January 31, 2003
A reader has asked me to comment. I suspect that I will create some controversy here. First, the news report - Professor's refusal to recommend creationist students draws complaint, investigation
So what does the professor say about this.
Dini has a web page. Letters of Recommendation.
Eugene Volokh has addressed this issue recently - PROFESSOR REFUSES TO WRITE LETTERS OF RECOMMENDATIONS FOR CREATIONISTS. He (Volokh) presents the pros and cons of this argument, but does not stick his neck out (as I am about to do). The following argument supports the professor.
I recently listened to an excellent college level course title - Biological Anthropology: An Evolutionary Perspective. This course comes from the Teaching Company (which sells college level courses on tape). This particular course I found fascinating. The lecturer focused on evolution. She did a wonderful job of marshalling the evidence and debunking the creationist view.
I do believe that being a scientist involves an attitude. That attitude drives one to seek truth, even when that truth does not fit ones preconceived notions. I do not believe it simplistic to assert that once one denies one scientific truth, he (she) would seem susceptible to denying other truths.
Medical care should not depend on whim or belief, but rather data. We strive to find the best data and design diagnosis and treatment based on those data. Dr. Dini asserts:
He is correct and brave. He will receive ridicule, and has a law suit pending. I hope he wins.Posted by at 05:29 AM | Comments (8) | TrackBack (0)
The cost of extra weight
Companies fight employee fat: Obese workers have insurance costs up to $1,500 higher. Duh! Overweight patients and especially obese patients have greater health care costs. And they needed a study.
So I have ranted often, why should I subsidize the overweight and obese? Why should I not receive a break on my insurance costs for living a healthy lifestyle?
Some companies are starting to consider programs to encourage exercise and weight loss. Given the impact on health insurance costs, I would bet that developing such programs should save money! Why not have more company gyms - and even schedule exercise as part of the work day? While this might sound radical, someone should try this. I would bet that one could save on health care costs, without impairing productivity.Posted by at 05:06 AM | Comments (1) | TrackBack (0)
To think better - exercise
I must link to articles on the benefits of exercise. Jogging the Mind: New Evidence Proves Exercise Keeps the Mind Sharp
I find this exciting as I work my way into the studied age group. I proselytize endlessly about exercise - both cardiovascular and weight training. This gives me more ammunition.
Posted by at 04:56 AM | Comments (0) | TrackBack (0)
January 30, 2003
Intensive treatment for diabetes to prevent cardiovascular disease
If you do not subscribe to the NEJM, go to theheart.org (free registration) and read their excellent summary of this most important article. If you do subscribe, here is the online link - Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes and the accompanying editorial - Reducing Cardiovascular Risk in Type 2 Diabetes. Interestingly, none of the major news outlets is covering this article. I believe it a most important study with MAJOR implications.
Thus, we have a study of very aggressive, time consuming intensive care compared with usual care. They ask the important question - how much benefit do we get from intensive attention to risk reduction?
So what were the goals of therapy? How did they differ?
We do not know which interventions made the difference. We do know that intervening makes a difference.
For those readers who dislike ratios, let me provide some raw numbers. The study lasted 8 years; each group had 80 patients. The usual therapy group had 85 CV episodes in 35 patients; the intensive group had 33 episodes in 19 patients. For diabetic nephropathy, the numbers were 31 versus 16. 3 patients in the usual care group developed end stage renal disease as opposed to none in the intensive group. Retinopathy shows similar numbers - 51 (7 blind in one eye) versus 38 (1 blind in one eye). Autonomic neuropathy progression - 43 vs. 24. Peripheral neuropathy progression did not show a difference - 37 vs. 40. These comparisons are dramatic. For example, the number needed to treat to prevent CV disease is only 5!
Quoting from the editorial
The editorial rightly reveals that this approach requires time for longer and more frequent visits. It requires aggressive behavioral interventions - the kind that I champion regularly. Newly diagnosed diabetic patients should pay attention to diet, exercise and stop smoking. We need insurers to come through here. They must fund the preventive care of these patients. It is the right thing to do, and it probably will save health care dollars. Please get these articles and read them. They are VERY IMPORTANT!!!!Posted by at 08:45 AM | Comments (2) | TrackBack (0)
Global AIDS initiative
Bush AIDS Plan Surprises Many, but Advisers Call It Long Planned. This was not a rabbit pulled out of a hat. Bush's announcement of a $15 billion committment to global AIDS treatment and prevention came after extensive planning.
I like it when good politics combines with good policy. This policy initiative has great implications for global health. I hope the Congress will develop bipartisan support!Posted by at 08:19 AM | Comments (0) | TrackBack (0)
January 29, 2003
ACE-I induced angioedema and ARBs
This link will only work for subscribers, but I provide it for them. Are Patients Who Develop Angioedema With ACE Inhibition at Risk of the Same Problem With AT1 Receptor Blockers? This article addresses a very important question - are ARBs safe in patients who develop angioedema from ACE inhibitors? Angioedema is a rare but life threatening complication of ACE inhibitors. Patients who have had angioedema on ACE inhibitors have an absolute contraindication to this drug class.
This leaves the physician with a dilemma, since ACE-I have so many indications (CHF, nephropathy, coronary artery disease). ARBs seem to work in a similar positive fashion. We worry whether angioedema would occur with ARBs (in those patients who have had angioedema on an ACE-I).
The authors report on 10 patients they placed on ARBs after ACE-I angioedema.
This does not mean that angioedema will never occur. However, I favor trying an ARB in this circumstance because I believe the potential benefit clearly outweighs the risk. I might not use an ARB in uncomplicated hypertension, but I clearly would try that class in CHF or nephropathy.Posted by at 09:01 AM | Comments (2) | TrackBack (0)
Bush was on target last night in his discussion of health care. Bush Seeks Medicare, Malpractice Reforms
Certainly the Democrats will oppose this. What will AARP say? What is fair?
Amen!Posted by at 08:37 AM | Comments (0) | TrackBack (0)
Improving phys ed
Getting Physical. Now that is more like it!
All school systems should adopt this philosophy. Educating students about physical activity represents an investment in future health. I hope this trend spreads rapidly throughout the country.Posted by at 08:33 AM | Comments (0) | TrackBack (0)
I hope European countries will step up and match this investment. Yes, this is an investment in the future of these countries. This is an investment in humanity. I hope politics do not interfere in any way.Posted by at 08:29 AM | Comments (0) | TrackBack (0)
Our health care system
Just read this article. Print it out, and pass it on. No quotes, you need to read the entire article. Please. An ailing systemPosted by at 06:43 AM | Comments (0) | TrackBack (0)
Ignore the headline, read the article - New Test Urged for Heart Disease Screening Could Help Doctors Target Those Needing Treatment, Panel Says The italicized part is more accurate. I have read the recommendations the related articles which appear in yesterday's Circulation (I will link to those later in this rant). First, I will quote from the Post -
So what are these level B and level C. Level A is the most desirable. To receive a level A a test or intervention needs multiple randomized controlled trials. Level B generally comes from epidemiologic data. Level C comes from expert opinion. My interpretation of this summary paragraph suggests that CRP has modest attractiveness as a screening test in patients with a high probability of coronary artery disease. Thus, I would consider it in patients with a strong family history, those with 'the metabolic syndrome', and other high risk patients. The next paragraph addresses secondary prevention, for which I feel much more positive.
There remains healthy disagreement among the leaders in this field. The panel addresses those disagreements and calls for the necessary studies.
The same issue of Circulation has a three part Mini-Review on CRP. These free articles add flavor to my understanding of the issues being discussed. Clinical Application of C-Reactive Protein for Cardiovascular Disease Detection and Prevention . This article reviews the literature and generally recommends using CRP to help decide whether or not to treat patients with hyperlipidemia.
One important feature here involves interpreting high CRP levels as a clue to possible pre-diabetes. Over the next decade, I expect an increase in efforts to find and treat pre-diabetes. When we find it, we do have interventions which can (in some patients) prevent diabetes). The next article in the Mini Review is titled - Coming of Age of C-Reactive Protein . Their summary
Thus, they argue that CRP not only is a marker, but truly a risk factor. We still have much to learn about the inflammatory process and coronary artery disease. CRP gives us a great start.
The final article in the Mini Review summarizes. The Fire That Burns Within
This article lays out the challenge. This decade will see answers to these important questions. As our understanding of coronary artery disease evolves, medical science will provide greater opportunities to help prevent or at least delay complications.Posted by at 06:40 AM | Comments (1) | TrackBack (0)
January 28, 2003
The insurers on malpractice
A reader sent me this link. The graph attempts to compare two key trends underlying the medical malpractice controversy: premiums per doctor (DPW/MD) and paid losses per doctor (DLP/MD). Both of these variables are expressed in constant medical dollars.
Did Investments Affect Medical Malpractice Premiums? Some samples of this detailed analysis.
Note that they are using statistical analysis rather than hyperbole!
In case that is not clear,here is the graph.
But the Democrats and the trial lawyers will continue their sophistry. And, dare I sound redundant, patient care suffers.
Now Florida and Mississippi
Doctors in Fla., Miss. Protest Insurance Rates I will just direct you to the article. I have one thought, partially taken from a comment left yesterday. Thinking over night, I hope that I make this clear.
If a business has increased overhead, it passes those costs over to consumers. They raise prices (within the context of supply and demand). Physicians generally work under price fixing (by the insurers, especially the government - Medicare and Medicaid). Thus, when overhead increases and gross income does not, net income decreases. So if I were working in a state with increased malpractice rates, my take home income would decrease, regardless of my own practice. I see no logic here, nor do my colleagues.Posted by at 05:26 AM | Comments (0) | TrackBack (0)
Sorting out the pyramids
I have written recently about Willett's alternate pyramid. Sally Squires (Washington Post) has done a very nice job comparing the two pyramids. Take the Pyramid, Please
As you read the article and the source (from the Harvard School of Public Health) you will quickly note more agreement than disagreement. I like the Willett formulation better. Here is their capsulized recommendations:
So I need to eat more nuts (which I like) and continue my quest at eating more fruits and vegatables. I have the exercise thing down. Maybe I should start a multivitamin. What about you? What should you be doing?Posted by at 05:20 AM | Comments (0) | TrackBack (0)
January 27, 2003
Another view of malpractice
A loyal reader sends this link - Malpractice crisis: It doesn't take a brain surgeon
Perhaps it does take a brain surgeon. With all due respect to the author, I do believe she tends to oversimplify the issue. It is easy enough to ask doctors to police themselves, but when one tries, lawyers threaten the boards, or the hospitals.
The author wants a graduated system for 'pain and suffering'. Again, who decides how quality of life is affected. How can one properly quantitate someoneelse's quality of life?
No, Virginia, there is no Santa Claus. We will find no easy solutions. But I still believe that we must be careful not to jeopardize patient care and access in the name of 'justice'. Afterall, the physician does not pay, the system pays. Physicians both guilty and innocent pay. And therefore patients pay.Posted by at 01:32 PM | Comments (3) | TrackBack (0)
Spironalactone and CHF
The RALES study showed a survival benefit from low dose spironalactone in CHF patients. The entry criteria for RALES included presenting with Class IV CHF sometime in the past 6 months. Many of us have observed that physicians are using spironalactone more aggressively than the study supported. A recent article in the Journal of the American College of Cardiology looked at spironalactone use at one VA hospital.
Why were there so many adverse effects? I suspect several problems - higher dosing, less frequent monitoring, and incomplete consideration of concomitant medications.
This study raises an important issue. We bemoan primary care physicians' delay in using those medications shown to benefit patients. (Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study ) We rarely focus on how one safely adopts these new treatment modalities.
Medicine, especially the care of chronic diseases), becomes more complex monthly. Since we can do more, we need time to learn new material, incorporate the knowledge rationally into our practices, and assess our outcomes. The current health care reimbursement system does not acknowledge the time investment.
I believe that these studies point to a fundamental problem in primary care. Payors assume perfect knowledge, and they assume that the time in the office represents the totality of physician work time. The office visit requires time to write notes, review labs, and read! Primary care practice requires time and resources to maintain a high level of knowledge. We must have radical reform to achieve the health care our patients deserve!Posted by at 08:48 AM | Comments (0) | TrackBack (0)
Bush and malpractice
As I write often, the unintended consequence of increased malpractice payouts becomes decreased access to health care. Obviously, trial lawyers worry about their client. One would think the Democratic party would understand the link between malpractice payouts and access. But, the trial lawyers give a lot of money to the Democrats, so they become apologists and try to blame everyone else.
So now we must wait for a political solution. And patients suffer with decreased access. I just do not understand this brand of politics.Posted by at 08:16 AM | Comments (1) | TrackBack (0)
January 26, 2003
Not so fast
Health care professionals are making their opinion of smallpox vaccination clear. Slim turnout for first smallpox shots
I do not know many physicians who plan to take the vaccine. Concerns include side effects, infecting family members, and infecting immunocompromised patients. Given the imprecision of the risk of smallpox, I am unwilling to take the vaccine.Posted by at 08:41 AM | Comments (0) | TrackBack (0)
Understanding exercise benefits
I know, I know - I am obsessed. Readers expect almost daily ranting on exercise. This article satisfies my addiction for today. Study: Exercise like a drug in heart disease.
I find this line of research very interesting. Once we understand more about this effect, we can study the differences in those patients who do exercise yet still develop heart disease. Do they have a different inflammatory response?Posted by at 07:51 AM | Comments (1) | TrackBack (0)
Wrap-up on the McDonald's suit
As I wrote earlier this week, the judge threw out the McDonald's obesity lawsuit. Your Honor, We Call Our Next Witness: McFrankenstein. For those who are interested in the details of the opinion, this article provides sufficient depth. As I noted previously, the judge did leave the door partially open.Posted by at 07:17 AM | Comments (4) | TrackBack (0)
January 25, 2003
I was busy all day at a retreat. Browsing the web just now I found this and smiled - Senate Bill Would Stop Doctor Pay Cuts
Hopefully, more on this tomorrow!Posted by at 06:43 PM | Comments (1) | TrackBack (0)
January 24, 2003
Preventing breast cancer
We suspected this, but confirmation is great. Drug cuts breast cancer risk
Posted by at 02:40 PM | Comments (0) | TrackBack (0)
Washington Post on concierge medicine
Retainer medicine continues to grow. Doctors on Call -- for a Hefty Retainer
We continue to have a vigorous debate on this issue. Detractors worry about equality of care. Supporters have a very different opinion.
But it will benefit their (the physicians') health! I believe that we should not reject this concept quickly. Rather we need to see this as an expression of ongoing physician dissatisfaction.Posted by at 02:34 PM | Comments (5) | TrackBack (0)
Public guidelines for managed care
Large H.M.O. to Make Treatment Guidelines Public. This is a very important advance in managed care.
This represents an advance, a very important advance. Hopefully, such disclosures will improve the doctor patient relationship, and make physicians more comfortable in discussing these issues.Posted by at 02:02 PM | Comments (2) | TrackBack (0)
Medscape discovers blogs Posted by at 01:56 PM | Comments (0) | TrackBack (0)
January 23, 2003
I could not have said it better. Unfortunately, as judges often do, he did leave a crack in the door - and we know that lawyers love cracks.
So now they must be searching for a fat kid who lives on Chicken McNuggets. That kid is out there. Get ready for the bulletin boards advertising - Are you Fat? Do you eat Chicken McNuggets every day? Do we have a case for you!Posted by at 05:13 AM | Comments (1) | TrackBack (0)
January 22, 2003
Drug companies in Court
Very interesting question posed here. Certainly, we have a huge problem to solve. I like this solution, however, I wonder if this would hinder research. Not really understanding the economics, I cannot comment.Posted by at 06:07 AM | Comments (3) | TrackBack (0)
Political Health News
Bush Seeks Funds for Wider Effort to Curb Chronic Disease . I like the initiative to try and reduce diabetes, obesity and asthma. These are becoming public health problems. We need to find creative solutions to encourage healthier lifestyles. Money will lead to innovative program trials.
This article also addresses smallpox vaccination side effects - and how we cover those. Primum non nocere!Posted by at 05:51 AM | Comments (0) | TrackBack (0)
January 21, 2003
Keeping your resolution
This is the time period that separates those who keep their resolution from those who do not. If you are wondering or wavering, read this Holding Fast for a Change New Habits Don't Come Easy, But Don't Call Failure Too Soon
So try not to give up. Keep working at your change. Remember why you made your resolution - and recommit to your new plan.Posted by at 07:08 AM | Comments (0) | TrackBack (0)
January 20, 2003
Washington Post on alcohol
So the Post understands the issue. But at the end they wimp out!
We just have a problem with the concept apparently. Most adults can drink moderately without few problems. I doubt that encouraging 1 drink 3 or 4 times each week will produce alcohol related problems. I am personally testing the hypothesis. Thus, far I am having no problem sticking with 1 drink. And I feel no urge for the second.
I cannot stay quiet on this issue. We have an enjoyable intervention which helps prevent disease. Maybe I should grow a beard and sell the stuff in a health food store!Posted by at 06:32 AM | Comments (1) | TrackBack (0)
Commentary on a plan for price controls on pharmaceuticals
As I have written recently, I believe that health care costs should rise (as a percentage of GNP). I still have major problems with the pharmaceutical industry - especially their advertising strategies and their physician bribes (purposely hyperbolic here). Nonetheless, we better not throw the baby out with the bath water (db using a trite phrase - if someone is grading me that probably takes 3 points off my grade). I believe that we can hold the industry to higher ethical standards, but free enterprise (and the attendant rewards) helps our patients.Posted by at 06:24 AM | Comments (2) | TrackBack (0)
Around the blogs
So what are the other medical blogs saying?
assumptions about her level of understanding - a nice piece about the importance of physicians gauging their patient's understanding of their disease. That piece links to this important issue - Death Talk Two. Let me add that very early in my career I did some ER work and had to give this talk. My father (a clinical psychologist) taught me to lead the loved ones to be the first to use the word dead. Thus, I generally would sit down with them in a room. I would start the conversation by outlining why the patient had come to the ER. Then I would state clearly that I had bad news. I would lead them to use the word dead - and almost always succeeded. Then like Richard Winters I would continue my shift and finally go home and think. Giving bad news is very necessary and it never feels right.
As a ward attending, I often model giving bad news to students, interns and residents. After each session (for example, we told a patient on Friday that he had metastatic cancer), we do a debriefing. We criticize my style - both positive and negative comments are encouraged. I grade my performance! I share what I thought I did right and how I could have improved that performance. Those of us involved in medical education must teach these skills by both role modelling and explicit discussion of the process.
Medpundit has recently tackled lawyers. This link will get you started - and take you over to Jane Galt's continuation of this topic - More Lawyer Letters. This dialogue should continue and I would hope gain national recognition. We need better understanding of their viewpoint. I believe that they need to better understand our angst (I assume they care). I also note the Rangel is weighing in on these issues. Start here - Reform the legal system! And also check out this - It's Not Just 'Sue the Docs' Anymore
Yesterday's Bloviator (see the links on the left column and then scroll to Sunday as he does not provide links to individual rants) provides more discussion of the vaccination issue I ranted about recently.
Posted by at 06:12 AM | Comments (0) | TrackBack (0)
Will Congress fix their mess?
This demonstrates the problem with our political system. Take an issue with general agreement and Senators will always try to attach another provision. I agree with finding relief for rural hospitals. But that is a different issue and should be a different bill.
And advocates cannot understand why physicians fear universal health plans. They would have to orginate with Congress. And we do not trust them to  pass the right bills or  correct their mistakes. Maybe we should just sue them for malpractice!Posted by at 05:43 AM | Comments (0) | TrackBack (0)
January 19, 2003
Diabetic retinopathy screening - what interval?
Living in Alabama, I must follow the diabetes literature. We (the state) are number One in per capita type II diabetes. As I teach medical students, interns and residents, I have developed my own mneumonic for ongoing diabetes care - FLECKS. FLECKS represents a checklist that we must consider every time we have a patient encounter with a diabetic patient:
Today I will focus on retinopathy, because of an important article in this week's Lancet. I first checked out the current ADA guidelines on retinopathy screening. You can find the guidelines (free) at Diabetes Care - Clinical Practice Recommendations 2003. Going to the chapter on diabetic retinopathy, I looked for the current recommendation.
This guideline matches our current practice and teaching. The guideline appropriately admits a lack of data on the appropriate interval for examinations. The interval question is a very important question which we rarely address in medical research. However, the issue now has an important hypothesis advanced for our consideration. Incidence of sight-threatening retinopathy in patients with type 2 diabetes in the Liverpool Diabetic Eye Study: a cohort study (free registration required to view this article). I will describe the study and then present their findings.
Thus, they used data on patients with at least two screening examinations to determine incidence rates. Let me define incidence precisely - the incidence is the rate of occurence. Thus, we want to know in this study the probability that a patient will develop diabetic retinopathy during any interval (per year or per 3 years).
Why is incidence important? If we want to develop an examination interval recommendation, then we need to know the probability that a patient will develop important retinopathy during any interval. If we examine the patient every day, we will never miss early retinopathy. If we examine the patient every 20 years, we will miss most early retinopathy. How do we optimize that interval?
Those data are difficult to understand. I have read the study and this summary several times. I believe that they are saying that given a normal baseline examination, the diabetic patient has less than a five percent chance of developing retinopathy until 5.4 years. They then discuss the problem of 'losing patients to followup' and decide to err on the side of more frequent examinations. Thus, they conclude
An accompanying editorial in the same issue - Screening interval for retinopathy in type 2 diabetes interprets the data.
I support this conservative approach in 2003. The Lancet data are intriguing and may well lead to an important study of examination interval. I hope investigators act on this important hypothesis generating article. If we could just extend the interval to every other year, we would save significant health care costs. Since patients go through stages with diabetic retinopathy, I believe that extending the interval in patients with normal examinations would not jeopardize vision.
Not every important study should change medical care immediately. We must remain skeptical and test this new hypothesis. That is how we make important advances in health care, methodically and one small step at a time. This article should start us on the road to more cost effective screening.Posted by at 06:54 AM | Comments (1) | TrackBack (0)
The price of success
We are winning the battles. Death rates from heart disease and stroke have decreased dramatically. How much does this success effect our health care system and health care costs? Gains on Heart Disease Leave More Survivors, and Questions
I see these patients every day in the hospital. They often have had bypass surgery and multiple coronary interventions. They develop chest pain and require either stress testing or cardiac catheterization. Having coronary artery disease means you should take a beta blocker, an ACE inhibitor and a statin (plus a baby aspirin). These patients develop other vascular complications - stroke and peripheral vascular disease. Eventually many develop congestive heart failure with more hospitalizations and medications.
We certainly have extended the quantity of life. But we do incur significant expenses as suggested in the above paragraph. And as patients live longer, they have more opportunity to develop additional diseases (with their attendant morbidity and costs).
So let us celebrate our great advances in care, but remember that we must be willing to pay for these advances. Our success does contribute to our financial health care crisis. But money seems a small trade off for our success.Posted by at 06:17 AM | Comments (0) | TrackBack (0)
January 18, 2003
How we dress
Posted by at 04:36 PM | Comments (2) | TrackBack (0)
January 17, 2003
The threat of vaccine lawsuits
Stories like this one are pushing me to start a new blog titled - Unintended Consequences. Trial lawyers, special interests and vaccines
Several thoughts come to mind here. First, I continue to think of the parable about the goose and the golden egg. Second, I recall Robert Burns
For the entire poem - Robert Burns To a Mouse Maybe I should name the blog - Unintended Consequence - the best laid plans.Posted by at 06:15 AM | Comments (2) | TrackBack (0)
The NY Times weighs in on malpractice reform
Thanks to President Bush, malpractice costs have become a major political issue. Not surprisingly the NY Times editorial page weighs in today - The Malpractice Insurance Crisis
They try to run the middle ground on this issue. While they understand the need for caps, they worry about medical errors and harmed patients. While I agree that we should work diligently to minimize error, and that we should continue our efforts at policing ourselves (i.e., suspending licenses when physicians become incompetent or dangerous), I believe that we can have much greater success if we are not besieged by the malpractice threat. These are difficult issues, but the tort system is not the answer.Posted by at 06:00 AM | Comments (5) | TrackBack (0)
Limiting VA access
Many readers know that I do my inpatient work at a VA hospital. The Bush administration has proposed a change in eligibility for care at VA hospitals. VA Stops Enrolling Higher Income Vets
This decision will save the VA some moneys - and hopefully improve care for needy veterans. I expect this decision will create significant political controversy.Posted by at 05:44 AM | Comments (3) | TrackBack (0)
January 16, 2003
Bush makes his speech Posted by at 03:27 PM | Comments (0) | TrackBack (0)
Today's NEJM has a clinical practice review on acute appendicitis. For those with a subscription - Suspected Appendicitis. The article focuses on the issue that I discuss in my rant about New Jersey, that is the problem of diagnostic testing. They include the following table.
Note that no single sign or symptom can make the diagnosis. One must combine the data and use pattern recognition to recognize the probable diagnosis. Often one will need further diagnostic testing. The authors conclude:
This article will remain in my references as an important summary of an important clinical issue. This condition demonstrates the problems in medical decision making that we face everyday.Posted by at 05:48 AM | Comments (1) | TrackBack (0)
Of course, the Democrats (being the puppets of the trial lawyers) want to blame the insurance industry. I have written many times, the Democratic position on malpractice reform is despicable and the Republican position on the pharmaceutical industry is equally despicable. Can someone find me a party to respect?Posted by at 05:30 AM | Comments (1) | TrackBack (0)
Now New Jersey
As usual the Governor, and I expect the legislature, thinks that this is the wrong strategy for the physicians.
They always try to pull out Hippocrates. Do lawyers have an oath? Do insurance companies have an oath?
The problem does not reside on the physician's court, rather the problem stems from the constant specter of malpractice cases. The trial lawyers (slick talking sophists) blame the insurance companies. I suspect that the insurance companies are not totally innocent, however, one cannot blame the malpractice climate on insurers. One cannot blame a shift in physician's thinking about the doctor patient relationship (is this patient going to sue me?) on insurers. One cannot blame the unnecessary ordering of tests on insurers.
The problem stems from a poor understanding of medicine and a wonderful understanding of argument by some malpractice lawyers. Patients in our society expect perfect diagnostic tests and perfect outcomes of treatment. Every test has a sensitivity (the probability of a positive test in disease) and a specificity (the probability of a negative test when the disease is not present). So we are forever having to interpret tests in light of first the probability that the patient has the condition prior to testing, and then incorporate the test result.
Medicine is not a straightforward science. We use many scientific principles, however, medical decision making generally remains an art.
I have a patient with a liver mass (which we just biopsied), chronic renal insufficiency (creatinine = 3), and new mitral regurgitation (secondary to a myocardial infarction 3 weeks ago). How can I develop a formula for addressing his issues? I am certain to being trading errors of omission with errors of commission.
We try to spend the necessary time to address these issues (and fortunately working in an academic setting I do have enough time to think and discuss). However, at some point we will have to make some decisions. Each decision may help one organ system, but may hurt another. How do we decide where to start?
Can a jury of the patient's peers evaluate my medical decision making? Will juries judge a physician defendant based on their medical expertise and understanding of the nuances of a particular case?
So often physicians resort to CYA. And CYA costs patients money. And yet we still get sued, and some (not all) judgements are clearly excessive. Who will fix the system? What oath have the lawyers taken that allows them to threaten the doctor patient relationship? Why do they want to transfer their adversarial style to us? They can keep adversarial relationships, we just want to help patients.Posted by at 05:22 AM | Comments (3) | TrackBack (0)
January 15, 2003
This just in - exercise is good!
Exercise critical to melt internal fat Study: Activity helps older women reduce chronic disease risk. This study provides even more evidence of the benefits of aerobic exercise. The original study is in today's JAMA.Posted by at 06:28 AM | Comments (0) | TrackBack (0)
We are improving!
U.S. Medical Care Improves Overall . This report refers to an article in today's JAMA. The study shows that on 20/22 quality measures (e.g., receiving antibiotics in a timely fashion after admission, receiving anticoagulation for atrial fibrillation) the 2000-01 results improved over the 1998-99 results. The authors do comment that we still have room for improvement. Eight of the indicators involved care of acute myocardial infarction; two referred to congestive heart failure; they measure three stroke indicators and five pneumonia indicators. Those were the inpatient conditions. The remaining measures occurred in any setting (which I assume means predominantly outpatient): two immunizations, mammography, and three diabetes care measures.
What we cannot learn from these data is why. We need more studies to understand why some patients receive suboptimal care. We may add such a study to our current research. Investigating physician decision making without talking with the physicians leaves me incomplete. What barriers do we not understand?
These are very interesting theories. We must test those theories.Posted by at 06:22 AM | Comments (0) | TrackBack (0)
I love this story. I love nuts, and have not eaten them enough. This information will influence my snacking (hopefully in a positive way).Posted by at 06:04 AM | Comments (1) | TrackBack (0)
January 14, 2003
No hype here - please just click and read this. We learn from stories, so perhaps we should all do a better job of hearing and relating those stories. The Word Doctor
Posted by at 08:37 AM | Comments (1) | TrackBack (0)
Sobering analysis of outcome data
So you need a particular type of physician. How do you find the best ones? A simplistic approach would focus on outcomes. For example, if you need heart surgery, find out which surgeon has the best survival rate. As this article explains in detail, it is much more complicated than a single number. Uncalculated Risks Medical Outcome Data, if Misused, Can Deprive Patients of the Care They Need As an outcomes resesearcher, I highly recommend this article. One must first frame the problem.
I have seen this phenomenon (and expect most physician readers have). As an internist, I have patients whose only hope is surgery. The surgeons are reluctant to operate because the patient predicts to have a poor outcome even with surgery.
This seems straightforward, we just need to develop risk adjustment criteria and then we can 'normalize' the data. However, most survival data come from 'administrative data bases' (that is our euphemism for billing data). Risk adjustment requires clinical data. We need clinical information to properly risk adjust. This works well in research studies, but may be too costly for routine report cards! This paragraph is telling.
But it can be done correctly. This requires proper data collection. Many cardiovascular surgeons participate in a program that does the risk adjustment.
Given the high costs (both monetary and patient risk) of cardiovascular surgery and the relatively low volume (compared with an outpatient generalist), the surgeons can collect the relevant data. This will unlikely work for many other conditions for time and money reasons.
Posted by at 05:25 AM | Comments (0) | TrackBack (0)
A difficult diagnosis
I recommend reading this article for those interested in differential diagnosis and patient presentation. I will not quote, as I believe one should read the entire article as written. Post-Mortem of a Death So PuzzlingPosted by at 05:05 AM | Comments (0) | TrackBack (0)
Two comments arise from this study. First, living in Alabama, I like stories that suggest that we are doing a bit better than other states. Second, as I write ad nauseum, the true cost of health care is increasing. The focus of our struggle with the health care crisis must be the TRUE cost. Improved technology, survival, medications all have costs. Are we willing to pay?Posted by at 05:01 AM | Comments (0) | TrackBack (0)
January 13, 2003
Quickly around the blogs
Today Medpundit writes about 'rebound headaches'. I had considered doing a rant on this subject. Rather, just go read what she says.
RangelMD has two very good rants on malpractice (responding to a trial lawyer's letter). Medical malpractice; A lawyer's perspective. Part II and Medical malpractice; A lawyer's perspective. Part I. Chris does a very nice job of debunking the classic trial lawyer arguments.
Finally, check out Da Goddess. Da Goddess is a pediatric nurse. She writes poignantly about terminally ill children - It's Been That Kind of a Week. She helps me remember the importance of the word CARE in health care!Posted by at 09:17 AM | Comments (1) | TrackBack (0)
What to eat?
So I went to Scientific American to read their article on the food pyramid (January issue) - Rebuilding the Food Pyramid: The dietary guide introduced a decade ago has led people astray. Some fats are healthy for the heart, and many carbohydrates clearly are not I highly recommend reading the entire article. Their recommendations come from data rather than from theory. They continue to research their recommendations and modify them. They eschew the simple approach adopted by the USDA pyramid. Their conclusions:
Read their work, and study it. There is a test! Your health benefits from passing this test.Posted by at 09:08 AM | Comments (0) | TrackBack (0)
Get Up and Get Moving. How could I pass on this article? It just could not happen. Newsweek has several articles on diet and exercise, which are available on MSNBC.com. I will review the diet article either later today or tomorrow. But first the exercise article. I love the title. Have you planned your exercise activities for this week? That is the key for me. I know when I will exercise each day this week. It is part of my weekly plan!
Research suggests that both greater duration and more rigorous give better results. One should not start with long runs and heavy weight. Rather one should strive to increase duration and intensity slowly over time.
So when will you exercise this week. Make a plan and stick to it. You owe it to your body.Posted by at 06:13 AM | Comments (0) | TrackBack (0)
Seeking fat dollars
Weight loss is big business. Ad Campaigns Expand for Weight Loss Programs. Maybe I should chuck this blog and write a weight loss book! Naw, go to any bookstore, we have too many such books already.
The article also includes Weight Watchers and Jenny Craig. Weight loss is big business. Unfortunately, the clients are often unsuccessful (taking the long term rather than the short term view). The business has no shortage of clients. So our society responds to excess food and decreased exercise with artificial fixes - the diet industry. These programs work, but few will continue to follow them for long periods. It is boring but true, successful weight loss with maintenance requires lifestyle changes. And how many Americans willingly and knowingly make lifestyle changes.
So I could write a book. But it would be very short. You need to make time for exercise - both aerobic and resistance - every week. You should modify your portions to first allow weight loss, and then maintenance. I believe in weighing daily and using short term aggressive dieting when I slip as little as 2 pounds.
Think I could turn that into a book? Anyone have a catchy title? Anyone know an agent?Posted by at 05:52 AM | Comments (2) | TrackBack (0)
January 12, 2003
Buying a toothbrush?
I just might buy a toothbrush after rounds this morning. After all, I am interested in limiting placque and gingivitis. Electric Toothbrush Tops Study: Other Devices No Better Than Manual Kind, Researchers Say
Posted by at 05:38 AM | Comments (0) | TrackBack (0)
January 11, 2003
New Jersey game of chicken
Thanks to overlawyered.com for this link. MDs will fly the coop rather than play chicken
We have too many states in crisis. Only a national solution will work. I have written often of the unintended consequences of huge malpractice settlements. We need sanity. Why can the trial lawyers not see that? Do they ever get sick?Posted by at 07:18 AM | Comments (15) | TrackBack (0)
Wall Street Journal endorses alcohol!
I just thought they I would try an outrageous headline. This opinion piece does reinforce the latest information on the value of moderate drinking. Nunc Est Bibendum No booze is bad news.
Well said; we should all celebrate (in moderation of course).Posted by at 06:59 AM | Comments (0) | TrackBack (0)
'Fat Land': Supersizing America is a book review.
The review shares some very interesting concepts. The book appararently champions the hypothesis that business has responded to our excess agricultural output. This stems from the 1970s.
When one reviews why 'agribusiness' has had such success, one starts to understand the problem. As usual we are the victims of 'unintended consequences'.
As I wrote yesterday, the only answer is personal responsiblity. The book's author comes to the same conclusion.
I suspect the book is even more sobering than the very well written review.Posted by at 06:43 AM | Comments (0) | TrackBack (0)
January 10, 2003
Thoughts on the health care crisis
As I have been saying, health care costs must increase if we provide more (and hopefully better care). A major factor is the cost of prolonging worthwhile survival. Chronic disease patients cost more than the healthy. We are doing a better job of keeping those patients healthier (i.e., acceptable quality of life) and alive (increased quantity of life). This comes at a real cost!!
The author makes relevant points. We must change our thinking on this issue, as the old models really do not work.Posted by at 09:37 AM | Comments (0) | TrackBack (0)
Blame Food Stamps????
Research Links Food Stamps and Obesity. If you have blinked twice on this story, join me. I really do not even believe the title!
I do not make up this stories - honest. People say and do these things.Posted by at 08:27 AM | Comments (3) | TrackBack (0)
Go to the left column, under medical blogs, and click on Bloviator. He has a response to Krauthammer's column which I discussed earlier this week. While I do not agree with everything the good Bloviator has to say on this issue, we all should read opposing opinions carefully. His piece runs on Thursday (I cannot get links to work to individual articles on his blog). You will not miss it.Posted by at 05:52 AM | Comments (0) | TrackBack (0)
Dick Meyer on health care costs
So, as I have written previously, maybe rising health care costs are not a HUGE problem.Posted by at 05:28 AM | Comments (0) | TrackBack (0)
Another law suit - you just might not believe this one
This really does not need extensive comment, but I do have one thought related to all these victimization suits. I am a fan of Stephen Covey's "7 Habits of Highly Effective People". I have read the book several times, and also periodically listen to the audiotapes. Currently, I am listening to the 1.5 hour version. Yesterday I spent time listening to and thinking about Habit 1
Few people in our world take responsibiltiy for their outcomes. They blame others rather than understand how they can succeed. They may take credit for weight loss success, but weight gain occurs because McDonald's tastes too good or Weight Watchers is ineffective. As long as our society rewards and supports this victimization role, we will have stupid law suits.
Admittedly, some people have greater difficulty with weight gain than others. Most people can succeed by changing their eating habits (especially portion control) and their exercise habits. Ones inability to succeed should compel one to reconsider the failure and understand how one can change to achieve success. Unfortunately, few have that strength of character. And character matters.
In the absence of responsibility and character, we are quick to blame (and apparently quick to sue). We should not accept such actions. We should restore the importance of responsibility and character to our society.Posted by at 05:24 AM | Comments (1) | TrackBack (0)
January 09, 2003
Alternative works for music not for medicine
I like a lot of alternative music. Some wonderfully creative rock has started in garages or fraternities or wherever. But the arts are different than health care. I am appalled by the popularity of non-scientific remedies. I am not alone. Save Us From Alternative Medicine! One good thing for Bill Frist's legislative calendar: Removing the Dietary Supplement Health and Education Act of 1994
Amen!Posted by at 06:14 PM | Comments (1) | TrackBack (0)
Drink - in moderation
I have said this before. Here are more data in support of moderate alcohol. Drink Often, Heart Study Suggests.
Let me emphasize that moderation is the key. The mortality curve is U shaped, that is, heavy drinkers have worse mortality as do teetotalers. The type of alcohol does not seem to matter.Posted by at 05:16 AM | Comments (2) | TrackBack (0)
January 08, 2003
Another critique of ALLHAT
I have felt like a voice in the wilderness. The ALLHAT study had critical flaws which diminish the extrapolations one can use in practice. I am not alone - Hyper Hypertension Hype
This analysis resembles mine at the time of the study release. The author is a bit more strident than me -
One of my teaching mottos is 'Context!'. In this case one must consider the context of the study. Clearly diuretics work as first line agents. Clearly ACE inhibitors are desirable for many reasons (renal disease, heart disease, even prevention of diabetes in some patients). They work very well in combination. But this study excluded that possibility. So we spent $40 million dollars and really asked the wrong question!Posted by at 09:44 AM | Comments (4) | TrackBack (0)
Krauthammer on malpractice
Yesterday evening my son pointed me to this article. Sick, Tired and Not Taking It Anymore: Surgeons are striking in West Virginia. Here's how to cure what ails them
Please read the entire piece. Krauthammer has nailed this subject!Posted by at 06:09 AM | Comments (10) | TrackBack (0)
Health care priorities
The Institutue of Medicine has released 20 health care priorities - areas on which we should focus greater efforts. Ensuring World-Class Health Care
Not a bad list in my viewpoint but let me add this disclaimer - I once served on an IOM panel.Posted by at 06:03 AM | Comments (4) | TrackBack (0)
Spiraling health care costs
Recently I wrote about increasing health care costs, and the reasons behind those increases. Today the NY Times addresses the issue - Spending on Health Care Increased Sharply in 2001.
Patients seek more health care. An unintended consequence of extending life expectancy for somel diseases is increased health care costs! For example, using ACE inhibitors and beta blockers markedly improve survival for heart failure patients. During those additional years, the patients require more care - both for their heart disease and for other disease that patients their age develop. Thus, we will spend more money as we improve health care.
The Democrats and the Republicans - so surprising that they view the same data differently! As Medicare decreases reimbursements (or fails to increase others), physicians, health care workers and hospitals shift costs to private insurers. One cannot look at Medicare alone and say that it is more efficient. It is efficient only at having physician limiting new Medicare patients (as I have written about often).
The Republicans do make an important point. Some health care costs come because the patient has no incentive to consider costs. That is a main argument for MSAs (medical savings accounts). For those who want the source article - Trends In U.S. Health Care Spending, 2001 Their abstract (the article requires subscription or you may buy it online) -
Posted by at 05:56 AM | Comments (1) | TrackBack (0)
January 07, 2003
More on sore throats
Since my early academic success stems from doing sore throat research, I probably overact to any comments on sore throats. A physician made these comments on an old story today -
There are four potential reasons to treat a streptococcal pharyngitis: 1. Prevent non-suppurative complications; 2. Prevent suppurative complications; 3. Decrease duration of symptoms; 4. Prevent spread of infection to close contacts. Let us consider each of these with respect to group A and group C streptococcal pharyngitis.
I do agree that in the United States, we are unlikely to gain much protection from non-suppurative complications given their rarity. That is not why I treat probably streptococcal pharyngitis.
Untreated streptococcal pharyngitis (either group A or group C) can progress to tonsillar abscess (or other suppurative complication). While these complications are unusual, they do cause significant morbidity.
The BMJ paper I cited in the article which stimulated this comment - Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults reports on decreased symptom duration in both group A and group C pharyngitis. Group A pharyngitis tends to present with more severe symptoms - but the symptoms do overlap. Penicillin decreased the duration of symptoms by 2 days in the group A patients and 1 day in the group C patients. Given the limited duration of the disease, this represents a major benefit - from the patient's viewpoint .
Both group A and group C are contagious and cause epidemic pharyngitis. Thus, treating index cases helps their contacts - much more important in a student health setting.
Thus, I will continue to treat patients on the basis of clinical symptoms, that is patients having 3 or 4 of the following - tonsillar exudates, swollen tender anterior cervical nodes, lack of cough, history of fever. These are the patients included in the BMJ paper. These are the patients with marked morbidity. They deserve penicillin (unless allergic). It just may decrease their days of illness. It may help their roommates and classmates.Posted by at 06:44 PM | Comments (1) | TrackBack (0)
The risks of obesity
The Annals of Internal Medicine has an important analysis of the Framingham data in the current issue - Obesity in Adulthood and Its Consequences for Life Expectancy: A Life-Table Analysis (subscription required). Several news articles summarize this article. Being Fatter at 40 Can Shorten Life by 3 Years
Sobering data, maybe this will stimulate some readers to start exercising and watching their diet.Posted by at 08:45 AM | Comments (0) | TrackBack (0)
What is primary care?
Dr. Abigail Zuger writes in the New York Times - In an Age of Specialists, One Doctor Is Primary.
Patients generally want a doctor - one doctor with whom they can trust, take counsel, and make decisions. We would all like to find that special doctor.
So what do I think primary care is? Some have used the term conductor, but I will reject that. Good primary care physicians (and there truly are many in this country - but not enough) care for patients. They know how to care for most problems and know when to get help (consult a specialist). The great primary care physician is the anchor. He/she remains there regardless. When I try to explain primary care, I always remember a former patient (doctors always come up with anecdotes based on actual patients!). He was a prominent person who was referred to me for 'routine primary care'.
One day he came to me with 'bronchitis'. He looked a bit sicker than most routine bronchitis, so I obtained a chest X-ray. The CXR showed a lung mass. I referred him to thoracic surgery and he had his early lung cancer removed. We patted each other on the back and just felt good about finding the cancer.
Eighteen months later he walked into the office without a visit, asking to meet with me. I asked him what the problem was and he asked me 'Would you be my doctor?"
I thought this a strange request and answered, "I am your doctor, and will remain your doctor. Why do you ask?"
He then told me that he had had a routine CXR (ordered by the thoracic surgeon) which showed a non-operable recurrence. The thoracic surgeon referred him to an oncologist who offered him chemotherapy but was honest enough to explain the negative impact chemotherapy would have on his quality of life. When my patient chose against chemotherapy, the oncologist 'lost interest'. The patient was coming to me to care for him, to provide him the best quality of life and death that he deserved.
I will tell the rest of the story another time, but it does involve much reasoned decision making. The patient died as he wished, in his home. I believe that I provided help in medical decision making, pain relief, diagnostic support, and end of life care. For him, I was the doctor. Don't we all want that?Posted by at 08:40 AM | Comments (0) | TrackBack (0)
January 06, 2003
A nice story
Patient reporter: Our columnist goes under the knife. This reporter had significant supraventricular tachycardia (SVT). The cardiologists cured her. Read her story.Posted by at 02:36 PM | Comments (0) | TrackBack (0)
I certainly hope that Senate (the bottleneck on this issue) will act swiftly with Dr. Frist as Majority Leader.Posted by at 09:34 AM | Comments (2) | TrackBack (0)
Guidelines for NSTEMI/unstable angina
Physician's Weekly provides this excellent summary of the recently revised guidelines - Treating Unstable Angina and NSTEMI. These are worth studying if you care for such patients.Posted by at 09:26 AM | Comments (1) | TrackBack (0)
The court system and obesity Posted by at 09:21 AM | Comments (0) | TrackBack (0)
Malpractice - the managed care perspective
Beware the Hidden Consequences of the Malpractice Crisis: Soaring malpractice insurance rates are thinning out provider ranks in at least a dozen states. Could access problems pose issues for HMOs in those areas?
Posted by at 09:09 AM | Comments (1) | TrackBack (0)
A surgeon's view of the crisis
Read the entire piece, and fret for patient care. That is my concern, patient care. I do not believe our current tort system works to support excellence in patient care.Posted by at 08:44 AM | Comments (0) | TrackBack (0)
Washington Times on the malpractice crisis
The West Virginia crisis has stimulated interest in the malpractice problem. Editorial pages and talk shows are now focused. We need this media interest to spur on legislative reforms. I will continue to blog on this issue and hope other bloggers who read these rants will join the debate. Bloggers do make a difference. And this problem needs a much different solution.Posted by at 08:35 AM | Comments (3) | TrackBack (0)
The LA Times has an interesting group of articles today (free registration required) - Five views on nutrition.
The article has links to the five opinions. I will summarize my take on these articles.
These are the points that I have been making (perhaps incessantly). They also recognize the different people need different diets. The diet must fit your likes, your personality, and you work/home situation.Posted by at 08:27 AM | Comments (0) | TrackBack (0)
January 05, 2003
Thanks to you - the readers of this blog. I have noted increased readership recently. I also have noted an increasing number of comments. While I write this blog primarily for the self discipline and what I learn, knowing that I am reaching an interested audience means much. As I view the readership numbers and read the comments, I am receiving positive feedback. This feedback suggests that I am stimulating thinking.
What do I get from writing this blog? Daily I consider medical care and new develoments in medicine. This discipline, and the striving to express those thoughts concisely and coherently, is a major personal reward. I know when I have done a good job, and when I have not thought clearly enough. Your participation adds an external reward to that internal reward, and for that I thank you! Please keep commenting, and if you do not choose to comment, consider scrolling back to rants that strike your interest to see if others comment. The comments often add greatly to my thought process and hopefuPosted by at 01:22 PM | Comments (6) | TrackBack (0)
Improving the quality of care
I frequently write about studies focusing on the process of care. We are getting better on some parameters - Docs Slow in Prescribing Better Heart Meds. These are important studies, but what key information are we missing? Few studies collect primary data and try to understand why. We (the research group that I work with) look at methods for improving the measurable processes of care. We need to better understand why physicians do not adopt these recommendations as quickly as one would like. Criticizing practicing physicians is easier than trying to understand the impediments. We should do more than point fingers. We should offer solutions.Posted by at 01:01 PM | Comments (0) | TrackBack (0)
Strike of health insurance?
GE Workers Vow to Strike Over Health Care Health care costs are rising for a variety of reasons.
Our health care system needs reform, and the reform must focus on encouraging a careful thought process rather than just ordering every test. We need to use medications intelligently and take advantage of cost savings when possible. Our current system perversely discourages thinking (which takes time).
Until we really address the causes of increasing costs (and explicitly make decisions about what we can afford and what we cannot afford), we will have more crises like this one.Posted by at 12:53 PM | Comments (1) | TrackBack (1)
Malpractice suits do cost society
So who is to blame? What causes the malpractice crisis?
Now, I ask you, do you really believe that settlement costs have nothing to do with insurance premium increases? If you believe that, then why does California have a much better situation (remember they have a rational cap on awards)? I do not believe that the insurance companies are entirely innocent, but the blame still must rest on our tort system. As I stated earlier this week, laywers do not acknowledge the unintended consequences of malpractice suits. Doctors consider these effects constantly. Ask The Trial Lawyers Why Your Health Care Costs So Much: - found after reading this on Viking Pundit - Right Wing News . Read those 2 rants and then please comment if you can really still defend the trial lawyers. I personally am very tired of their sanctimony!Posted by at 12:45 PM | Comments (4) | TrackBack (1)
January 04, 2003
Bush Medicare proposals
This issue will generate much heat and maybe even fire. This story started yesterday with a piece in the NY Times - Bush to Propose Changes in Medicare Plan
The Democrats have responded in predictable fashion - Bush administration to propose Medicare changes
For another opinion on this issue, read The Bloviator's piece on 1/3/03 (unable to link to a specific article on his site).
So what do I think? First, Medicare is broken; it has been broken; it needs fixin' (as we say in Alabama). Physicians are opting out of Medicare in record numbers, and therefore access suffers. Because Medicare payment structures result from legislation, we have a huge unwieldy plan which cannot respond to obvious problems (see my many rants on the decrease in office payments). Many rules associated with Medicare are heinous and just add to office staff.
I am puzzled though. The Democrats are always engaged in class warfare. They oppose tax cuts for the wealthy at every turn. Why are they against reforms which ask wealthy seniors to pay more than those on a low fixed income? If I understand the Bush prescription drug proposal, the benefit does relate to income. When I retire, why should those working support my prescription drugs. I should be able to afford them. I have save since first joining academic medicine in 1980. My retirement should be very reasonable. I will not need that benefit in the same way my patients who only have a social security check need the benefit.
Now my insurance rant. I dislike most health insurance companies, but I do think some more experimentation could work here. We need less restrictions from the legislature. Perhaps competing insurance companies could decrease bureaucracy and costly rules. Actually, I am dubious, but a man can hope.
One proposal that I do not see here involves MSAs (Medical Savings Accounts). Robert Prather at NNP (see blog list in left column) touts MSAs. Perhaps he can shed some light here.
Regardless, this issue looms large over the next Congress. I plan to follow this issue carefully. The results will have a major impact on patient care. And I hope that is the goal. I hope this is not just politics. But I am actually not that naive. I understand EVERYTHING in Washington is politics.Posted by at 06:55 AM | Comments (6) | TrackBack (0)
My only CloneAid post
I have avoided this subject assiduously. But I found this commentary, and recognized that it expressed my feelings perfectly. Media bungled clone claim coverage Rather than quote at all, please read the entire opinion piece (if you have any interest left in what should never have become a story).Posted by at 06:34 AM | Comments (0) | TrackBack (0)
January 03, 2003
And the WVa strike continues
But note that the surgeons have not abandoned the critically ill -
I do believe this walkout is principled. If the state does not resolve these issues expect few if any physicians moving to WVa.Posted by at 01:05 PM | Comments (2) | TrackBack (0)
TV drug ads
Well said - When TV Commercials Play the Doctor.
Posted by at 01:00 PM | Comments (2) | TrackBack (0)
Singulair (montelukast) for seasonal rhinitis
This is an interesting development. As an allergic rhinitis sufferer, I understand the major impact that attacks have on ones quality of life. I may well try Singulair when I next have an attack. Browsing the Prescribers's Letter I found reference to a study comparing Singulair, Claritin, placebo and the 2 drugs in combination. The 2 drugs in combination had the best results. Probably many generalists already know this. Please share your anecdotes with the readers!
January 02, 2003
Instapundit on malpractice
Instapundit rants on West Virginia and malpractice. Well Instapundit is the 500 pound gorilla of the blogging world. He is a law professor. His comments on malpractice do make sense.
Well I agree with some of what Glenn says. I believe that he underestimates the improvements in policing our own. But then I have an obvious bias in favor of physicians. Glenn's rant leaves me as confused as I was this morning. But I do feel better that he seems confused also!
Prather on tort reform
Lawyers Vs. Doctors. Robert Prather rants about a Wall Street Journal piece on tort reform. His opinion -
Robert, I hope you are wrong. I at least hope that Congress passes the reform. The court tests would attract much needed attention.
Discussions of this issue tend to obscure the real question. What are the unintended consequences of the successful law suit judgement? I do understand that some patients or customers are harmed by physicians or nurses or hospitals or insurance companies or defective products. But should I as a patient or customer have to contribute to the settlement. The loser in the lawsuit rarely pays the judgement themselves. Physicians have malpractice insurance. So if you sue one physician (and win) all physicians will pay (with increased insurance costs). Thus all patients will then pay (with increased doctor's fees). The same concept applies to suing McDonalds or Toyota or an airline.
I do not know the way out of this quandry. We live in a country and a society which champions individual rights. I support this and revel in the attendant freedoms. However, as Oliver Wendell Holmes (probably influenced by John Locke) said ""The right to swing my fist ends where the other man's nose begins." So you swing at the physician (or some other defendant) and I get hit (in the wallet).
I fear that I digress and know that I am waxing philosophic. Perhaps some readers can expound on this issue and help me. I would hope that there are some reasoned legal minds who can help find a solution to this dilemma.Posted by at 08:53 AM | Comments (5) | TrackBack (0)
In Obesity Epidemic, Many Now Turn to Surgery. I harp on fitness and diet. Fortunately, I have a body habitus that allows success towards my goals. Some people have major weight problems. I watched a moving interview which Tim Russert conducted with Al Roker, discussing Roker's weight loss surgery. Al Roker has a web page and has several discussions of his surgery, the most poignant - Here's The Story!. Jane Brody has done a wonderful job of synthesizing information on bariatric surgery.
Surgery is a final option. It is a last resort. Surgery has significant risks.
You can calculate your own BMI - Body Mass Index Web Calculator. I have run a few numbers to bring a BMI of 40 into perspective. At 6 feet I would have to weigh 295 to reach morbid obesity (BMI of 40). At 5'6" the weight is 248. At 5' the weight is 205. We are discussing the morbidly obese. Note that patients with serious medical complications are eligible at lower weights.
Again I must emphasize the risks of surgery.
For many patients the risks are worth the benefits. Patients must make a careful and informed decision with a full understanding of those risks.
I have cared for a number of patients who have had successful bariatric surgery. This is a major decision for patients. It requires careful physician counseling and support. It is the right treatment for some patients. This review is worth saving for interested patients.Posted by at 08:10 AM | Comments (4) | TrackBack (0)
January 01, 2003
New Year's Resolutions
For those who get the Wall Street Journal, yesterday's issue does have a good article on New Year's Resolutions. The article's gist is to make small resolutions, that one can actually keep. Since I have succeeded with those resolutions in the past, my main resolution involves continuing some good habits.
So there you have my resolutions.
Now for something slightly different - New Year's goals!
There I have my goals. I have published them and am now accountable.
Please take advantage of the comments section to post your resolutions and goals. One way of achieving success is to make a public declaration. I am trying that method with you. Please try it with me.
And Happy New Year!!!Posted by at 07:15 AM | Comments (6) | TrackBack (0)
And we just keep eating
Obesity, Diabetes On Rise In U.S. What we have here, unfortunately, is a 'dog bites man' story.
Posted by at 06:55 AM | Comments (0) | TrackBack (0)
Pennsylvania wins a reprieve
Good for the patients, this proposal treats the symptoms, not the disease. I guess we can only hope that Congress takes up the mantle of nationwide tort reform.Posted by at 06:50 AM | Comments (1) | TrackBack (0)
Thanks to Robert Prather (NNP) for this link! Hold the Lard! The Atkins Diet still doesn't work. The title of this article misleads a bit. The author does not deny weight loss with Atkins, rather he downplays it.
I fail to see the 'Eureka' here. Of course diets are about eating less calories!
So what is the point? What should we do; what should we tell patients?
I would argue that Atkins belongs in the armamentarium of acceptable diets. While it is not the diet that I would personally choose, I know many people who have success with the diet. Each of us must individualize how we attack too much weight. This option works for some and does not seem dangerous.
What principles do I use? First, I do try to minimize refined carbohydrates. I do try to maximize protein, fruits and vegatables. Finally, I am convinced that sustained weight loss works best when one combines life style dietary change with life style fitness changes. Diet can work well in the short run, but I believe exercise becomes important for maintenance.Posted by at 06:42 AM | Comments (3) | TrackBack (0)
It would be nice if everybody could find a doctor with half the common sense of this one. - Junkyardblog
An academic general internist comments on medical issues and the current state of medicine.
The Sunday Issue of the Week continues. This feature will challenge me to carefully ponder an issue that I've referenced and commented on recently.
Current hot issues:
Click for Weekly Archives