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Evolution controversy 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 byThe 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 byTo 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 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 byGlobal 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 byACE-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 byMedicare reform 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 byImproving 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 byBush understands Bush pledges $15bn to fight Aids
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 byOur 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 system Posted byC-reactive protein 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 -
AHA/CDC Scientific Statement: Markers of Inflammation and Cardiovascular Disease
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 byThe 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 bySorting 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 byAnother 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 bySpironalactone 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 byBush and malpractice Bush turns up the heat on liability reform.
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 byNot 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 byUnderstanding 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 byWrap-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 byGood news 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 byPreventing breast cancer We suspected this, but confirmation is great. Drug cuts breast cancer risk Posted by 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 byPublic 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 byMedscape discovers blogs Medical blogs are starting to hit the big time. Medscape Enters the Blogosphere and Medscape. Posted byCommon Sense!! Big Macs Can Make You Fat? No Kidding, a Judge Rules
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 byDrug companies in Court High Court Considers Drug Pricing Plan
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 byPolitical 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 byKeeping 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 byWashington 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 byCommentary 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 byAround 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 Will Congress fix their mess? Congress weighs bill to stop Medicare 4.4% pay cut
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 [1] pass the right bills or [2] correct their |