

Other measures mentioned in the report were: redesigning roads to accommodate networks of bicycle tracks, removing junk food vending machines from schools, reintroducing cooking skills into the school curriculum and the establishment of a new medical specialty that takes a comprehensive approach to obesity.

We likely will continue to hear more and more pressure on diet control. While I am empathetic towards the problems, and I try to work with patients, colleagues and friends to eat more intelligently, I am against too much intrusion here. If I eat too much aspirin, I could die. One baby aspirin a day likely will decrease my chances of a cardiac event. Many vitamins are like that. I like the occasional junk food. We need to proactively provide diet options. We should beat the bad diet options in the marketplace. But please do not give us more regulations.

I love the idea of providing for more bike trails (and running trail are also good). We need more side walks in the suburbs - they encourage walking at least. We should sponsor exercise training in schools. Those are positive ideas.

My episodic efforts as a music critic returns. I have become somewhat obsessed with Duncan Sheik's Daylight. If you are interested in reading my review - Daylight Sheik

First, check out these 2 links to articles about the prostate cancer surgery articles. Prostate Cancer Surgery Found to Cut Death Risk (NY Times headline) - Prostate Cancer Therapies About Equal: Having Surgery May Extend Patient's Life (Washington Post headline). So what did the articles really say? I printed out the articles last night and digested them. While I need to consider the data a while longer, I will try to summarize my reading.

• This is a Scandanavian study. Thus, we cannot learn if their are any racial differences. This is important because prostate cancer is a bigger problem for African-Americans than Caucasions.
• Most patients entered this study with symptoms - only about 5% came from screening
• The average age on study entry was 65. The data may not extrapolate to those patients in their 50s
• Given those caveats, the disease - prostate cancer - benefits from radical prostatectomy. Less patients die from the disease. Less patients have metastases after a median followup of 6.2 years.
• Despite improvements in treating the disease, the overall mortality did not differ at 6.2 years. The patients in the watchful waiting randomization more likely died of prostate cancer, but less likely died of other causes.
Quality of life overall did not differ, but separate components did differ. Surgery leads to more erectile dysfunction and urinary incontinence. Watchful waiting leads to more urinary obstruction.
• This study gives me more data to present to patients. I could use those data to support either side. I suspect urologists (who are surgeons) will focus on the disease benefits. I understand that position, but would argue that each patient must have his life expectancy estimated, and his preferences for side effects elicited. The decision for or against surgery is still not a slam dunk.

Another important study is still underway.

Some answers should emerge from a study, now under way, sponsored by the Department of Veterans Affairs, the National Cancer Institute, and the Agency of Health Research and Quality. It includes 731 men, mostly veterans, with localized prostate cancer, usually found by a P.S.A. test. Half were randomly assigned to have a their prostates removed and the rest to watchful waiting. The study is to continue until 2008 unless a clear survival advantage emerges for either the surgery or watchful waiting.

So far, five years into the study, no such advantage has appeared, said Dr. Timothy J. Wilt of the Minneapolis V.A. Medical Center.

"I would like to conclude that while the Swedish study is a very important piece of information, when put into context, the preferred treatment for prostate cancer still is not known," Dr. Wilt said.

The two articles and a well written article appear in today's New England Journal of Medicine.

The Invisible Women - describes the plight of home health aides.

This is important work. Home health care is much cheaper and, for patients, generally preferable to lengthy hospital stays or other forms of institutionalization. And as the baby boomers continue to age, home care will become more and more common — not just in New York, but across the nation.

So now would be a good time to stop the utter exploitation of these workers, who are among the most poorly paid and poorly treated that you can find. There are more than 20,000 home health aides in New York City. Most are paid a pathetic $6 or $7 an hour. Some are paid less. Nearly all of the workers are women, and most of them receive no health care, no sick pay, and get no vacations.

As I have stated many times, insurers and society treats primary care physicians poorly. Many in this country want to blame our competitive insurance industry and lack of a single payor. This article throws cold water on that theory - One in five GPs 'plans to quit' - oops this is British article!

Thousands of GPs are planning to quit their jobs over the next five years, two government studies reveal.

A report for the Scottish Executive suggests that one in five doctors will leave general practice by 2007.

A second study for the Department of Health in England suggests that an even higher proportion of doctors south of the border are considering quitting.

The findings indicate that 7,000 doctors will leave general practice over the next five years and raise serious doubts over government plans to tackle the shortage of GPs across the UK.

The vaunted NHS (national health service) abuses GPs!!

The Scottish report, compiled by the National Association of Primary Care Research and Development Centre at Manchester University, found overwork and stress are the main reasons why GPs want to leave.

...

The main things influencing their dissatisfaction were paperwork, administration, demand from patients and organisational change."

So the primary care crisis appears an international phenomenon. Patients want a relationship with a single generalist. Physicians enjoy that relationship. But those physicians have become devalued and suffer work abuse (in my opinion).

A colleague recently made me aware of a well written, thorough article in the August 21, 2002 JAMA. The following link gets you the abstract - and you can read the article if you have a subscription - A Primary Care Home for Americans: Putting the House in Order

The clearest symptom that these combined factors are creating stresses in primary care practice is the frequent complaint about lack of adequate time during office visits. As noted earlier, growing numbers of US primary care physicians believe that they cannot spend sufficient time with patients. Physicians in other nations voice similar complaints. Paradoxically, there is no evidence that the actual length of office visits in the United States is getting shorter. Between 1989 and 1998, the mean length of a primary care office visit in the United States increased from 16.3 to 18.3 minutes. What explains this paradox of longer average visit times and physician complaints of less adequate time? One explanation is the increasing distractions that cut into meaningful patient care time. The average family physician or internist in the United States wastes 40 to 50 minutes each day on managed care administrative hassles. However, the clinical demands on primary care physicians during the typical office visit are also increasing. In the face of heightened expectations for comprehensiveness, accessibility, coordination, continuity, and accountability in primary care practice, a decade's addition of 2 minutes to the average visit time is experienced as losing rather than gaining ground.

I highly recommend the entire article. My frustration comes from understanding the problem, but not being able to visualize a proper solution. It actually is about money, because money buys time.

Obesity will 'become the norm'. Obesity may become as big a crisis in GB as in the US.

Three-quarters of the UK population could be overweight within the next 10-15 years, top experts have warned.

They say obesity will overtake smoking as Britain's top preventable killer.

And they have accused the government of being too scared of the food and transport industries to tackle the problem properly.

I guess the blame culture lives across the pond. We should blame industries because people eat too much and exercise too little. Poppycock!

Restrictions will not work. We need to provide options. We need more fast food with low calories and reasonable portions. Subway does great business, and the do have reasonable food on the menu.

We need to make exercise easier and more desirable. Use positive reinforcements and change behaviors. But please do not blame and regulate.

Mallard Fillmore - he has a great funny strip at this link. It would fit here. Check it out!

Chris Rangel writes eloquently about retainer medicine - "Boutique" medicine comes to Dallas . He links to the following article - Boutique doctors shun the insurance companies

Read Rangel's comments and read the article. He has an excellent summary of this issue. For those who want to read more, I have extensive previous takes on this issue - just use the search engine.

Slow down; do not get excited; this only represents step one. House Panel OKs Malpractice Limits.

The legislation would limit noneconomic damages, such as pain and suffering, to $250,000. Punitive damages would be limited to twice the amount of economic damages awarded or $250,000, whichever is greater. Patients' ability to file suit over old cases would be limited, and lawyers' fees would be curtailed under the legislation.

Committee Democrats unsuccessfully tried to change the legislation to lift the cap limits and extend the time period during which a patient has the right to sue.

Rep. James Sensenbrenner, the committee's chairman, described the situation as "a national insurance crisis."

"Doctors and other health care providers are being forced to abandon patients and practices, particularly in high-risk specialties such as emergency medicine and obstetrics and gynecology," said Sensenbrenner, R-Wis.

Dr. Yank Coble, president of the American Medical Association, said the legislation will "bring common sense back to our nation's medical liability system and bring much-needed relief to patients throughout the country who are struggling to find physicians."

From the other side, Rep. John Conyers of Michigan described the bill as "the most far-reaching and dangerous malpractice bill before Congress."

"The proposed new statute of limitations takes absolutely no account of the fact that many injuries caused by malpractice or faulty drugs take years or even decades to manifest themselves," said Conyers, the committee's top Democrat.

I remain mystified with the Democratic position. What principle do they espouse? How much money do the trial lawyers give them?

For those who care, you can read the bill at THOMAS: Legislative information on the internet by searching bill H.R. 4600.

McDonald's Fat Debate Goes On

Lost in all the hoopla is that even with fewer trans fatty acids and saturated fats, anyone ordering a Big Mac, super-size fries and a super-size Coke will consume more than 1,600 calories. For children, the meal takes care of all daily calorie needs, with some left over for the day after.

"This is nothing more than dressing up nutritionally poor and calorie-dense food, at a time when obesity has reached epidemic proportions" and 10 to 15 percent of children younger than 10 are obese, said Dr. Henry Anhalt, director of pediatric endocrinology at Maimonides Medical Center in Brooklyn. "McDonald's will sell more French fries, and the public is being duped."

I was sitting in clinic yesterday with 5 residents. We were discussing diet philosophy. One resident has lost 30 pounds over the past 6 months (since delivering her son). Having read the literature, and understanding physiology, we quickly focused on portion size and especially 'unnecessary calories'. I specifically mentioned french fries. One has a perfectly filling meal with a Big Mac and a diet drink. The fries are not necessary, but are tasty and very easy to eat.

The McDonald's announcement diverts attention from the real issue: calories. No one wants to talk about calories because cutting them means dealing with the concept of eating less food, an unwelcome thought for many people. It smacks of privation. Except for the most disciplined (who probably don't eat a lot of fast food anyway), when people are confronted with more food than they need, they will eat it.

Dr. David Levitsky, a professor of nutrition and psychology at Cornell University, has produced a fascinating study to prove the point. "The more food you put in front of college students, the more they will eat," he said. At the beginning of the experiment, the results of which were presented this year, 13 students took as much as they wanted from a buffet on Monday, Wednesday and Friday. That food was weighed. The following Monday a third of the students were given the same amount they had eaten the Monday before, a third were given 25 percent more, the final third 50 percent more. Each group had an opportunity to eat the three different amounts. "The more we gave them, the more they ate," Dr. Levitsky said, adding that when they ate at the 150 percent level, they ate about 200 additional calories. "I think this shows that if we are served larger portions, we will eat them," he concluded.

Dr. Levitsky also said that people tend to eat larger portions when they eat out and that the fat content of fast-food meals is far higher than what people consume at home.

And that is my point exactly. We must work on calories and the most important key is portion control. While this seems simple, how often have you heard others, or even yourself, complain about a restaurant serving small portions.

When I was losing my weight 2 years ago, I became fanatic about portion control. I still fail sometimes and will eat too much. In our society this requires planning and will power. But one can control portions. And we must.

Generalists see many patients complaining of hand pain or numbness. Over the past two decades we have increased our index of suspicion for carpal tunnel syndrome. We have wondered about optimal management. Today's JAMA has an article which helps our decision making. Study Finds Surgery Works Best for Carpal Tunnel Syndrome. A review of the primary article Splinting vs Surgery in the Treatment of Carpal Tunnel Syndrome:A Randomized Controlled Trial reveals several important points. First, all the patients had idiopathic electrophysiologically confirmed carpal tunnel syndrome. Dissecting that phrase, they excluded patients with diseases which can cause carpal tunnel syndrome (like diabetes mellitus). They also excluded patients who already had thenar weakness.

One should keep the results in mind. The surgical success rate was 80%. While this is a very good result, I always remember the surgical failures. That is a clear bias, because those are the patients who keep coming back to see us. The success rate for splinting was a respectable 54%. I have always used splinting as a first line management. If it worked, we could avoid surgery. If it failed, then surgery made more sense. If I had carpal tunnel syndrome, I would still probably try conservative measures (splinting) first, but be more willing to proceed to surgery if the results disappointed me.

The Dutch investigators have done a nice, important study. This one will influence how I care for these patients.

McDonald's marketing cited for teens' obesity - a more complete report on the 2nd suit against McDonalds.

"We feel that the advertising strategies [of quick-service chains] target young children," said Samuel Hirsch, the attorney representing the teenagers. "Toy promotions and Happy Meals are a lethal combination."

Mr. Hirsch said his clients ate at McDonald's almost every day for at least five years. One teenager, who is 5-foot-9-inches tall, now weighs 270 pounds; another, who is 5-foot-3-inches tall, now weighs 200.

Obviously, neither the clients nor their parents should accept any responsibility for their weight. Responsibility is abandoned as a concept in this country, rather let's blame someone for our own shortcomings, and sue the bastards.

The lawsuit drew criticism from consumer groups and plaudits from medical groups, which said yesterday such cases alert people about the health risks of consuming fast food.
"We advocate for people to take control over their diets, but these lawsuits keep fast food in the news and point to the real issues that fast food can cause," said Brie Turner-McGrievy, a clinical research coordinator with the Washington-based Physicians Committee for Responsible Medicine, a nonprofit organization that promotes preventive medicine.

Others disagree.

"The Caesar Barber case was clearly a legal belly flop in the eyes of the public," said Mike Burita, a spokesman for the Center for Consumer Freedom in Washington.

"The trial lawyers are back at the drawing board, now using kids as their new pawns to try to get their multimillion-dollar payday in court. This has everything to do with fattening attorney wallets and nothing to do with slimming down Americans."

Either concept bothers me. You should not file a suit to attract attention. That concept perverts our legal system. This legal grandstanding sickens me. I certainly do no advocate poor diet, quite the contrary. Could the lawyers use their profits to pay for an advertising campaign for healthy diet and exercise? Could they defend the downtrodden? Why do they play the victimization game?

Train Your Brain

This report makes sense - Survey: Thousands to be affected by HMOs dropping out of Medicare

Nearly 200,000 people may have to change health plans next year as health maintenance organizations continue their exodus from the Medicare program, according to a survey by an HMO trade group.

THE AMERICAN Association of Health Plans said Monday that HMOs are continuing to pull out of Medicare’s managed care program because they don’t get enough money to care for each patient amid rising health care costs.

Federal officials have said that the overall cost of the nation’s health care rose 6.9 percent in 2000. But the amount of money that an HMO gets to care for patients has risen by just 2 percent, said Susan Pisano, spokeswoman for AAHP, which represents health plans.

“That’s arithmetic that can’t be sustained over time,” she said.

Last year, 58 health plans withdrew or cut services. That meant 536,000 seniors — about 10 percent of the 5.6 million in Medicare HMOs — had to find a new way to receive Medicare benefits.

Medicare HMOs typically provide benefits that traditional Medicare does not, including prescription drug coverage. But the program has struggled in recent years to keep HMOs involved.

We obviously need a different approach to the financial crisis in health care. Could our health be worth the extra mone?

The finding was so serious that it could be comparable in its health effects to a vitamin deficiency, medical experts said. It was so shocking that U.S. News & World Report published a special 11-page section warning the nation.

"There is deep concern in high places over the fitness of American youth," the magazine's report began. "Parents are being warned that their children — taken to school in buses, chauffeured to activities, freed from muscle-building chores and entertained in front of TV sets — are getting soft and flabby."

The date of that report was Aug. 2, 1957.

Decades of Admonitions Fail to Get Americans Moving. You can probably tell that I am not adverse to beating a dead horse. I cannot resist providing more and more evidence of the benefits of exercise and the problems of inactivity. This article does a great job of summarizing data that I have written about previously.

"We can't just throw up our hands and say, `We tried,' " Dr. Haskell said. He is convinced that one reason people are getting fatter is because they are so sedentary and because they don't know it, with many thinking they are moving more than they really are.

Dr. Haskell and others are undeterred, determined to keep trying to find a way to change Americans' exercise habits.

"Physical activity is as close as we've come to a magic bullet for good health," Dr. Manson said. "It's more difficult than popping a pill, but it's worth it."

Amen! Posted by at 05:46 AM | Comments (0) | TrackBack (0)

High-Fat Diet: Count Calories and Think Twice. Jane Brody in today's NY Times writes intelligently about the Atkins diet and the low fat philosophy. The entire article makes good reading. I will excerpt some high points.

Does it help people lose weight? Of course it does. If you cannot eat bread, bagels, cake, cookies, ice cream, candy, crackers, muffins, sugary soft drinks, pasta, rice, most fruits and many vegetables, you will almost certainly consume fewer calories. Any diet will result in weight loss if it eliminates calories that previously were overconsumed.

This diet seems easy because it places no limits on the amounts of meats, fats, eggs, cheese and the like you can eat. These foods digest slowly, making you feel satisfied longer. Also, a diet without carbohydrates causes the body to make substances called ketones that may create a mild nausea, suppressing hunger.

We all really knew that much. Atkins is not magic. You omit so many foods that you almost have to decrease caloric intake.

What is surprising is that after three decades of simmering and soaring popularity, the Atkins diet has yet to be tested for long-term safety and effectiveness.

In an interview, Dr. Atkins said: "A long-term study would cost millions and millions of dollars. We can afford to do a six-month study." Those shorter studies, he said, have shown "major improvements in lab tests and well-being." He said his foundation has contributed to a study under way at Harvard comparing the short-term effectiveness and health effects of diets low in carbohydrates versus diets low in fat.

Dr. Abby Block, nutritionist at the foundation, said studies of the Atkins diet lasting six months to a year and extensive clinical experience, have shown consistent improvements in blood lipids and glucose levels, suggesting that the diet can improve health despite its high levels of saturated fats and cholesterol, long associated with heart disease risks.

Why hasn't the government tested it? One possible reason is that it is unlikely to be approved by any review committee, given what is known about the effects of animal fats and cholesterol on the risk of heart disease, strokes and some cancers, as well as accumulating evidence that diets rich in fruits and vegetables and moderate in protein and fat can prevent diseases like high blood pressure, prostate cancer, heart disease and diabetes.

The Atkins diet is shy on several vital nutrients, including the B vitamins and vitamins A, C and D, antioxidants that slow the effects of aging, and calcium. And, a diet rich in animal protein can draw calcium from the bones, increasing the risk of osteoporosis and hip fractures.

Brody may be correct, but as I have stated on multiple occasions, one should not use theories to stop research. There are preliminary data on the Atkins diet which seem counterintuitive. Maybe our theories are wrong. Given appropriate consent (which would include disclosing the countervailing theory) one could easily get volunteers. I understand the argument; I just do not buy it!

When nutrition experts began urging Americans to cut back on fats, many filled in by eating more carbohydrates — a lot more than anyone recommended. Food producers jumped on the bandwagon to produce low-fat snacks and desserts, and Americans went hog wild, eating as much of them as they wanted.

Many fat-free foods have as many calories, or nearly as many, as their original high-fat versions, since sugars and other carbohydrates replace the fat and reduce the loss of flavor.

Third, Americans are not eating a low-fat diet. Despite a decline in the percentage of fats in the American diet, most people still eat the same amount. As caloric intake rose, the percentage of fat calories dropped but the total amount did not. Americans are eating more of everything, especially refined carbohydrates, which are made from white flour and sugars, doing neither their health nor their waistlines any good.

Too many refined carbohydrates can raise blood levels of heart-damaging triglycerides and may increase the risk of diabetes as well as obesity. Neither is it wise to cut out all fats. The body needs fat to aid in the absorption of essential nutrients, fat enhances flavor and satiety, and some fats actually promote health.

Brody points out the key problem with the low fat movement. By emphasizing low fat, we did not focus on carbohydrates. Most diet gurus agree that too much carbohydrates (especially refined carbohydrates) will cause weight gain. The question and challenge we all have is how to cut back on carbohydrates. To which Dr. Alice H. Lichtenstein, professor of nutrition at Tufts University in Boston, added: "Reducing fat alone is no guarantee of weight loss. You must cut calories or increase physical activity."

Dr. Denke concurred: "No matter what anyone tells you, it's calories that count. Carefully controlled metabolic studies show that it doesn't matter where extra calories come from. Eat more calories than you expend and you'll gain weight."

There you go. It really is simple. Expend more calories than you ingest (the fancy doctor's way of saying burn more than you eat). There is no magic.

If you want to hear creative cursing, ask almost any physician what he (she) thinks of E&M coding. One cannot imagine a more Byzantine method for determing physician reimbursement. Only a truly confused bureucrat - or worse a committee of the confused - could have developed this system. Because the government determines payments using this system, I have to go to classes to learn it. The lecturer always starts saying that it is actually simple - and I zone out. That lecturer has started with a lie, and I cannot believe anything else said.

I am right!!! Study confirms: Even experts confused by Medicare coding: Specialized coding agencies can't agree on proper E&M codes. The system is indecipherable. The fundamental flaw is to link documentation to reimbursement. We have inflated charts - inflated with 'fluff' for billing purposes. Our charts should speak to the patient's problems and reflect our thinking and plans. Rather we document long histories, review of systems, social histories, and physical exams - on each and every visit!

A new study bolsters what many physicians have claimed for years -- Medicare's evaluation and management coding process is horribly confusing.

Researchers from the Dept. of Emergency Medicine at the William Beaumont Hospital System in Royal Oak, Mich., set out to determine how well even experts could do in appropriately coding emergency department visits.

The study, published in the September issue of Annals of Emergency Medicine, looked at the five E&M codes that represent 70% of the codes emergency physicians use to bill for their services.

The researchers, led by Raymond Jackson, MD, sent copies of 389 medical records to four private coding firms and asked them to correctly assign codes to the emergency department visits documented in the charts. They found little consensus.

The agencies agreed on the proper coding in only 15% of the charts. In 6%, the four coding firms came up with four different codes. And in 29% of the records, the coders disagreed by more than two code levels.

The study also compared the coding decisions made by four coders within the same coding agency. The results were only slightly better.

Bravo !!!! Sometimes a study needs to be done. If one could sue the federal government, physicians would have a great case here. Think of the mental anguish we have suffered. Wait! We would have to work with lawyers on a contingency basis. I prefer that we just have E&M abolished. I can forgive and forget. But Congress should restore penalities leveled against those charged with fraud on the basis of E&M problems.

For physicians, the coding morass is more than just an issue of frustration. Because E&M codes account for about $18 billion in Medicare payments each year, investigators from the Dept. of Health and Human Services' Office of the Inspector General have been focusing on improper use of E&M coding in their antifraud efforts.

The hospital's study seems to support physicians' claims that many cases of improper coding result from the confusion surrounding E&M codes, rather than an effort to defraud the government.

"The truth is that most of what the government calls fraud and abuse results from simple billing errors and the problems inherent in complying with Medicare's more than 100,000 pages of rules and supporting documents," said Michael Carius, MD, president of the American College of Emergency Physicians.

According to Brent Asplin, MD, an emergency physician from the Regions Hospital and HealthPartners Research Foundation in St. Paul, Minn., the study shows that E&M coding methods are not reliable enough to be the basis for antifraud efforts.

"This study is similar to the famous tax test that Money magazine conducted a couple of years ago," Dr. Asplin said. "Money sent a hypothetical family's tax return to 46 different tax preparers and got back 46 different answers. Dr. Jackson's team finds that the Medicare coding system is just as prone to inconsistency and disagreement, even when specialists are put to the task."

This study is VERY important. We need to have this problem fixed - and quickly. I am certain the AMA will work towards that end. I hope that all rational politicians (oops another oxymoron) will end this nightmare with swift legislation.

The Washington Post has this one right - Equity for Mental Illness

Very interesting story appears on the BBC site - Warning over killer throat disease. I have done sore throat research early in my career. This article describes a condition so unusual that I know little about it.

It follows a significant rise in the number of cases of Lemierre's disease this year.

The disease, which is most common in young adults, can cause serious illness and even death if left untreated.

With this disease patients can go downhill quite quickly

The disease is cause by a bacterium called Fusobacterium necrophorum that normally lives harmlessly in people's mouths.

However, for reasons unknown to scientists, it can start to attack the body of previously healthy people.

It mostly affects young people between the ages of 16 and 23 and is more common in men.

The disease is rare and affects just a handful of people each year. However, there have been 30 cases so far this year - as much as the total for all of last year.

...

"Most viral sore throats get better of their own accord in a few days but with this disease patients can go downhill quite quickly."

Lemierre's disease starts off as a very sore throat and leads to a fever, swollen glands and a general feeling of being unwell.

The question of which patients need antibiotics for their sore throats actually causes great controversy. Two somewhat conflicting guidelines have appeared in the adult literature over the past two years - Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background printed in the Annals of Internal Medicine a journal of the American College of Physicians (the main internal medicine society) and Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis printed in Clinical Infectious Disease a journal of the Infectious Disease Society of America. Briefly, the ACP guideline recommends treating patients on the basis of clinical symptoms, while the IDSA guidelines wants a positive 'rapid test" prior to providing antibiotics. The controversy is not surprising when one understands each groups advocacy position.

The internists have focused on patient relief. An excellent study for the BMJ - Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults showed that penicillin can give as much as 2 days relief from the symptoms of sore throat.

In constrast, the IDSA, while considering patient relief, has a much stronger bias towards decreasing unnecessary antibiotics usage. They want stronger proof than clinical symptoms prior to prescribing antibiotics. Given my background in this field, I do plan to write a longer analysis of this conflict and submit that for publication.

This controversy - Diagnosis of Strep Throat in Adults: Are Clinical Criteria Really Good Enough? - points out the problem of guidelines. Any group of experts will have biases influencing their guideline development. Thus, one cannot produce an unbiased guideline. Two respected groups developed guidelines on one small problem - and came to very different conclusions. I could make the strong case for either side. But what perspective should we take? I suspect that most adult generalists (internists and family physicians) will side with the ACP approach - as will I. As a side benefit, we would probably prevent the syndrome which started this rant.

Ten years ago I was sitting in my office seeing patients. The nurse asked me if I could squeeze in AA - he had just shown up at the front desk and wanted to see me. I agreed, and he and his wife came to the room.

AA was 15 months from what we thought was successful surgery for lung cancer. He had presented with an acute bronchitic attack and something made me get a chest X-ray. That X-ray showed an early lung cancer. I referred him to Thoracic Surgery. He was a good surgical candidate and we thought he was cured.

His thoracic surgeon saw him every 3 months, getting repeat X-rays. His most recent X-ray had shown recurrence. The surgeon told him that she could not operate on him again, and referred him to an oncologist. The oncologist give him a choice between chemotherapy and supportive care. The patient choose supportive care, and in the patient's opinion, the oncologist seemed to lose interest. He came to my office that day to tell me the story (no one had kept me informed).

He actually started with a most unusual request, 'Will you be my doctor?' The question astonished me. As I quickly told him, I am your doctor, and will remain your doctor.

AA had started seeing me about 5 years prior to that incident. He was a prominent person in town, now aged 77. He had had a good full life. We talked for some time at that first visit.

While I cannot remember the precise details, I do remember the gist of our planning. AA wanted dignity until the end. He wanted to remain lucid as long as possible. He did not want any heroic measures. At that visit, he cried and I consoled. We discussed advance directives and made plans. I scheduled him to return in 3 weeks.

Over the remaining 4 months of his life I probably saw him 6 times. We had long visits and just talked about 'stuff'. He was a most interesting man, and loved to tell his stories. His first project was to produce an autobiographical audio tape for friends and family. He achieved that within the first month.

His wife and daughter (from a previous wife) gave him outstanding support and strength. One incident sticks in my mind.

During this time I was being recruited by 2 medical schools. I finally decided to move to my current school that spring. I took a trip here one week for 2 days (making plans to start). The next day I was in my academic office handling the details of severing my relationship with my former institution. Given the whirlwind of my interviewing, visits, and pending move, I forgot my beeper at home. That afternoon I got a telephone call that AA was in the hospital.

I went to visit him to find out what was wrong. Apparently, he started feeling poorly, tried to call me, finding me out of town then called the surgeon. She admitted him and let her resident and intern care for him. He had a rapid heartbeat (due to a superventricular tachycardia), so the surgical housestaff called the electrophysiology service. They gave him some medication to slow his heart rate, and put a monitor in his room. The monitor beeped incessantly.

Now he was in a special section of the hospital known as the 'Pavilion'. He had two rooms - so the family had a sitting room. I go in and everyone is crying. The family explains that he is frustrated because he does not want a monitor or IV fluids. I go to see the patient.

He quickly explains his frustration. He tells me that he is ready to die, but he does not want to die with an IV or a monitor. He wants to die at home with his loved ones around him.

As I assess the situation, I note that while he might die that night, he might stabilize, regardless of our therapy. Fortunately, he had no pain or other discomfort.

I quickly took over the situation to the relief of the patient, family and nurses. I wrote orders discontinuing the IVs and monitors. I wrote a long note in the chart explaining what I had done, and making clear that I would accept the patient on my service if thoracic surgery desired such. It was 6 p.m

At 7:30 p.m. I was starting dinner, when I received a page to the hospital. Answering I found the surgical intern on the phone. He seemed frantic and nervous. His resident had apparently told him to call me. He said 'My resident said that if we can't do anything for the patient, we would have to transfer him to your service'. I was astonished because my note stated clearly that I would willingly accept that patient. But even more, I knew that I was doing much for the patient. I wanted to teach the intern and resident, but knew by the intern's tone that they were not ready for this important lesson. I told him that I was glad to take responsibility for the patient (my note had made that clear). I discharged AA the next morning to the relief of all.

AA lived another 2 months. He started to deteriorate soon thereafter. Fortunately excellent hospice care made his final days fit his dream. I remember the last time I saw him. I visited his house, and talked to his wife. He was already stuporous, but comfortable. I did not have anything medical to offer, yet my visit helped the family and helped me. He died 3 days after I moved.

Later that month I received a wonderful and cherished note from his daughter. She thanked me for the dignity with which his death occurred. She thanked me for caring about his humanity more than his disease.

That was 1993, and I knew little about palliative care. I am now exposed to excellent palliative care daily, as we have one of the superior programs in the country. In reflecting about AA, I probably could have made him even more comfortable if I had known more.

The Center to Advance Palliative Care (CAPC) is a resource to hospitals and other healthcare settings interested in developing palliative care programs. CAPC is a national initiative supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Mount Sinai School of Medicine. We are fortunate to have an active aggressive palliative care program at our VA hospital. My housestaff and I are exposed to these principles daily.

This brings me to the ethical dilemma that I suggest in the title of this rant. Given a patient with no reasonable chance for recovery, is paternalism acceptable? How do we provide humane compassionate care when we as physicians understand the risks and benefits of treatments in a more complete way than the patient does? A recent patient on my service may illustrate this point.

Mr. S. is a 74 year old gentleman with advanced dementia. He has contractures and does not communicate at all. He came from his nursing home because of a volvulus, which the GI fellow reduced in the ER. The nursing home had him scheduled for a PEG tube placement that week. For those who are not familar a PEG tube is a feeding tube that goes directly into the stomach through the abdominal wall. I have a visceral reaction to the general concept of PEG tubes, understanding that they are worthwhile in selected circumstance.

His 99 yo mother had verbally agreed to the PEG tube, because the nursing home had asked. We (my resident, interns and I) did not agree. We involved the palliative care physician and evaluated the patient carefully. He (with my resident) called the mother and had a long conversation about the patient. He directed her towards comfort and minimizing suffering. He acted paternalistically with these woman who clearly wanted direction. We discharged him to hospice care the next day without a feeding tube, either nasogastric or PEG. We expected him to die within the week.

Many situations call for some degree of paternalism. I would argue that palliation must combine patient autonomy with paternalism. We must understand the patient's goals and desires even if he (she) can no longer communicate them. We generally guide the patient's family towards comfort. In many ways, achieving comfort represents the ultimate medical achievement. We want our patients to die with the same dignity that they want. If that requires paternalism, then we should choose it.

Thank you AA, for you taught me much. I try to bring your lessons to every dying patient. You live in my memories.

In medicine, things are not always what they appear. Read this interesting story with an O'Henry ending - Seizures That Won't Stop, a 102° Fever, an Infection in the Blood

Plan to Raise Medicare Pay for Providers

Just weeks after rejecting proposals to help the elderly with prescription drug costs, the Senate is poised to increase Medicare payments to doctors, hospitals, nursing homes and health maintenance organizations.

Consumer advocates are furious at the prospect that Congress will address the needs of health care providers without doing anything on prescription drugs, and their anger is putting political pressure on Congress to try again to pass at least a modest drug bill this year.

This is a difficult issue. If one assumes a zero sum game, where should the money go? If we do not increase Medicare payments to physicians, more patients will not be able to find physicians. Physicians are closing their practices to Medicare in droves.

So what is more important, having a doctor or having a prescription drug benefit? I do not know the answer to that question. I am certain that physicians should not lose money seeing Medicare patients. How we address a prescription benefit remains a very expensive and challenging question.

Many lawmakers said that doctors had the strongest claim to new money because their Medicare payments were cut 5.4 percent in January, and they face similar cuts in each of the next two years. Significant numbers of doctors are refusing to take new Medicare patients, saying the government pays them too little to cover the costs of caring for the elderly.

"Unfortunately," said Representative Billy Tauzin, "the Senate has chosen to ignore this growing crisis." Mr. Tauzin, a Louisiana Republican, is chairman of the Committee on Energy and Commerce, which has authority over Medicare payments to doctors.

The House bill would increase Medicare payments to hospitals by $14 billion over 10 years. Hospital lobbyists are seeking twice that amount in the Senate, to help them cope with a shortage of nurses, rising numbers of uninsured and the new threat of bioterrorism.

I guess that I must go back to Congress watching.

Medpundit weighs in on the IOM report - An Hour a Day?!!!!. She finds the second day 'spin' debriefing from the Philadelphia paper. The spin:

Walk and take stairs whenever possible, advises Penny Kris-Etherton, a nutrition professor at Pennsylvania State University and a member of the committee that drafted the guide.

...

"It seems like a lot of time for very busy people, but remember, you have 16 hours every day to work with," said Kris-Etherton, who gets in her hour by walking for 15 minutes on a treadmill in the morning and again in the evening, and by walking and taking stairs during the day.

"We're not calling for an hour of formal exercise in the gym," she emphasized. "We're trying to encourage people to incorporate more physical activity in their daily lives so an hour doesn't seem so daunting."

I was taught early in life to say what I mean. Common parlance suggests that when recommends exercise, one means exercise above and beyond that achieved in daily activities. I believe that the report meant to sensationalize. However, if your recommendations seem unreasonable to even health conscious physicians, then you have missed your target. 'The road to hell is paved with good intentions.' I do not know if that fits here, but I did think it. The should more precisely say what they mean, and not sensationalize their reommendations.

I agree with more daily walking. I climb stairs all day and walk from place to place. This makes sense for me, but will it work for those who have less freedom in their work place. What rankles me is that the most people will only remember the headline and shrug off the report as unrealistic! They missed an opportunity. As Abba Eban once said about the Palestinians - 'they never miss an opportunity to miss an opportunity'. This frustrates me.

Thanks to the Bloviator for this link! Docs rally at Statehouse for malpractice cap

The Ohio State Medical Association, which supports the bill, is concerned that Ohio doctors will close their practices or leave unless the law is passed.

"Doctors' ability to provide care is contingent upon having the ability to acquire malpractice insurance," association lobbyist Tim Maglione said after the hearing.

He cited federal studies that found the median medical malpractice judgment increased 43 percent between 1999 and 2000.

From our redundancy department - the trial lawyers oppose the bill.

NY Times bashing has become great sport in the blogosphere. If one can bash them when wrong, then one must congratulate them when they are right. They have this one right. The Battle Over Drug Discounts

The Pharmaceutical Research and Manufacturers of America, a trade association, argues that the states have no right to press its members in this way after they have already negotiated prices with the federal government. Most of their arguments sound like procedural quibbles. In the private sector, health maintenance organizations and medical institutions have long used formularies, or preferred lists, to favor low-priced medicines and extract discounts. There is no good reason state Medicaid programs should not be allowed to do the same. If the Medicaid laws need to be modified to let that happen, then Congress should do so quickly.

The more difficult issue comes when states tell manufacturers they cannot be on a preferred list for Medicaid unless they offer discounts to non-Medicaid patients as well. Some states do this on behalf of the near-poor, but a few have pushed the idea further. Maine is demanding discounts for any resident who lacks insurance coverage for prescription drugs and wants to be part of the state program. The Maine case is headed for the Supreme Court, and the solicitor general's office has expressed doubts about its legality. Some patient groups fear that Medicaid beneficiaries will be harmed if manufacturers who would otherwise provide drugs for Medicaid drop out rather than grant discounts to the broader population.

I have noticed that I agree with the Democrats on this issue, and the Republicans on the trial lawyer issue. That probably makes me an independent - or I would claim a free and clear thinker.

A loyal reader sends this link - NEW FAT LAWSUIT AGAINST FAST-FOOD CHAINS: Attorney Files Overweight Children Case .

The attorney representing an overweight New Yorker in a lawsuit against four fast-food chains has filed a second class action case on behalf of overweight children.

Samuel Hirsch, the lawyer for Caesar Barber of New York, today said he has filed the second case because "we feel the advertising strategies [of quick-service chains] target children."

We could easily make a case for Sam as a public nuisance. He is trying to compare his campaign to the campaign against the tobacco companies. These suits should fail forever. These suits differ in many important ways.

Tobacco is addictive. One need not smoke to live. The tobacco industry used advertising and other manipulations to seduce non-smokers to smoke. Once they started they often became addicted - leading to huge profits for the industry. One cannot smoke 'intelligently'. Almost any smoking is hazardous to one's health.

Everyone must eat. The only choice is what to eat. No food is addictive. When pressed, anyone can remove a particular food from one's diet.

Since one must eat, the only argument is what constitutes healthy food. As readers of this blog know, that question remains debatable. Probably no single food is bad, what is bad is various combinations and amounts.

McDonalds and colleagues do not make you eat too much. They certainly do not encourage lack of exercise. Do we need a law to prevent these suits? What a waste of time and money!

Or for those who do not know the meaning - Happy New Year. Rosh Hashanna started at sundown. Here is wishing you and yours a healthy sweet New Year.

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Panel Urges Hour of Exercise a Day.

Americans need to exercise more — at least an hour a day, twice as much as previously recommended — to maintain their health and a normal body weight, according to new guidelines issued yesterday by the Institute of Medicine, the medical division of the National Academies.

In a thousand-page report, a team of 21 experts suggested for the first time a range of recommended amounts for what are called macronutrients — proteins, fats and carbohydrates — and also included advice on how much dietary fiber and exercise people should strive for to maintain good health. Previous reports over the last 60 years have dealt only with recommended levels of vitamins and minerals.

The panel's recommendations give wide leeway in choosing an acceptable diet. The report said that to meet daily needs for energy and nutrients while minimizing the risk of developing chronic ills like heart disease and diabetes, adults should get 45 percent to 65 percent of their daily calories from carbohydrates. It recommended a maximum of 25 percent of calories from added sugars, 20 percent to 35 percent of calories from fats, and 10 percent to 35 percent of calories from protein. In addition, the panel recommended that adult men 50 and under consume 38 grams of fiber a day and adult women 21 grams a day.

The new guidelines, called the Dietary Reference Intakes, are intended for use by professional nutritionists in private practice, hospitals and schools, as well as by individuals.

Do these recommendations sound difficult on exercise and loose on sugars? They do to me, and apparently they do to this expert.

Dr. Marion Nestle, chairwoman of the department of nutrition and food studies at New York University, called the exercise recommendation "amazing but impractical," given that 60 percent of the population is now totally sedentary.

"I hardly know anyone — and I know a lot of health-conscious people — who exercises an hour a day," Dr. Nestle said. "This creates a lot of tension between what's ideal and what's possible. We know half an hour a day confers substantial benefits. Wouldn't it have been better to say some exercise is better than none, and more is better than some?"

Dr. Nestle said she was also concerned about the panel's recommendation that as much as 25 percent of calories could come from added sugars, the caloric sweeteners added to manufactured foods and beverages like soda, candy, fruit drinks, cakes, cookies, ice cream and other sweets. The 25 percent limit would allow a person who consumes 2,000 calories a day to drink three and a third 12-ounce sodas each day, if soda was that person's only source of added sugars.

"This is a huge amount of added sugars in a country where soft drinks, a major source of sugars in the American diet, are increasingly a factor in the rise in overweight," Dr. Nestle said, adding that most earlier recommendations called for no more than 10 percent of calories from added sugars."

For those interested, the press release can be found here - Report Offers New Eating and Exercise Targets To Reduce Chronic Disease Risk and the entire report is available online - Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Protein and Amino Acids (Macronutrients) (2002).

Small Employers Severely Reduce Health Benefits. We see more patients with inadequate or no health insurance among workers. These patients fall through the cracks just as often as the truly indigent. The crisis is here, how will we address it?

Health Insurance Prognosis Is Poor: Survey of Employers Finds Premiums Rising, Coverage Shrinking

"We should expect to see sharply rising health care costs for the foreseeable future," Altman said. "Workers can expect to pay more and get less coverage."

The increases are attributed largely to more spending on prescription drugs and hospital care by an aging population. For the first time in four years, more workers experienced reduced benefits than increased benefits, the report said.

Altman said he was struck by the drop in coverage for retirees. Over the past two years, 9 percent of large employers -- those with 200 or more workers -- have eliminated retiree benefits for new hires or existing employees, the survey said.

What's more, 11 percent of large employers say they will likely eliminate retiree benefits for new or existing workers over the next two years.

"There will be less and less retiree coverage," Altman said. "If I were a baby boomer, I would be quite worried about that."

As we say in the South, push is coming to shove. Note that the increasing costs are hospitalizations and prescription drug costs. Physicians are not reaping in larger salaries.

This time physicians must invest in developing a new system. We cannot sit on the sidelines. Our patients and their care demands our activism.

While a single payor system intrigues many, the Canadian and British experiences do not seem that attractive. We need good economic minds to assist in our thinking. Somehow we need a system with little bureaucracy (a major problem in our system). Malpractice reform would help also.

I believe things will worsen before they improve. Democrats want to fix some problems (pharmaceutical prices), but not others (malpractice reform). The Republicans are probably opposite. No one seems to address bureuacracy or the costs of the various controlling legislations. Can physicians influence the debate? One can only hope.

A loyal reader writes

I too agree with you that it would be helpful to have more physicians in politics, both serving in a representative capacity and continuing the already strong advocacy groups.

Perhaps my gut instinct is naive, but I feel that both lawyers and physicians share a common goal of advocacy. Physicians advocate what is best for their patient as does a lawyer for his client. The difference is the system in that, by definition, our legal system is an adversarial one, thus pitting two or more sides against each other, whereas medicine is often one-sided (always doing what is in the best interests of the patient). Perhaps medicine is sometimes adversarial in trying to maneuver through the confines of the insurance system, when the doctor seeks what is best for the patient while the insurance company sees only the "bottom line" cost. Lawyers are not "indifferent to truth" -- truth is more of a subjective end that a system such as the scientific method does not provide an answer for in the same way our judicial system does. Because truth is subjective, there can be many versions of the "truth," thereby creating the adversarial system.

That said, I concur with your assessment that our political system needs more physicians to make legislative decisions. If more and more medical decisions are made by legislators and administrative agencies, many of whom lack any medical background (moreso with the legislators) then we are only cheating ourselves as a society if we do not make informed decisions, guided by the input and counsel of physicians throughout the process. I worry, though, that we would only have on or two physicians in the room for any given decision. Instantly I think of the Senate. While Bill Frist is a respectable individual with a distinguished medical career at Vanderbilt, it troubles me that the other 99 Senators (assuming Strom Thurmond is awake) look to Frist as the lone doctor in the Senate to set health policy for the country. We need more individuals such as Bill Frist to guarantee that one doctor does not guide an entire legislative body. I am not saying Frist is ever off base, but we should have more than one person in the Senate deciding health policy.

Well stated! I do not find being a physicians adversarial generally. Do we rant and rave when we think our patient is not receiving optimal care (because of the insurance company or the expense of a tradename drug)? Darn right we become adversarial.

I am not a good enough philosopher to debate the existential question - what is truth. Lawyers do seek truth in some situations. In other situations they seem to debate arcane rules (that their colleagues wrote as laws), looking for loopholes for their clients. We do need lawyers, and would love to have more ethical lawyers. We clearly agree that our legislative system needs other professionals to bring balance to law making.

New twist in Medicare debate. Remember Yogi! It ain't over 'till it's over.

Norah Vincent writes about how our language affects our eating habits. Is she right? I'll Have the Burger Deluxe, With a Side of Guilt

Doctors inject political influence into laws

America's doctors, stung by rapidly rising malpractice insurance costs, are seeking to become a more potent political force in state legislatures across the country.

From West Virginia to Nevada, doctors are picketing, protesting and running for political office in greater numbers than ever. Some are even withholding services. The most recent example is in Philadelphia, where more than 300 doctors shuttered offices one day last week to attend a conference on medical malpractice issues.

That's behavior rarely seen before by doctors. Some hope that by becoming politically active, they can influence issues beyond medical malpractice, such as Medicare's solvency and prescription-drug costs.

"It's completely weird for physicians to be doing this," says Weldon Havins, CEO and special counsel for the Clark County Medical Society in Las Vegas. "Doctors are competing with lawyers who have, from their first day of law school, been trained and are aware of the political process and the importance of law. Doctors have absolutely zero training with that."

What an interesting trend! In my own mind I have often contrasted medicine and law. If this trend continues, we will all have to consider this contrast. At the risk of becoming pedantic and one sided I will share my concept.

Medicine involves a search for truth. The scientific method provides the basis of our decision making - what is the true diagnosis and what therapies really help. While we do not always succeed either in caring for individual patients or in finding the right principles (examples here include estrogens to prevent heart disease, antiarrythmics after myocardial infarctions), we are willing to reexamine our principles and methods - and then change to a better method.

In contrast I see law as advocacy. Legal methods include sophistry. The desired result is to win - regardless of truth. Lawyers are indifferent to truth - and define truth as their ability to influence the jury. While this characterization includes some hyperbole, it is not that far from truth.

If my formulation makes sense, then logically we would like physicians as legislators. They should look at issues searching for the best and most logical course - weighing all the pluses and minuses. I fear that politics being what they are, they too will succumb to the desire for power and reelection. But just maybe, they would do a better job. You will allow this general internist his dream won't you.

Legal Pot For Canada?

A parliamentary committee called for legalizing marijuana use among adults, increasing pressure on the government to shift drug laws away from the zero-tolerance policy of the United States.

The report by the Senate Committee on Illegal Drugs recommended that Canada adopt a system that regulates marijuana the same way as alcohol, and expunge criminal records for marijuana possession.

"There is no good reason to subject the consumers of cannabis to the application of criminal law," said Sen. Pierre Nolin of the Progressive Conservative party. "In a free society as ours, it's up to the individual to decide whether to consume cannabis or not."

While not binding, the report will force Prime Minister Jean Chretien's Liberal Party to explain what provisions it accepts or rejects and why.

And if they do legalize marijuana, how does that effect the United States? Could our politicians have the courage to examine this issue logically and scientifically? We have preached for years about the evils of drugs - lumping all drugs into one large basket. What have we accomplished?

We made drug dealing very profitable. We made a large number of citizens (especially starting in mid-adolescence) law breakers. We have deverted many resources to the drug law enforcement. And we still have a huge illegal drug industry in this country. On this issue, I must take what I believe is a libertarian stand. I believe that Canada may take such a stand on marijuana. The implications on the US will be very interesting.

With a resounding 'Duh ' comes this report based on a NEJM article - Girls stop exercising in teen years.

The study did not ask the girls why they were not exercising.

“Is it they think it’s less cool? They’re more interested in shopping? Does it seem like more of a tomboy-is activity? These are all interesting questions worth pursuing,” said Eva Obarzanek, a research nutritionist at the National Heart, Lung and Blood Institute, which funded the study.

The girls’ decline in physical activity was affected by lower levels of parental education, heavier weight, smoking and pregnancy. Girls with better-educated parents may be better informed and more encouraged to exercise, the researchers suggested.

The investigators also indicate to the reporter that obesity doubled during the teen years. What I find most disturbing is the inverse association of parental education with exericise. We have a de facto social class system (as does every country with which I am aware). How can we provide equal opportunity when a fundamental factor (parental education) puts children at such a life disadvantage? Should we do more in the schools? Would it help?

Wow! I hit the big time! Sci-Tech Daily has a link to Medical Rants. I am honored and humbled. Sci-Tech Daily is a page I check daily. I'm not worthy, I'm not worthy.

Sunday morning I wrote furiously about generalists, time and money. I had thought about this issue for some time, and had difficult remaining dispassionate, yet complete. Chris Rangel's continuation of those thoughts adds greatly to my point, and gives me the gratification of knowing that I struck an important nerve in at least one other reader - How much would you pay for YOUR health? - Thanks Chris!!!!

The Patent Expiration Fun Continues - nice report by Derek Lowe of Lagniappe.

The Active Life

I have a confession to make: For too long, I believed you had to be a hardcore jock to be fit. But I've learned my lesson - solid research shows that moderate physical activity can reduce the risk of heart disease and early death.

This article has a great message. If you are a total couch potato, get off that couch. Start walking and moving. The activity will help you even if you do not lose weight !

Primary Care at the Crossroads: PCPs Overworked, Underpaid and Disaffected - This article should not surprise regular readers of Medical Rants.

Declining reimbursements; mountains of paperwork; cascading liability premiums; loss of autonomy and the widening gap between generalist and specialist income all contribute to the troubled state of today’s primary care physician (PCP).

Signs of PCP dissatisfaction are everywhere. A Kaiser Family Foundation survey found 58 percent of PCPs say their enthusiasm for practicing medicine has lessened over the last five years and 45 percent say they would not recommend the practice of medicine today to a young person! The Massachusetts Medical Society reports that almost 2 out of 3 PCPs are dissatisfied with their current practice environment.

Steven A. Schroeder, MD and President/CEO of the Robert Wood Johnson Foundation believes primary care is indeed at a “crossroads”. In a speech delivered at the annual meeting of American Medical Colleges, Dr. Schroeder noted, “the field has been beleaguered for decades, but it seems to be especially precarious today, ironically just when many expected primary care to experience a resurgence”.

Dr. Schroeder and many experts believe that managed care is one of the culprits, having created many unintended consequences when implemented in the early 1990s. By establishing PCPs as “gatekeepers” medical generalists lost favor, as many patients came, unfairly, to see them as “keepers” of a system that denies necessary care.

Managed care also created an over supply of primary care practitioners, promoting the growth of NPs and PAs as a means of enhancing physician efficiency. Positioning NPs and PAs as physician “equivalents” has diminished the perceived stature of medical generalists. The attendant rise of “hopitalists” has also created yet another specialty that directly challenges a defining benefit of medical generalists...continuity of care. Dr. Schroeder, commenting on continuity of care, observes that, “emergency rooms are increasingly becoming the off-hours source of continuity of care for many patients, and that is contributing to the devaluing of primary care”.

This article paints an accurate picture. I believe that we must reinvent generalism. I write often about this crisis. We must all work with our national societies to redefine the agenda. As I have stated and written, we must recapture the meaning of primary care. Managed care companies are the enemy of physicians and patients. We need a new paradigm.

We clearly have a health care crisis. Traditional politics are not solving the crisis. A weakened economy exacerbates the crisis. Read these reports - State budget cuts reduce flu vaccine stock for winter. This report comes from Boston

The Department of Public Health cut its purchase of flu vaccines by 19 percent this year - 132,000 doses - but the reduction is hardly catastrophic. With 560,000 doses expected to be on hand by November, state officials said yesterday they will not refuse anyone requesting vaccination at a state-run clinic.

The state public health department initially requested 700,000 doses costing $22 million based on vaccine use in 2001, a year when the threat of anthrax and its much-publicized flulike symptoms led to record immunization requests. The Legislature, contending this year with a slowing economy and dwindling tax revenue, budgeted $20 million for adult vaccines, $2 million less than the public health department's request.

Children's vaccine stocks, maintained separately from adult stocks, are unaffected by the funding reduction. But state supplies of vaccine for pneumococcal disease and hepatitis A and B will also be cut, though state officals yesterday did not release specifics.

State vaccine supplies account for about half of all flu immunizations in Massachusetts; the rest are administered by private health providers. State officals have traditionally targeted the elderly for vaccination. Those with kidney and blood diseases have also been the focus of past outreach efforts.

DeMaria said the state will urge community clinics to use their vaccine allotments on the elderly and the sick first.

California also has problems as noted in these two articles - A Messy Miracle for the ER

In a miracle of resuscitation, the state Legislature on Saturday approved a new way to pay for California's ailing emergency-care system. How it happened was messy, but the outcome is hard to fault.

Senate Bill 807, which now awaits Gov. Gray Davis' signature, would help pay for emergency care by adding a $200 surcharge to fines for reckless driving, speeding and drunk driving. It's almost a user fee, since so many of these folks end up needing trauma care.

The money raised--projected at $25 million--wouldn't cure the state's health-care woes; neither would it lift the pressure from Los Angeles County. But it would prop up the system facing the most immediate crisis, the one that all of us count on in the event of an accident injury or a heart attack.

If Hospitals Close, Research Flat-Lines : Funding crisis in Los Angeles County threatens clinical studies. I write about health care costs regularly. We need good medical input on understanding costs. Politicians do not have the answers. Talk to generalists, physicians who provide the important overall care of patients. They can help us understand how to address these issues.

Obesity burden 'outweighs smoking' -

More people are now falling ill through their couch potato lifestyle than through smoking, suggest Europe-wide figures.

The figures, compiled by the Swedish Institute for Public Health, and revealed at the European Society of Cardiology annual meeting in Berlin on Monday, were accompanied by a call for governments to encourage people to take more exercise.

The study suggests that smoking can be blamed for 9% of all chronic diseases in the EU.

As well as lung cancer, long-term smoking also causes or contributes to heart disease and other serious lung problems such as chronic obstructive pulmonary disease.

However, a combination of sedentary lifestyles and fat-laden diets mean that obesity is an increasing problem for Europe.

In addition, smoking rates have been falling generally in many European countries.

The research suggested that 9.7% of chronic disease could be blamed on lifestyle factors such as diet and exercise.

How should we interpret these data? First, smoking is clearly a greater individual risk factor than the 'couch potato' lifestyle. The day one stops smoking, the risk of cardiac events decreases (by eliminating carbon monoxide). Smoking probably puts others at some risk.

Fortunately, smoking addiction is decreasing in the US and Europe. Unfortunately, obesity, poor diet and lack of exercise are increasing. The prevlance of the latter has far surpassed the prevalence of smoking. Thus the 'couch potato' lifestyle has a similar total effect as smoking. I provide this article as 'food for thought'. (Yes that was a deliberate pun)

We know that BMI does not perfectly predict insulin resistance. Patients with BMI greater than 35 are labeled obese. New research suggests that we should disentangle obesity and insulin resistance in determining heart disease risk. Obesity Alone May Not Up Risk of Heart Disease - describes a new article in the cardiology literature.

More than 300 study volunteers free of diabetes and hypertension underwent a regular glucose challenge test to measure insulin sensitivity. The test measures the amount of glucose (sugar) remaining in the blood after a person consumes a sugary drink or is infused with a glucose solution.

The volunteers were categorized as normal weight (BMI less than 25), overweight (BMI between 25 and 30), or obese (BMI over 30). BMI or body mass index is a measure of a person's weight in relation to their height and is considered a more accurate predictor of heart disease and type 2 diabetes, than weight alone.

As expected, the likelihood of insulin resistance rose in tandem with BMI. Insulin resistance and BMI were also independently related to a person's age, blood pressure, cholesterol levels, and other heart disease risk factors.

But about 25% of those who were insulin-resistant were normal weight--the same proportion of all insulin resistant individuals that was obese. Some obese volunteers were not insulin-resistant. Overall, BMI alone contributed just 22% to the risk of insulin resistance, report researchers.

"Obesity does not equal insulin resistance," Reaven told Reuters Health. The researchers estimate that 50% of the variation in insulin resistance is due to genetic factors, 22% to BMI and the remainder due to a sedentary lifestyle.

We also know that exercise benefits all people, regardless of BMI. This article does not address the effect of exercise on insulin resistance. This article does not give obesity a free pass. Note that the probability of insulin resistance increases as weight increases. I suspect that insulin resistance has both genetic and environmental components. One can control the environment with exercise and a healthier diet.

My hopes realized, Medpundit weighed in on the recent mammography guidelines - read what she has to say - Mammography Debate Continues

I have written recently on CRP (C-reactive protein). CRP increases suggest widespread inflammation. These increases correlate with cardiac risk. Patients with elevated CRP are more likely to have coronary events. A new study supports exercise - showing that exercise lowers CRP levels - Heart-Stopping News on Exercise: It Reduces Inflammation, Too

Apparently when one raises the issue of diet, especially the Atkins diet, one gets deluged with letters. The Washington Post received this stack - Fat in the Fire . These letters are passionate, but not surprising. Anyone who has been reading Jane Galt's 'Live from the WTC' over the last week understands the religious fervor that Atkins engenders. I only hope we get the right studies down to settle the controversial points. We should all deplore unrealistic fervor without supporting data. Similarly, we should deplore denouncing this demonstrably effective diet on a theoretic basis alone. The great thing about theories is that they should provide a framework for testing. Theories are not laws. Many are wrong, even when 'conventional wisdom' supports them. The good scientist asks questions, even when the questions are not popular.

Jane Brody brings us 2 great resources today. She has reviewed the current state of our knowledge on estrogen - Sorting Through the Confusion Over Estrogen. This article contains a nice summary of the risks and benefits.

The benefits of temporary use of estrogen to weather disruptive menopausal symptoms have not been challenged. Nor is there concern about vaginal applications of estrogen to counter the atrophy that can destroy the joy of lovemaking.

Rather, the focus is on how long a woman can safely stay on hormone replacement that is taken orally or by skin patch and what effects, good or bad, the long-term therapy may have on her health.

This summarizes the appropriate angst on estrogen use.

But the most certain benefits of estrogen replacement involve relief of menopausal symptoms, especially hot flashes and night sweats, as well as vaginal and mucous membrane dryness. Estrogen also helps to preserve a more youthful distribution of body fat, keeping more in women's hips and thighs than around their waists. By preserving skin moisture, estrogen can also delay the appearance of wrinkles.

"Quality of life is very, very important," said Dr. Schiff of Massachusetts General. "From a heart and breast cancer point of view, the drug should be outlawed. But for hot flashes, there's nothing better." But for vaginal dryness, which can radically alter a woman's ability to enjoy sex, and for recurrent urinary tract infections, vaginal application of estrogen works well without incurring the risks associated with swallowing a pill every day.

Some women choose to stay on hormone replacement because they say it makes them feel better. But, Dr. Ettinger said: "Clinical trials are not supporting this. I think it's a strong placebo effect. When we switched women to half the estrogen dose and progestin once every six months, overall they said they felt better."

Thus each woman becomes a case study in medical decision making. I would frame the question this way - how much risk are you willing to accept to improve your quality of life. That is actually the question we could ask ourselves every time we get into the car, or a plane, or an elevator. Going outside we could get bitten by a mosquito or a tick carrying some known or unknown disease. Going to a restaurant gives us a chance of food poisoning or hepatitis A. We take risks constantly. We, physicians, must help women understand enough to balance the risk of estrogens with the benefits, especially in the perimenopausal period.

Many women will ask about alternative treatments for menopausal symptoms and risks (osteoporosis and heart disease). Fortunately, Jane Brody comes to the rescue again - The Search for Alternatives to Hormone Replacement Therapy. This article nicely summarizes treatment for the various menopausal symptoms and risk.

I found this letter to the editor in the Washington Times this morning. The entire letter is so important that I have copied it to the blog.

A chill pill for drug industry advocates

Nonsense. That is the best description of the opinions expressed by Peter Ferrara in "Poor prescription for health prospects" (Commentary, Thursday).

He states that members of Business for Affordable Medicines (BAM), working to close loopholes in the federal law that governs pharmaceutical competition, are "charlatans" seeking to "posture themselves on a high moral pedestal as champions of the poor, the sick, and the needy ."

The 1984 Hatch-Waxman Act was passed to protect patented drugs from competition by lower cost generic alternatives and to ensure robust generic competition as soon as possible after the patents expire. The result was a careful balance that ensured brand drug companies would invest in new drug research and that consumers could eventually get access to new cures at lower prices. Today, the brand drug industry has perfected a scheme to prevent generic competition well after the patents on their drugs expire.

Mr. Ferrara states that our advocacy of legislation to restore the balance intended by the Hatch-Waxman Act constitutes an "assault" on intellectual property and the patent system. He also claims drug companies will simply stop investing in research if their ability to market drugs without competition is affected in any way.

In fact, the Senate-passed bill does not change patent protections at all. Drug patents will still remain in effect for 20 years under the bill, an element demanded by our coalition members such as Kodak and Motorola, who are among the nation's largest patent holders. No BAM member will support any effort to undermine strong patent protections.

In addition, it is competition — not the lack of it — that drives pharmaceutical innovation. Drug industry spending for research has increased dramatically since 1984 as a result of, not despite, increasing generic competition.

Mr. Ferrara freely uses drug industry propaganda to conclude that "cures will dry up" if our efforts to bring free-market principles back into the equation are successful. He claims the average new drug costs $800 million to produce, without pointing out that only the drug industry uses this figure with a straight face. The data to support it is based entirely on internal surveys that have never been shared with outside auditors. He also fails to point out that, despite this, the brand pharmaceutical industry is more profitable than any other industry in the world, according to Forbes magazine.

The Federal Trade Commission reported last month that the industry has perfected schemes to "game" the system, and encouraged Congress to act now. The Congressional Budget Office has determined that bills to close loopholes in the Hatch-Waxman Act will save purchasers — including taxpayers — $6 billion annually.

Mr. Ferrara also implies that increased use of generic drugs "are a threat to the public health." He fails to assure the public that the FDA requires all generics to be bioequivalent to the brands they replace and to provide the same levels of safety and efficacy.

By passing Hatch-Waxman reform legislation, Congress has an opportunity to provide significant prescription drug cost relief to voters this year — and without costing taxpayers a dime. Despite drug industry claims, restoring competition to the pharmaceutical industry is the best prescription for the health of Americans and the industry.

WILLIAM JANKLOW
Governor
South Dakota
Pierre, S.D.

This well written letter defines the battle. With some researching, I found BAM's home page - Business for Affordable Medicine includes the nation's leading employers, organized labor, and governors. BAM was established to improve employee access to affordable health care through reform of the federal Hatch-Waxman Act.

The herbal supplement industry uses the same strategies as the pharmaceutical industry - no surprise. A Tug of War in a Larger Battle: Ephedra is now under intense scrutiny. Its fate could affect other supplements.

Wes Siegner is trying to save ephedra, the herbal stimulant that is under attack from a chorus of critics who say it is dangerous to your health. Even opponents of the lobbyist marvel at his victories so far, but it is looking more and more as if he is fighting a losing battle.

Siegner's task grew more difficult last month with news of a federal investigation of Metabolife International, a leading seller of ephedra in the United States. The fate of Metabolife, and of ephedra generally, is likely to influence the broader debate over the effectiveness and safety of herbs, sports drinks, diet pills and hundreds of other products for which Americans spend about $4.2 billion annually.

What tactics does he use? I find this difficult to type. He (representing an industry that eschews effectiveness data) argues that the data on harm are not conclusive. This arguement must involve obfuscation.

Siegner, a lanky man with a plaintive face, looks more like the high school biology teacher he once was than an Ivy League-educated lobbyist whose role is to rebut the arguments of scientists and politicians alike. Although he says he has no need to take ephedra, he would do so "in a heartbeat." In conversation, the 50-year-old Buffalo-born lawyer never strays far from his essential--and, clearly, well-practiced--message.

"Adverse events don't prove causality," he says. "These are a random set of events that happened to people who happened to be taking ephedra."

When millions of people use a product--any product--the law of averages dictates that a certain percentage of them will have heart attacks, strokes and seizures, which may or may not be linked to use of the product. Only a rigorous scientific study, say experts, in which one group is taking the supplement and another is using a placebo or dummy pill, can prove a direct connection. Otherwise the evidence is circumstantial.

...

In 1997, when the FDA sought to limit dosages of ephedra and require warning labels on products, Siegner helped persuade Congress to order a General Accounting Office audit. The GAO concluded that the FDA's proposed rules were based on only 13 cases of adverse events, and that the data in those reports were too sketchy to blame them on ephedra, scuttling any regulatory action.

Since passage of the Dietary Supplement Health Education Act in 1994, supplement makers have not had to prove that their products--herbal or otherwise--are safe and effective before they put them on the market. The law, in effect, mandates that the FDA assume that supplements are harmless until proven otherwise, according to Christine L. Taylor, director of the FDA's Office of Nutritional Products, Labeling and Dietary Supplements in Rockville, Md. To remove a supplement from the market, the agency must demonstrate that it is dangerous.

Why do we allow politicians to make health decisions? From a patient advocacy perspective (the only perspective I understand) I find this situation deplorable.

I do work hard. I try to plan free time into each week, and other than making rounds on selected Saturdays and Sundays (generally taking 2 - 3 hours), I almost never work on weekends. Many think we Americans work too hard. Maybe the economic downturn will have some benefits - Why Americans Should Rest

The NY Times features an article on the political implications of drug costs for the elderly - In an Election Year, These Protesters Have Power. In many ways this will probably become a major 'single issue'.

The Senate deadlock resulted from divisions over costs and levels of coverage, as well as whether such a program should be run by Medicare or the private sector. A poll of 1,071 adults 45 and over, conducted by AARP from July 31 to Aug. 4, immediately after the Senate deadlock, found considerable concern about the issue. More than 60 percent of those surveyed said that prescription drug benefits were a "very important" issue and that they were "angry" or "very angry" that the two parties could not reach an accord.

The same percentage said they were more likely to vote for their senator if he or she supported a prescription drug plan; more than 25 percent said they would vote against their senator if he or she allowed partisan differences to thwart the legislation.

Advocacy groups are marshalling energy over this issue. They are surveying voters and trying to crystallize a position. Financial realities do not matter to those groups, they want their program!

For Mr. Hickey and the groups with which he is aligned, a good bill would set up a price-controlled prescription drug program run by Medicare that covers all drugs for all older Americans and is not "means tested," or linked to income. That is pretty much what most Democrats want. The problem is that it could cost $800 billion or more over 10 years.

Drug companies object to price controls, and most Republicans and some conservative Democrats want a program run by private insurance companies and with limited coverage. That position is best reflected in a Republican bill passed by the House. In that version, there would be coverage for part of drug costs up to $2,000 a year, but then people would be on their own until costs reached $3,700 — a gap that critics call the hole in the doughnut.

The wild card in all this is rising drug costs. Families USA, a consumer advocacy group for health care issues, says the prices of the 50 most prescribed drugs for older adults rose, on average, by nearly three times the rate of inflation last year. The group criticizes big drug makers, saying they pay high executive salaries and spend about twice as much on marketing, advertising and administration as on research and development of drugs.

Jeff Blum, executive director of US Action, an advocacy group, argues that the public is far ahead of elected officials in linking access to drugs with cost control. "People know if there is not some serious controlling of drug prices, they're not going to get the benefit of a prescription drug program," he said.

Of course many would prefer avoiding means testing. The cost of a 'free' program would be very difficult to afford. The pharmaceutical companies will probably lost a battle here on price controls. I wonder if a true compromise will satisfy the activists?

Er, What Were We Saying?

Of course, in place of the $16-billion supplement industry, we could just eat good foods. Who needs carrot pills if you're munching carrots? But eating properly is too simple. We're too rushed to chew. And after all the supplements, we don't have room left for food anyway.

How long should the average generalist patient visit last? While this certainly varies with the visit reason, we all understand that the visit should last long enough. Most adults require appropriate time to do a variety of tasks. I have read, but cannot find the reference, that the average visit length with an internist is currently around 21-22 minutes. As we ask our generalists to do more each visit, and hold them responsible, can patients possibly receive adequate care?

Imagine a 50 year old woman with Type II diabetes, hypertension, obesity (BMI of 31), and depression. She smokes 1 pack per day for the past 30 years. She says she cannot exercise because of knee pain. We can imagine the agendas at the visit.

First, we must address her diabetes. We review her medications. We then go through the FLECKS (my mneumonic for diabetes care). Check her feet for lesions, and for early peripheral neuropathy. Review her lipid profile (remember to treat hyperlipidemia aggressively in type II diabetes. Consider her eyes by reviewing her record to see if she has visited the opthalmologist. If we have no record then ask her who she saw - and request their consultation report. Ask her about her blood sugar control, and review her HgbA1c value. Again review her labs for evidence of early kidney disease, or check to see how much proteinuria she has on treatment - considering whether to increase her ACE inhibitor or ARB (or add one). Review her shot history - is she uptodate on her immunizations (especially pneumovax and influenza vaccine). Ask her an open ended question about diabetes complications and medication adherence. That handles her diabetes.

We then review her hypertension history, her medications, her blood pressures (especially if she checks them at home or at the fire station or at the pharmacist. Ask her about medication side effects again. Reassess her regimen and adjust as is appropriate.

Review her depression, evaluate any medications for side effects. Ask about sleep, crying, her social situation. Reassess that treatment and try to understand her satisfaction and needs with the management of this problem.

She is 50 so we need to consider prevention. Have we screened her for colon cancer? If not, we take time to discuss her options (this is not usually a quick discussion). We review her breast cancer screening and gynecologic screening history. At 50 we start to check on symptoms of impending menopause.

Now we get to the cigarette smoking. We have counseled her in the past, but we must try again. We try logic, we try emotional appeals, we try anything that we can imagine.

We discuss exercise and diet. She states that she cannot exercise because her knees hurt. This new complaint takes several minutes to assess. While one's initial thought is osteoarthritis secondary to a BMI of 31, one must be thorough - occasionally it is something else.

We finish with an open ended discussion allowing her agenda to come forth. Anything could happen at the end of the visit. We sometimes joke in teaching clinic that we hate hearing (at the end of the visit) the phrase, 'Doc, by the way'. Often that phrase does not occur until you are getting ready to leave the office.

The direct patient encounter has finished (probably 20-25 minutes if one is very efficient), but the true visit time continues. If any prescriptions have expired, or we changed medications we write new prescriptions. We order appropriate laboratory tests, and determine when to see that patient back. One must then dictate the visit. This will probably take around 5 minutes - documentation is important for the next visit, but we must dictate even more to satisfy the bureaucrats and the lawyers. Our notes are longer and include redundant information than is necessary. Nonetheless, in 2002 we must dictate a fairly complete note.

So we can assume 20 minutes with the patient (and that was very efficient), and 5 minutes after the visit dictating. But time continues. The next day or so, our laboratory data returns. We must review the results in the context of the patient. We might decide to alter her medication regimen based on her lipid profile, or change her diabetes medicines because her HgbA1c has increased. Or we find increased proteinuria and consider that regimen. Often we need to talk to the patient on the phone (another 2-3 minutes). I will assume 2 minutes on average for laboratory and test review.

If we dictate our notes, they come back soon, and we need to proof the dictation and sign it (hopefully just 1 minute). Between visits, the patient likely will call the office with an issue (add another minute to answer the question). Have you kept track? I would estimate that the true time of the visit is 30 minutes.

How many hours should a generalist work each day? How many days a week? Should physicians also have a life?

We will assume that one can see 90 such patients each week (hoping for few 'no shows'). If my time assumptions hold, that represents a 45 hour week in the office (with extra time for 'keeping up'). If one restricts the practice to outpatient medicine, we must add time for telephone calls with specialists, hospitalists, emergency rooms and pharmacies. Give me another 5 hours.

What is a fair salary for that physicians? I would argue that $150,000 seems reasonable (remember 4 years of college, 4 years of medical school and 3 years of residency - leaving > $100,000 debt). The physician first generates income at age 30 (if he or she goes straight through schooling and residency). Assume a 50 week year (2 weeks for much need vacation), that comes to $3,000 per week. Divide by 90 patients each week and you need $33 per patient visit after overhead (rent, supplies, nurse salaries, clerical salaries, and malpractice insurance). Overhead generally runs around 50-60% for such a practice. Assume 50% overhead, then the physician would need to charge and receive $66 per patient visit. If you assume that $100,000 is a large enough income, then we could lower our estimates to $45 per visit (assuming we could really decrease overhead costs - a very debatable point).

Many readers are now thinking that I am whining about physician income (damn rich doctors). The problem is that the generalist should be the key to one's ongoing best health. Only the generalist will consider the array of issues that the patient has. Every specialist makes more than the generalist. With current reimbursement, the generalist has difficulty making the $100,000. Medical students and residents know this - and they choose more lucrative fields in medicine. Specialization follow money.

If we assume the $100,000 income (and 2500 hours per year), we get $40 per hour for a highly trained physician to attend to your health. You pay more for car repair, or a plummer, or an electrician. Our health care system has undervalued your generalist. We have a decreasing number of physicians practicing general medicine (either family medicine or general internal medicine). Health care costs will increase because prevention will decrease. Concientious medical care requires time. In our current system, time is not on your side.