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

A biology professor who refuses to write letters of recommendation for his students if they don't believe in evolution is being accused of religious discrimination, and federal officials are investigating, the school said.

So what does the professor say about this.

Dini writes that he has the policy because he doesn't believe anyone should practice in a biology-related field without accepting "the most important theory in biology."

"Good scientists would never throw out data that do not conform to their expectations or beliefs," he writes.

Dini also says he refuses to write letters of recommendation for students he doesn't know fairly well and those who haven't earned an "A" in one of his classes.

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:

Why do I ask this question? Let?s consider the situation of one wishing to enter medical school. Whereas medicine is historically rooted first in the practice of magic and later in religion, modern medicine is an endeavor that springs from the sciences, biology first among these. The central, unifying principle of biology is the theory of evolution, which includes both micro- and macro-evolution, and which extends to ALL species. How can someone who does not accept the most important theory in biology expect to properly practice in a field that is so heavily based on biology? It is hard to imagine how this can be so, but it is easy to imagine how physicians who ignore or neglect the Darwinian aspects of medicine or the evolutionary origin of humans can make bad clinical decisions. The current crisis in antibiotic resistance is the result of such decisions. For others, please read the citations below.

He is correct and brave. He will receive ridicule, and has a law suit pending. I hope he wins.

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.

Medical costs rose as weight did, said the report in the January-February issue of the American Journal of Health Promotion. The average cost for those of average weight was $2,225. The lowest category of overweight was slightly more, at $2,388, but costs rose more sharply after that, reaching $3,753 for the fattest people.

The finding is in line with a report by the U.S. Surgeon General, which estimated the economic cost of obesity in 2000 at $117 billion. And it comes as the Centers for Disease Control and Prevention documents a rising level of weight gain. The worst fatness - extreme or morbid obesity - nearly tripled among adults between 1988 and 2000.

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.

I must link to articles on the benefits of exercise. Jogging the Mind: New Evidence Proves Exercise Keeps the Mind Sharp

The researchers used high-resolution magnetic resonance imaging to study the brains of 55 volunteers between the ages of 56 and 79. They found that those who were physically fit had lost far less of their brain's gray and white matter than those who got very little exercise.

"People who are most fit showed the largest benefit," says psychologist Arthur F. Kramer of the University of Illinois at Urbana-Champaign. "They showed the least amount of reduction in brain volume."

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.

Another study led by Kramer, which will be published in the March issue of Psychological Science, revealed some similar results. It found:

Exercise programs involving both aerobic exercise and strength training produced better results on cognitive abilities than either one alone. That suggests that the old rule of walking 30 minutes a day, three days a week, may not offer as much protection against mental decline as a more vigorous routine.

Older adults benefit more than younger people because age-related declines are more pronounced.

The magnetic imaging study will be published in the February issue of the Journal of Gerontology: Medical Sciences. The studies were funded by the National Institute on Aging and the New York-based Institute for the Study of Aging.

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.

Methods

The primary end point of this open, parallel trial was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, revascularization, and amputation. Eighty patients were randomly assigned to receive conventional treatment in accordance with national guidelines and 80 to receive intensive treatment, with a stepwise implementation of behavior modification and pharmacologic therapy that targeted hyperglycemia, hypertension, dyslipidemia, and microalbuminuria, along with secondary prevention of cardiovascular disease with aspirin.

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?

Results

The mean age of the patients was 55.1 years, and the mean follow-up was 7.8 years. The decline in glycosylated hemoglobin values, systolic and diastolic blood pressure, serum cholesterol and triglyceride levels measured after an overnight fast, and urinary albumin excretion rate were all significantly greater in the intensive-therapy group than in the conventional-therapy group. Patients receiving intensive therapy also had a significantly lower risk of cardiovascular disease (hazard ratio, 0.47; 95 percent confidence interval, 0.24 to 0.73), nephropathy (hazard ratio, 0.39; 95 percent confidence interval, 0.17 to 0.87), retinopathy (hazard ratio, 0.42; 95 percent confidence interval, 0.21 to 0.86), and autonomic neuropathy (hazard ratio, 0.37; 95 percent confidence interval, 0.18 to 0.79).

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

Despite the benefits of a multifactorial strategy, making it routine practice is not easy. Interventions similar to those implemented by Gæde et al. are currently recommended but are underused for several reasons. They require education and time on the part of physicians. In addition, patients must be willing to follow a schedule of regular office visits and blood tests and often to take multiple medications, which may have side effects, at substantial expense for those who lack prescription-drug coverage. In a recent study of nearly 2 million Medicare beneficiaries with diabetes, almost 50 percent had not undergone lipid testing in the preceding two years; rates as low or lower have been reported with other recommended components of a multifactorial approach to care. Furthermore, target levels for coronary risk factors and glycemic control are achieved in only a minority of patients who undergo the recommended testing. Participants in trials are particularly motivated, yet at the conclusion of the current study, the target systolic blood pressure was reached in less than half the patients in the intensive-therapy group, and target glycosylated hemoglobin levels were achieved in less than a fifth. Although these findings point to the difficulty of achieving the targets in the real world, they also suggest the possibility of even greater benefits if the targets can be met more frequently.

The study by Gæde and colleagues builds on recent data demonstrating that lifestyle or pharmacologic interventions may substantially reduce the risk of diabetes. Surely the most effective way to reduce cardiovascular risk associated with diabetes would be to prevent diabetes itself. But for patients who already have diabetes or in whom it will develop, the advantages of a multifactorial approach to the reduction of cardiovascular risk are clear. The challenge is to ensure that this approach is widely adopted.

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!!!!

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.

That program, $15 billion over the next five years to fight global AIDS, caught many people by surprise when President Bush announced it Tuesday night. But while critics have long accused Mr. Bush of neglecting the epidemic, Dr. Fauci and other officials have been working on the initiative since June, they say, at Mr. Bush's explicit direction.

Mr. Bush's aides say the president has always been committed to the global AIDS cause, though not convinced that taxpayers' money could be well spent. But in recent months, a string of people from inside and outside the administration ? including Colin L. Powell, the secretary of state; Condoleezza Rice, the national security adviser; and Bono, the Irish rock star ? made a passionate case to persuade Mr. Bush that the time was right.

Among those most surprised by Mr. Bush's announcement were officials in 12 countries in Africa, which along with Haiti and Guyana will receive the money.

In the United States, the president's unexpected initiative has political ramifications, as well as humanitarian ones. With Republicans still smarting from racially charged remarks of Senator Trent Lott, the former Republican leader, Mr. Bush's initiative may help mend fences with African-American leaders in Congress.

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!

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.

In all cases, the ARB was well tolerated and the patient's subsequent course has been uneventful. Although this is by no means a rigorously controlled study, it should help alleviate the concerns of physicians who may be reluctant to use an ARB in such patients, despite anticipated benefits.

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.

Bush was on target last night in his discussion of health care. Bush Seeks Medicare, Malpractice Reforms

The central feature of the president's Medicare plan includes a drug benefit for older Americans who leave the traditional fee-for-service program and join government-subsidized health care plans administered by insurance companies, according to administration officials.

"Seniors happy with the current Medicare system should be able to keep their coverage just the way it is," Bush said. But he added that, just like federal employees, "seniors should have the choice of a health care plan that provides prescription drugs."

The plan will offer prescription drug benefits and catastrophic illness coverage to seniors as inducements to give up their fee-for-service Medicare benefits and enroll in private plans, administration officials said earlier.

Certainly the Democrats will oppose this. What will AARP say? What is fair?

Bush also called for a federal cap on medical malpractice awards. The president has said he believes excessive lawsuits are driving up the cost of health care. "No one has ever been healed by a frivolous lawsuit," he said.

Bush's guests for his speech Tuesday included two doctors the White House said had changed their practices because of rising malpractice insurance premiums.

Amen!

Getting Physical. Now that is more like it!

Ten years ago kids like Kale Granda warmed the bench instead of working up a sweat. Physical-education classes were showcases for budding athletes, a yawn for the able-bodied and a hardship to be endured by the rest. But now baby fat has morphed into a national health crisis. Nearly 15 percent of kids between 12 and 19 are overweight?up from 5 percent in the late 1970s. They?re also more sedentary than ever. Less than 25 percent of school-age children get even 20 minutes of vigorous daily physical activity, well below the minimum doctors prescribe. Public-health officials predict that many members of the Joystick Generation will begin to experience costly, debilitating illnesses like high blood pressure, heart disease and diabetes even in their 20s and 30s. These warnings have prompted some physical-education teachers to rethink their old Darwinian view of gym class. Instead of helping the natural athletes refine the perfect jump shot, proponents of the New PE say their goal is to get "mouse potatoes" moving again.

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.

Bush pledges $15bn to fight Aids

In his State of the Union address, Mr Bush said the money would provide drugs for two million people with the disease and help to prevent seven million new infections.

The money will be targeted at projects in sub-Saharan Africa, where as many as one in three adults in some countries have HIV.

The president said his Emergency Plan for AIDS Relief would also help those Caribbean countries worst affected by the disease.

Most of the fund's $15bn budget will be earmarked for use in Botswana, Ethiopia, Guyana, Haiti, Ivory Coast, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia.

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.

Just read this article. Print it out, and pass it on. No quotes, you need to read the entire article. Please. An ailing system

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 -

The CRP -- for C-reactive protein -- test can help doctors target people who need to be treated aggressively to protect their health, according to an expert panel convened by the American Heart Association and the Centers for Disease Control and Prevention.

The panel stopped short of endorsing universal screening with the test, which became the subject of intense debate in recent years as its popularity soared. Thousands of Americans are getting the tests, which proponents argue can save lives by identifying people with developing heart and blood vessel disease who might otherwise be missed. Others argue there is not yet enough evidence to justify widespread use.

The panel, assembled to provide doctors with formal guidance on using the test, concluded there was insufficient evidence to put CRP testing on the same footing as cholesterol and blood pressure testing, which have become mainstays of good medical care.

But the panel did say the simple test is the first new screening tool since cholesterol for patients on the borderline of needing treatment because of moderately high cholesterol, blood pressure readings or other factors. Between one-third and one-half of adult Americans may fall into this category.

AHA/CDC Scientific Statement: Markers of Inflammation and Cardiovascular Disease

On the basis of the available evidence, the Writing Group recommends against screening of the entire adult population for hs-CRP as a public health measure. The Writing Group does conclude that it is reasonable to measure hs-CRP as an adjunct to the major risk factors to further assess absolute risk for coronary disease primary prevention. At the discretion of the physician, the measurement is considered optional, based on the moderate level of evidence (Evidence Level C). In this role, hs-CRP measurement appears to be best employed to detect enhanced absolute risk in persons in whom multiple risk factor scoring projects a 10-year CHD risk in the range of 10% to 20% (Evidence Level B). However, the benefits of this strategy or any treatment based on this strategy remain uncertain. The finding of a high relative risk level of hs-CRP (>3.0 mg/L) may allow for intensification of medical therapy to further reduce risk and to motivate some patients to improve their lifestyle or comply with medications prescribed to reduce their risk. Individuals at low risk (<10% per 10 years) will be unlikely to have a high risk (>20%) identified through hs-CRP testing. Individuals at high risk (>20% risk over 10 years) or with established atherosclerotic disease generally should be treated intensively regardless of their hs-CRP levels, so the utility of hs-CRP in secondary prevention appears to be more limited.

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.

In patients with stable coronary disease or acute coronary syndromes, hs-CRP measurement may be useful as an independent marker for assessing likelihood of recurrent events, including death, myocardial infarction, or restenosis after percutaneous coronary intervention. However, secondary preventive interventions with proven efficacy should not be dependent on hs-CRP levels. Further, serial testing of hs-CRP should not be used to monitor effects of treatment.

There remains healthy disagreement among the leaders in this field. The panel addresses those disagreements and calls for the necessary studies.

These recommendations should not be interpreted to mean that the scientific evidence is fully adequate. Randomized trials in which inflammatory marker testing was the primary intervention have not been performed to provide Level A evidence, nor have cost-effectiveness analyses been completed to assess additional costs or cost savings through the use of such tests. The currently available evidence was assessed in the formulation of these recommendations. A long list of recommendations for further research reflects the need to clarify numerous issues. Nonetheless, basic and epidemiological studies suggest that this will be a fertile topic for investigations and will help define the most effective and efficient use of inflammatory markers in the prediction of CVD.

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.

In outpatient settings, the primary use of CRP should be at the time of cholesterol screening, when knowledge of CRP can be used as an adjunct for global risk assessment. For individuals with LDL levels above 160 mg/dL and for whom the ATP III guidelines already call for therapeutic intervention, an elevated CRP level should aggressively encourage physicians and patients to institute pharmacological therapy in those instances where none is currently being used or where compliance is poor.

For individuals with LDL levels between 130 and 160 mg/dL, the additional finding of an elevated CRP indicates an elevated global risk. In almost all cases, this information should lead to better compliance and adherence with current ATP III treatment guidelines.

For individuals with LDL levels below 130 mg/dL, the finding of an elevated CRP implies substantially higher risk than predicted on the basis of LDL alone. As shown in Figures 3 and 6, such individuals will have risk estimates as high as some individuals with overt hyperlipidemia. Patients with this profile should be advised to adhere carefully with ATP III lifestyle interventions, despite "low" LDL cholesterol levels. Individuals with the low LDL/high CRP phenotype are at elevated risk of having the metabolic syndrome and should have fasting glucose levels measured. Large-scale, randomized trial evidence is critically needed before such patients should be considered for statin therapy.

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

CRP is not only an excellent biomarker of inflammation, but it is also a direct participant in atherogenesis. It provides a valuable tool for identifying patients at risk of cardiovascular events in primary prevention in conjunction with lowering LDL cholesterol and may also have utility in the treatment of acute coronary syndromes and with percutaneous coronary intervention therapy. Finally, CRP will provide a readily accessible marker for further testing of the inflammatory hypothesis in atherosclerosis.

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

The time has come! The hypothesis is generated and remains untested. The list of potential adjunctive therapies with demonstrable antiinflammatory activity is growing rapidly and includes aspirin, statins, angiotensin converting enzyme inhibitors, clopidogrel, fibrates, thiazolidinedione (peroxisome proliferator-activated receptor) agents, low molecular weight heparins (especially enoxaparin and tinzaparin), platelet glycoprotein IIb/IIIa receptor antagonists (especially abciximab), and cyclooxygenase-2 inhibitors. At the very least, further insight into this important arena will be gleaned by the inclusion of inflammatory markers into ongoing randomized trials, whereby the level of inflammatory activity and its response to therapy (or lack thereof) may be correlated with clinical outcomes.

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.

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.

In 64 different regressions between the economy, yield, and premiums, the highest coefficient of determination was 0.1505.[5] Therefore, we can state with a fair degree of certainty that investment yield and the performance of the economy and interest rates do not influence medical malpractice premiums.

Note that they are using statistical analysis rather than hyperbole!

Over the last 27 years, the average paid loss ratio was 47% and the minimum paid loss ratio was 16%.[11] In 2001, the industry paid loss ratio was nearly 75%. In other words, for every dollar that comes in the door, 75 cents is paid out.  When combined with the expense ratios cited earlier, it is clear that it has been extremely difficult ? if not impossible ? for insurance companies to earn a profit writing medical malpractice insurance. Further, at this rate of expenditure, after the company pays its losses and expenses, there is very little ?float? on which they can earn investment income.

In case that is not clear,here is the graph.

Summary

The magnitude of these changes suggests that the eventual solution to the current malpractice problem will be a blend of premium increases and tort reform. Since the financial shortfall compounds itself over time, it is imperative that the solution set be developed as quickly as possible. Without significant relief in fairly short order, the country may find itself facing an accelerating loss of available medical care.

But the Democrats and the trial lawyers will continue their sophistry. And, dare I sound redundant, patient care suffers.

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.

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

If you've been following the recent debate over that well-known dietary icon -- the U.S. Food Guide Pyramid -- and the alternative Healthy Eating pyramid touted by Harvard School of Public Health researcher Walter Willett, you may be feeling a bit unbalanced.

Fear not. If you've also been following this space regularly, you know how to eat in a way that will put you pretty close to both pyramids' recommendations. Plus, if you've taken up the Lean Plate Club Everyday Challenge, which is designed to move you toward healthy habits, you're also getting daily physical activity and aiming toward a healthy weight -- the two recommendations that form the base of the Harvard pyramid.

How can the recommendations be that similar, you say, given the stories about the vast differences between these approaches to eating? (The two can be compared at What Should You Really Eat?.)

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:

• Whole grain foods, vegetable oils, and fruits and vegetables are emphasized.
• Physical activity and weight control are emphasized.
• Red meat and refined grains (like white bread and white rice) are de-emphasized and listed as items that should only be eaten sparingly.
• Nuts and legumes receive their own category.
• Dairy products are de-emphasized and placed in a category with calcium supplements.
• A daily multivitamin tablet is recommended for most people, and moderate daily alcohol intake is a healthy option unless this does not make sense for the individual.

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?

A loyal reader sends this link - Malpractice crisis: It doesn't take a brain surgeon

So who's right?

Both sides are, and that's what's so darn irritating about this tit-for-tat political dance in which neither side is willing to concede to the other that there's room for improvement. How can they? Bush and his Republicans are beholden to the doctors and insurance executives who paid big bucks to get them elected. Democrats' biggest financial backers are the trial lawyers who claim to fight "for the people" so long as there are deep pockets at the other end to recover damages.

Most people don't want to have their rights to sue for cause taken away. Yet the answer isn't to attack rights, it's to seek a fair system.

It doesn't take a brain surgeon to know what should happen. First, we must punish the bad docs who continue to make the same mistakes and yank their medical licenses. At the same time, government must regulate the greedy business practices of insurers so that they don't treat reserves as profits, make bad investments and then turn around and try to recoup losses from the rest of us. Finally, curtail frivolous lawsuits without trivializing the suffering of those who have been unnecessarily hurt, and that means some kind of cap on awards.

Bush wants a national cap of $250,000 on awards for patients' pain and suffering caused by bad medical decisions, regardless of the type of screw-up a doctor, hospital or other health professional might have caused. He's off the mark. It should be a graduated system that considers the severity of mistake, a medical professional's history of wrongdoing, and how a person's quality of life will be affected.

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.

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.

Twenty-four percent (n = 25) of our patients developed hyperkalemia (levels 5.2, normal potassium values at our laboratory: 3.5?5.1 mEq/l). Twelve percent (n = 12) developed serious hyperkalemia (levels 6 mEq/l), compared with only 2% reported in the RALES trial. Thirty-one percent (n = 32) developed hyponatremia, and 25% (n = 26) developed renal insufficiency. Only 2% of our patients, compared with 10% in the RALES study, developed gynecomastia. Seven percent (n = 7/104) of our patients developed hypotension and 3% (n = 3/104) required temporary pacemaker insertion for hemodynamically unstable bradyarrhythmia related to serious hyperkalemia such as complete heart block, Mobitz type II atrioventricular block, or pauses 3 s. Twenty-one percent of our patients were subsequently discontinued from spironolactone compared with 8% in the RALES trial.

Why were there so many adverse effects? I suspect several problems - higher dosing, less frequent monitoring, and incomplete consideration of concomitant medications.

Adverse outcome rates, especially hyperkalemia, exceeded those reported in the RALES trial for several reasons. First, the higher angiotensin-converting enzyme inhibitor doses used in our study, closer to the recommended target doses, may have resulted in more hyperkalemic complications. Second, more patients with baseline renal insufficiency were started on spironolactone, and potassium supplements or potassium-sparing diuretics were not adjusted. Third, half of our patients had diabetes and may be prone to hyporeninemic hypoaldosteronism and hyperkalemia. These findings, however, are similar to other studies reporting life-threatening hyperkalemia during combined therapy with angiotensin-converting enzyme inhibitors and spironolactone. Thus, the long-term safety of combination therapy in HF with high-dose angiotensin-converting enzyme inhibitors, digoxin, beta-blockers, and spironolactone is not well established and needs careful monitoring.

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!

Bush turns up the heat on liability reform.

President Bush in January renewed his push for Congress to pass legislation aimed at making medical liability insurance more affordable and available for physicians. This time, he emphasized how the "broken" system is hurting patient care.

The president first unveiled his tort reform plan last summer. It calls for a $250,000 cap on noneconomic damages in medical malpractice lawsuits, a shorter statute of limitations for such cases and other reforms.

But the then-Democrat-controlled Senate failed to pass legislation last year after the Republican-controlled House approved a bill that included the measures Bush favors.

The crisis has worsened in some places since then. Now more patients are directly affected, as physicians can no longer afford to keep their practices open because of rising liability insurance costs combined with low HMO and Medicare payments.

These problems have spurred physician protests. Surgeons in Wheeling, W.Va., took leaves of absence from area hospitals starting Jan. 1; massive office closures were averted in Scranton, Pa., this month after Gov. Edward Rendell promised to make changes; and New Jersey physicians are planning a partial work stoppage starting Feb. 3.

"When a doc can't pay the premiums and, therefore, can't practice, somebody is going without health care," Bush told a crowd gathered at the University of Scranton in mid-January. "It strains the system. So what happens is, doctors say, 'Well, gosh, I can't afford it here in Pennsylvania, I'm moving. I'll just take my heart and my skills to another community where I can afford it.' But when that happens, somebody hurts. Somebody doesn't have the care."

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.

Still, GOP control in the Senate is not a guarantee that a bill will pass there. Sen. John Edwards (D, N.C.) criticized Bush for "siding with insurance companies over children and families." He is strongly considering introducing his own legislation, a spokesman said.
"The truth is that the insurance industry has done poorly in the market and is simply passing those costs on to the doctors and patients," Edwards said. "First and foremost, we need to address the root causes of premium increases and take away the special rights of the insurance industry."

Senate Democrats could stymie legislation that includes noneconomic damage caps with a filibuster. Sixty votes would be needed to stop such a tactic, and could be difficult to get.

So now we must wait for a political solution. And patients suffer with decreased access. I just do not understand this brand of politics.

Health care professionals are making their opinion of smallpox vaccination clear. Slim turnout for first smallpox shots

The risk of a smallpox attack is unknown, and the chance that any given person will be exposed is small, an advisory panel for the Institute of Medicine said recently in urging the government to go slower with the vaccinations.

But the risks of the vaccine are well-known. Some people may have sore arms and fever or feel sick enough to miss work. As many as 40 people out of every million vaccinated for the first time will face life-threatening reactions, and one or two will die.

The vaccine is not recommended for people with skin problems, such as eczema, or those with weak immune systems, such as HIV, transplant or cancer patients. The government says even people with close family members in those categories should be screened out.

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.

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.

Exercise can act like a drug on the blood vessels, reducing the risk of heart disease by literally getting the blood flowing, U.S. researchers said this week.
It works in a surprising way, reducing inflammation, which has recently joined high blood pressure and high cholesterol as a leading known cause of heart disease, the researchers said.

The blood stresses the walls of blood vessels as it passes over them, reducing inflammation in a way similar to high doses of steroids, the researchers reported in Friday's issue of Circulation Research.

"Inflammation in blood vessels has been linked to atherosclerosis, a hardening of the arteries, and here we see how the physical force of blood flow can cause cells to produce their own anti-inflammatory response," Scott Diamond of the the University of Pennsylvania's Institute for Medicine and Engineering, said in a statement.

"Conceivably, exercise provides the localized benefits of glucocorticoids -- just as potent as high doses of steroids, yet without all the systemic side effects of taking the drugs themselves," added Diamond, who led the study.

"Perhaps this is a natural way in which exercise helps protect the vessels, by stimulating an anti-inflammatory program when the vessels are exposed to elevated blood flow."

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?

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.

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

The budget bill passed by the Senate would prevent a scheduled Medicare payment cut for doctors from taking effect in March as scheduled.

The provision was in the spending package that passed 69-29 Thursday night. The Senate and the House, which has already passed a form of the package, must negotiate a compromise bill before it can go to President Bush for signature.

Hopefully, more on this tomorrow!

We suspected this, but confirmation is great. Drug cuts breast cancer risk

Scientists say they now have conclusive proof that tamoxifen can prevent breast cancer in healthy high-risk women. An international team led by Professor Jack Cuzick, of the charity Cancer Research UK, conducted an extensive review of the drug's track record in prevention trials.

The findings show the drug reduced the incidence of breast cancer by 38% in healthy women with a high chance of developing the disease.
Researchers say the next challenge is to minimise the side-effects of tamoxifen so that it can fulfil its potential as a frontline preventative drug.

Professor Cuzick said: "In our analysis we combined all the available evidence from studies using tamoxifen for breast cancer prevention collectively involving over 40,000 women - and it is clear to us now that the drug can reduce the chance of high-risk women developing the disease."

Retainer medicine continues to grow. Doctors on Call -- for a Hefty Retainer

In a few weeks, more than 4,800 people who have been patients of two Bethesda physicians will have to find new doctors -- all because they aren't willing to pay an annual membership fee of $1,500 to continue seeing their internists.

The membership program, described as a way to promote wellness and preventive care, has been adopted by 19 doctors nationwide who have retooled their practices to cater to a select group of patients willing to pay the retainer. In addition to the annual fee, the doctors will collect all the usual fees from patients' health insurance plans.

The roster of doctors signing up with the Florida-based MDVIP program includes a Fairfax County physician and two in Severna Park.

The smaller patient load gives doctors time to see patients on short notice and allows them to pledge round-the-clock telephone availability. Michael A. Hattwick, 61, of Fairfax, who switched his practice in October, said that instead of seeing 24 patients on a busy day, he sees 10 or 11.

This new brand of "concierge care" has intrigued patients including Alvin J. Brooks of Potomac and Martin Fine of Bethesda. They intend to pay and stay with the Bethesda physicians, Alan R. Sheff, 49, and his partner, Lee R. Pennington, 51.
But it has provoked criticism in Congress and warnings that more doctoring does not equal better health care. "This just gives the rich the illusion of comfort and good care," said Meri Kolbrener, a physician who treats low-income patients at a District clinic. "Not only do you not necessarily get better outcomes, you can, in fact, get worse outcomes."

Others worry that if MDVIP gets large enough, shifting patients will only increase the stresses on their new caregivers' offices.

We continue to have a vigorous debate on this issue. Detractors worry about equality of care. Supporters have a very different opinion.

Sheff said he knew it was time for a change when his patients starting asking him if he was feeling all right. Seeing a crush of 24 patients a day in the office, navigating health plan bureaucracies, watching insurers cut his fees -- the toll on him was obvious, he said.

Sheff and Pennington signed up with the MDVIP program, they said, because they want more time to ponder their patients' health problems, and the annual fee includes an annual physical exam and personalized wellness planning.

Those who have signed up with MDVIP include Hattwick and two doctors in Severna Park who joined in December, Marsha Y. Blakeslee, 39, and Maryrose F. Eichelberger, 42. There are eight member physicians in Florida, two each in New York and Massachusetts, and one each in New Jersey and California, company officials say.

Of why he changed, Sheff said, "It wasn't one episode -- it was a thousand cuts." He said: "It was being here late into the evening, struggling to return phone calls, apologizing daily about non-timely test results, apologizing to my family for not being around. Patients were asking me if I was okay, because I looked tired. This was not healthy for me, my practice or my patients."
So next month, Sheff and Pennington will begin providing care to a smaller group of patients -- up to 1,200 who are willing to pay.

Like the average primary care physician nationwide, Sheff and Pennington each had about 3,000 patients. Soon each will limit his practice to 600. A physician with a full MDVIP enrollment would collect $600,000 a year and send $300,000 to MDVIP for its continuing oversight.

"If this does as well as we hope it will, then Lee and I will be able to earn a more comfortable living with less stress and strain to our personal lives than before," Sheff said. "It will not make either one of us rich."

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.

Large H.M.O. to Make Treatment Guidelines Public. This is a very important advance in managed care.

Kaiser Permanente, the nation's largest nonprofit health maintenance organization, said yesterday that it would publish on its Web site the guidelines developed and used by Kaiser's doctors for treatment of hundreds of diseases, "from asthma to visual impairment." Kaiser also agreed to share with the public information about the way it pays doctors, including financial incentives.

The new guidelines, which are being published as part of a settlement of two lawsuits brought by consumer groups over patient care, are not compulsory, according to people familiar with them, so doctors will still be free to deviate from them without penalty. But Kaiser patients ? and the public ? will now have access to information they can use to assess the treatment they receive and discuss it with their doctors. Patients will have to look up the information themselves on Kaiser's Web site.

Consumer advocates said the moves by Kaiser would push other managed care companies and medical groups to make similar disclosures regarding both treatments and doctors' compensation.

The actions by Kaiser are the latest example of efforts to help consumers have more informed discussions with their doctors. Health policy experts say the disclosures may also help narrow the gaps in the treatments offered for identical diseases by doctors and health plans across the country.

"This sets a new standard for the competition and the doctors," said Dr. John Wennberg, a health policy scholar who has studied disparities in care and is an advocate for medical practices with clear evidence of effectiveness. "Patients seeking information on the standards of care will have a new place to go. They could use it in negotiating with their own physician."

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.

Medical blogs are starting to hit the big time. Medscape Enters the Blogosphere and Medscape.

Big Macs Can Make You Fat? No Kidding, a Judge Rules

The suit, which had not reached trial, sought class-action status on behalf of potentially millions of children and teenagers who buy McDonald's hamburgers, French fries and other products. The suit accused the fast-food chain of deceiving consumers about the high levels of fat, sugar, salt and cholesterol in its products.
The judge, Robert W. Sweet of Federal District Court, said there was no evidence that McDonald's had concealed information about its ingredients, and he said it was widely known that fast food, and McDonald's products in particular, contained high levels of such potentially harmful ingredients.

"If a person knows or should know that eating copious orders of supersized McDonald's products is unhealthy and may result in weight gain," Judge Sweet wrote, "it is not the place of the law to protect them from their own excesses."

He added wryly: "Nobody is forced to eat at McDonald's.

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.

Their lawyer, Samuel Hirsch, said the court had given the case a fair hearing. He added that he intended to file an amended suit in line with one aspect of the ruling, in which Judge Sweet suggested one avenue by which such a suit might be pursued.
The judge said that such a complaint could accuse McDonald's of altering its food during processing, thus creating an "entirely different ? and more dangerous ? food than one would expect" at home or in a restaurant other than McDonald's.
The judge noted, for example, that Chicken McNuggets, rather than being merely chicken fried in a pan, are what he called "a McFrankenstein creation of various elements not utilized by the home cook."

Such an argument, the judge added, "may establish that the dangers of McDonald's products were not commonly well-known, and thus that McDonald's had a duty toward its customers."

McDonald's argued that it was known that processing food can make it more harmful. The judge did not say how he might rule on such an allegation.

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!

High Court Considers Drug Pricing Plan

If the court signs off on an experimental program in Maine, other states would soon try the same thing, lawyers said. The court was hearing arguments Wednesday in an appeal brought by drug companies that claim the state overstepped its legal and constitutional bounds.

The Maine program, known as Maine Rx, would try to force drug companies to negotiate lower drug prices with the state, which would then offer the savings to the uninsured. The state estimates it would help more than 300,000 people who do not have prescription drug coverage.

If prices didn't drop in three years, the state could impose price controls.

Twenty-eight states are backing Maine, and about a dozen are poised to pass similar laws quickly if the Supreme Court sides with the state.

Business groups and conservative legal organizations sided with the drug industry, which lost a lower-court attempt to overturn the 2000 law. The law is on hold pending the drug companies' appeal.

The issue for the Supreme Court is whether the Constitution and the federal Medicaid law allow such freelancing by state governments. The Pharmaceutical Research and Manufacturers of America contends the state program violates Medicaid law and is an unconstitutional regulation of interstate commerce.

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.

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!

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

This time "is absolutely a crossroads," says John C. Norcross, a professor of psychology at the University of Scranton in Pennsylvania and author of three studies on New Year's resolutions. "But the interesting thing is that people who will ultimately have success in keeping their New Year's resolutions have already slipped as many times as those who will fail." In other words, having "succeeded" at three weeks is no better a predictor of successful long-term change than having "failed" by this point.

That's just one of the surprises in the field of behavior change -- an area of study poised to play an increasingly important role in public health as research continues to confirm that some of the most confounding, expensive and deadly conditions of the day -- heart disease, diabetes, obesity, high blood pressure, some arthritis, some cancers -- are the result of alterable behaviors. Eating the wrong foods, moving too little and failing to take recommended drugs are wreaking havoc on public health. Researchers need to understand how it is that some people can change unhealthy behaviors while others stay stuck where they are.

"It's very difficult to change a habit," concedes psychologist James Prochaska, a professor of clinical and health psychology at the University of Rhode Island.. "The majority of people can't make it on their first time."

But experts say that doesn't mean that anyone should stop trying, particularly just a few weeks into attempting a habit change.

"We expect instantaneous change in a nanosecond culture," Norcross notes. Yet we accept that other skills and behavior changes can take time to cultivate and integrate -- hitting a backhand in tennis, learning to read, driving a car or playing the piano. Those skills take months, if not years, to master and often involve long hours of practice and instruction. So it should be with common daily habits like overeating, sedentary living, overspending, having unhealthy relationships, smoking or drinking too much alcohol, Norcross says.

So try not to give up. Keep working at your change. Remember why you made your resolution - and recommit to your new plan.

Go Easy on That Drink

If consumed in moderation. Should we repeat that? In moderation. Thirty years ago government health officials forbade the authors of the first study showing alcohol's benefits to publish their results, fearing they would be misinterpreted. Now there are decades of studies on hundreds of thousands of subjects around the world that add up to a convincing link between a pattern of daily moderate drinking and health benefits, such as a decreased risk of heart attack. There is some conflicting evidence, and it's difficult to control for overall lifestyle, but researchers are fairly certain about at least this much: If you are a man in your fifties who has already had a mild heart attack, abstinence could be harmful to your health.

So the Post understands the issue. But at the end they wimp out!

The benefits of alcohol are preventative, and thus vague. The downsides are obvious in drunk-driving death statistics and other violence. So public health officials probably should do what they're already doing concerning alcohol, which is stay silent until the research holds steady for a decade or two more.

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!

Misguided drug plan

West Virginia Gov. Bob Wise wants a Canadian-style system to control pharmaceutical prices.
     But if he gets his way, West Virginians will have fewer drug choices and longer, more costly illnesses.
     Faced with a state budget crisis, deepened by rising Medicaid costs, Mr. Wise blames higher drug prices for West Virginia's fiscal woes and wants drug-makers to charge the same prices set by the Canadian government, not by the marketplace.
     But Canada's rigid price-control system isn't the answer. Because of its price-fixing, many of the newer and more effective pharmaceuticals for illnesses like cancer and hypertension are unavailable there.
     The price of many medicines here is high, but they treat or prevent illnesses that would cost people hundreds of thousands of dollars more than the medicines themselves. Price controls that impose disincentives to develop new drug treatments, or prevent the best drugs from getting to ill patients, would make health care worse, not better.
     A study by economist Frank Lichtenberg at Columbia University shows that every dollar spent on newer generations of drugs saved four times that amount in hospital costs.
     Citizens for a Sound Economy (CSE), a Washington-based free market group that is lobbying against Gov. Wise's plan, explains that "because prescription drugs are more often used for preventive care, they stave off more debilitating, more costly medical conditions requiring expensive and lengthy hospitalization. While a $600 annual prescription for two leading cholesterol-reducing drugs may seem expensive, it is the long-term effect of those drugs that helps avert an emergency bypass operation and lengthy hospital stay at an average cost of $300,000."

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.

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.

But as the OpEd points out (and as I pointed out a month ago, although I say it with far less shrill of a tone) the Thimerosal suits opened up the door to a new type of lawsuit concerning vaccines that, for whatever reason, the Vaccine Injury Compensation Program did not appear to cover. Failing to close that loophole means opening up the childhood immunization program (and, yes, the companies that make those vaccines) to a much greater risk of lawsuit, thereby jeopardizing the vaccine supply.

The vaccine ingredient bill should be refined to accommodate such things as extended statutes of limitations for injuries such as autism (should such a connection be definitively made), and to tie up the funding-related loose ends left out of the Homeland provisions. But it should not be revoked.

Congress weighs bill to stop Medicare 4.4% pay cut

A bill introduced by Rep. Bill Thomas (R, Calif.) on the first day of the 108th Congress would halt implementation of the physician fee schedule rule -- including the pay reduction -- released by the Bush administration in late December.

"One of the biggest problems is that physicians face significant and successive payment cuts that could harm patients' access to care," Thomas said. "Our newest legislation would block the 4.4% cut from taking effect."

The measure would rely on an infrequently used mechanism that allows Congress to overturn regulations issued by federal agencies within 60 days of publication. The Congressional Review Act limits debate in the Senate to 10 hours and bans filibusters.

The House approved a bill last year that would have replaced the 2003 cut with a 1.9% increase. The Senate, however, was unable to pass the measure as key lawmakers, including Sen. Charles Grassley (R, Iowa), balked at offering a bailout for physicians without including funds for other health care groups.

Grassley, who is now chair of the Senate Finance Committee, has objected to the Thomas bill this year because it would set aside other provisions contained within the physician fee schedule rule. Grassley is trying to broker an alternative approach in the Senate that would maintain physician payments at 2002 levels and provide some limited relief for rural hospitals.

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.

"Physicians have already taken a 5.4% cut in 2002," Dr. Coble said. "If Congress doesn't act by March 1, physicians will take cumulative payment cuts of 10% for treating our nation's seniors and disabled, with more cuts to come."

Dr. Coble said there was widespread agreement in Washington that the cuts resulted from a mistake in calculations and should have been fixed long ago.

Many physician practices already have decided to limit the number of new Medicare patients they will take, while others are contemplating a change to nonparticipating status this year. That would allow them to make up for the shortfall in government payments by billing their Medicare patients more.

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 mistakes. Maybe we should just sue them for malpractice!

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:

• Feet
• Lipids
• Eyes
• Control
• Kidneys
• Shots (immunizations)

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.

Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after diabetes diagnosis. (B)

Subsequent examinations for both type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing the presence of diabetic retinopathy and is aware of its management. Examinations will be required more frequently if retinopathy is progressing. This follow-up interval is recommended recognizing that there are limited data addressing this issue. (B)

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.

Methods We investigated all patients with type 2 diabetes registered with enrolled general practices (except those who were attending an ophthalmologist) who had retinopathy data available at baseline and at least one further screening event. To screen patients, we used non-stereoscopic three-field mydriatic photography and modified Wisconsin grading. Sight-threatening diabetic retinopathy was defined as moderate preproliferative retinopathy or worse, or clinically significant maculopathy in either or both eyes.

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?

Findings Results were obtained from 20 570 screening events. Yearly incidence of sight-threatening diabetic retinopathy in patients without retinopathy at baseline was 0·3% (95% CI 0·1-0·5) in the first year, rising to 1·8% (1·2-2·5) in the fifth year; cumulative incidence at 5 years was 3·9% (2·8-5·0). Rates of progression to sight-threatening diabetic retinopathy in year 1 by baseline status were: background 5·0% (3·5-6·5), and mild preproliferative 15% (10·2-19·8). For a 95% probability of remaining free of sight-threatening diabetic retinopathy, mean screening intervals by baseline status were: no retinopathy 5·4 years (95% CI 4·7-6·3), background 1·0 years (0·7-1·3), and mild preproliferative 0·3 years (0·2-0·5).

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

Interpretation A 3-year screening interval could be safely adopted for patients with no retinopathy, but yearly or more frequent screening is needed for patients with higher grades of retinopathy.

An accompanying editorial in the same issue - Screening interval for retinopathy in type 2 diabetes interprets the data.

Should the 3-year interval for dilated eye examinations in individuals without diabetic retinopathy be adopted as a new guideline for care? Some have argued that long intervals between follow-up visits may lead to difficulties in maintaining contact with patients and may give patients the impression that visual loss is unlikely and therefore not a concern. Further, it has been suggested that it is better to have a conservative guideline of yearly examinations with deviations based on evaluation of risk (eg, glycaemic and blood-pressure control) for each individual patient rather than having a uniformly longer interval. In addition, the ability to generalise the observations from the Liverpool study to other screening situations will depend on the comparability of the diabetic population being screened to those in Younis' study, and the sensitivity of the approaches used to detect sight-threatening retinopathy and other ocular conditions.

Before adopting new guidelines for intervals for retinal examination in individuals with type 2 diabetes, effectiveness in achieving a significant reduction in vision loss from diabetes at least similar to that achieved by routine yearly dilated-eye examinations should be demonstrated.

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.

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

The stereotypical heart attack patient is no longer a man in his 50's who suddenly falls dead.

"That death rate is so low now that we're no longer able to track it," said Dr. Teri Manolio, director of the epidemiology and biometry programs at the National Heart, Lung and Blood Institute. "It's almost gone."

Instead, the typical patient is a man or woman of 70 or older, who survives.

Statisticians at the institute calculate that if death rates were the same as those of 30 years ago, 815,000 more Americans a year would be dying of heart disease and 250,000 more of strokes.

"In the old days, you had a heart attack and you died," said Dr. Claude Lenfant, who has monitored the changes as the institute's director for the last 21 years. "You were almost signing the death certificate in advance. Now you know you can get another 20 or maybe 25 years."

Dr. Eugene Braunwald, a cardiologist who is the chief academic officer at Harvard Medical School's Partners Health Care System, said the reductions in the death rates were "one of the great triumphs of medicine in the past 50 years."
But these triumphs have brought new problems. Many more men or women in their 70's and 80's are surviving heart attacks only to live on with severe heart disease.

"These people aren't cured," Dr. Braunwald said. "They are maintained alive. We have converted heart disease from an acute illness to a chronic disease."

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.

Patients 'like smartly dressed doctors'

Patients feel more comfortable with doctors who are smartly and professionally dressed, researchers have found. Any attempt at a more casual dress-down approach appears not to put patients at their ease at all. And the very worst thing a doctor can wear to undermine their standing with a patient is a nose ring.

Stories like this one are pushing me to start a new blog titled - Unintended Consequences. Trial lawyers, special interests and vaccines

Since early November, when the homeland security bill was being debated in the Senate, Mrs. Stabenow and many of her Democratic colleagues on Capitol Hill have denounced the vaccine language as a special-interest measure benefiting big drug companies that would "severely limit parents' ability to get justice for their children." Mrs. Stabenow accused advocates of the vaccine measure of seeking "to reward powerful special interests under the guise of homeland security."

But these assertions by Mrs. Stabenow, (who according to the Web site opensecrets.org received $474,412 from trial lawyers during her 2000 Senate campaign, the seventh-highest total received by senators that year), stand the truth on its head. Her proposal, which will be voted on in the Senate in coming weeks, will hardly make Americans safer. Instead, it could well jeopardize public health and homeland security by making it less likely that essential, lifesaving vaccines ? including vaccines against diseases caused by chemical or biological weapons ? ever make it to market.

Victor Schwartz, a veteran Washington lawyer who serves as general counsel for the American Tort Reform Association, points out that Congress, with the support of liberals such as Rep. Henry Waxman, California Democrat, instituted the no-fault vaccine injury compensation program in the mid-1980s to provide a quick alternative to enable individuals to receive compensation when they are injured by a vaccine. Mr. Schwartz, who was involved in drafting that legislation, says that Congress always intended the program to cover ingredients along with the vaccines themselves. The provision of last year's homeland security legislation (which was added in response to trial lawyers' efforts to create an artificial distinction between vaccines and their ingredients) was nothing more than an effort to clarify this point.

What's more, the provision didn't take away anyone's right to sue. Instead, it allows people injured by vaccines and their ingredients the chance to quickly recover damages for their injuries from a compensation fund paid for by manufacturers. "Most people agree to a settlement through this fund, but if they are not satisfied with their award, they can then choose to file a civil lawsuit," Mr. Schwartz says.

By contrast, the Stabenow approach will effectively guarantee that, unless a vaccine ingredient works perfectly and without adverse side effects in every person who receives it ? an impossible standard to meet ? that the manufacturer could face a multimillion-dollar lawsuit. This will make it far less likely that vaccines, including ones that could protect Americans in the event of deadly attacks using chemical or biological weapons, will ever be produced. Already, the number of foreign and domestic vaccine producers has declined from roughly 24 in 1967 to just four today.

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

But, Mousie, thou art no thy lane
In proving foresight may be vain:
The best laid schemes o' mice an' men
Gang aft a-gley,
An' lea'e us nought but grief an' pain,
For promised joy.

For the entire poem - Robert Burns To a Mouse Maybe I should name the blog - Unintended Consequence - the best laid plans.

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.

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

The agency is suspending enrollment as of Friday for veterans with higher incomes who don't have military service-related ailments or injuries and use the VA for health care ranging from routine visits to heart disease.

The enrollment suspension, scheduled to last through 2003, goes against VA policy set in 1996 when Congress ordered the agency to open health care to nearly all veterans. The change is expected to affect about 164,000 veterans.

The chairman of the House Veterans Affairs Committee, Rep. Chris Smith, R-N.J., said the decision was disappointing, but "underscores the need to develop long-term solutions to VA's health care funding problems."

This decision will save the VA some moneys - and hopefully improve care for needy veterans. I expect this decision will create significant political controversy.

Bush Urges Nationwide Limits on Medical-Malpractice Awards

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:

The evaluation of acute pain in the right lower quadrant is a common clinical problem. The diagnosis relies heavily on an accurate history and physical examination. Figure 3 shows our proposed approach. A patient, male or female, who presents with acute abdominal pain that has migrated from the umbilicus to the right lower quadrant and that is associated with tenderness in the right lower quadrant should be taken directly to the operating room for an appendectomy. The expected diagnostic accuracy in these circumstances approaches 95 percent and is probably not improved by imaging. If the clinical presentation is equivocal or if there is the suspicion of a mass or perforation with abscess formation, we advocate CT imaging to help establish the diagnosis, as in the patient described in the clinical vignette. CT has demonstrated superiority over transabdominal ultrasonography for identifying appendicitis, associated abscess, and alternative diagnoses. We reserve the use of ultrasonography for the evaluation of women who are pregnant and women in whom there is a high degree of suspicion of gynecologic disease.

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.

Bush to Meet Docs on Malpractice Reform

President Bush was making a fresh pitch Thursday for his solution to high malpractice insurance costs: a nationwide limit on the amount injured patients can win from doctors.
In the 18th trip of his presidency to politically important Pennsylvania, Bush was calling on Congress to deliver on medical malpractice reform.

The president was to argue, in remarks at the University of Scranton in northeastern Pennsylvania, that lawsuits are behind soaring health care costs and doctor shortages and that limiting jury awards in medical malpractice suits is the way to solve the problem.

Before his remarks, Bush was to meet with doctors and officials at Scranton's Mercy Hospital.

"We are in a medical liability crisis because excessive and abusive litigation is driving up costs, decreasing access to quality care, threatening patient safety and leading to a badly broken system," White House deputy press secretary Scott McClellan said.

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?

Doctors in New Jersey Plan Job Action Over Insurance

"We need to do this for our patients," said Dr. John Poole, chief of surgery at Holy Name Hospital in Teaneck. "Just like you don't wait until a patient has a stroke to treat his high glucose levels, we want to take action now because our state is in a meltdown situation when it comes to malpractice insurance rates." Dr. Poole said he would refuse to perform elective surgeries "until they fix the problem."

The idea for a work stoppage rippled through the state's medical community in the last few days, by word of mouth, at meetings of county medical societies and by individual e-mails and faxes between doctors spurring others to join them.

The problem is not unique to New Jersey. The American Medical Association has made a list of 12 "crisis states" where higher premiums are forcing some doctors to leave their states, retire early or restrict their practices. New York State is also on the list. "This is our No. 1 legislative priority," said Dr. Donald J. Palmisano, president-elect of the American Medical Association. "There is a crisis in the nation and we are concerned about it spreading."

As usual the Governor, and I expect the legislature, thinks that this is the wrong strategy for the physicians.

"The governor and his administration have been working cooperatively with doctors, insurance companies and the lawyers to address the high cost of malpractice insurance," said Micah Rasmussen, a spokesman for Mr. McGreevey. "But the governor does not believe the doctors of New Jersey should be getting up in the middle of that process and deciding that they're going to put patients at risk by not living up to the Hippocratic oath."

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.

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.

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.

Published in today's Journal of the American Medical Association, the study is the first to measure treatment quality both in and out of hospitals in every state. Although it looked only at care given to Medicare patients -- mostly people 65 and older -- the findings in many cases almost certainly reflect changes that benefit younger people, as well.

For instance, many hospitals now require that every pneumonia patient ill enough to be admitted receive a first dose of antibiotics before leaving the emergency room. That greatly increases the chance that the medication will be started within eight hours. Studies have shown that patients who don't get antibiotics that soon are more likely to die.

"We hope the public will pay attention to these indications, because they are linked to survival rates," said David Shulke, executive director of the American Health Quality Association.

Like earlier surveys, this one revealed substantial geographic differences in quality. New England and the Upper Midwest performed best. All of the Deep South states were in the lowest quarter of the rankings.

To determine whether physicians and hospitals were following best practices, the researchers reviewed a random sample of medical charts (usually about 750 per state) and insurance claim forms sent to the government.

Although all 22 treatments or interventions in the study have been shown to be of unquestionable benefit, there was wide variation in how often physicians provided them.

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?

Jencks said he believes there are two reasons why practitioners fail to provide optimal care. Some don't know about the evidence or are unconvinced by it. For instance, most doctors trained more than a decade ago were taught not to vaccinate people with infections or fevers -- a prohibition that has since been found to have no scientific basis. Older practitioners may not know that, which could explain why so few pneumonia patients receive the vaccine while they are still in the hospital.

The more important reason is that hospitals and practices have not retooled their systems to assure that the best practices are used.

Carolyn Clancy, the acting director of the federal government's Agency for Healthcare Research and Quality, said getting hospitals and clinics to make simple measurements of performance is the first step.

"No [hospital] system thinks it's taking eight hours to give a patient antibiotics," she said.

These are very interesting theories. We must test those theories.

Pass the Nuts, Pass Up the Guilt.

"We can dispel the myth that eating nuts makes you fat," said Dr. Joan Sabaté, chairman of the nutrition department at the Loma Linda University school of public health in California. "Those that eat nuts tend to be thinner."

Preliminary evidence suggests that even though nuts are high in fat and calories, they help people lose weight and keep it off. They also help people stick to diets better than fat-free foods that are high in carbohydrates but have no fiber. The reason is that they provide a feeling of satiety.

The usual caveat applies, of course: the calories from nuts have to replace other calories ? you can't just add them on and expect to lose weight.
Defying the conventional wisdom that no more than 30 percent of calories should come from fat, dieters in a Harvard study who ate 35 percent of their calories from the more healthful fats ? the kind that nuts have ? were three times as likely to keep the weight off as those who ate a diet with just 20 percent of the calories from fat.

Research over the last 15 years strongly suggests that everyone's diet should include nuts, even though an ounce of unroasted nuts provides 157 to 204 calories and 13 to 22 grams of fat. Large studies including the Harvard Nurses' Health Study (86,000 women), the Physicians' Health Study (22,000 men) and the Adventist Health Study (more than 40,000 people) have confirmed the link between eating nuts and a reduction in heart disease.

The monounsaturated fat in nuts, like the fat in olive oil and avocados, helps lower low-density lipoprotein cholesterol, the bad kind, without affecting high-density lipoprotein, the good kind. The more nuts in the diet ? up to a point, of course ? the greater the drop in cholesterol. (The point seems to be two ounces a day, researchers say.)

I love this story. I love nuts, and have not eaten them enough. This information will influence my snacking (hopefully in a positive way).

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

A serious literary magazine published by a hospital? Sounds unlikely. But the Bellevue Literary Review, published by the New York University department of medicine at Bellevue Hospital, is drawing on a long literary heritage. Bellevue has nursed William Burroughs, Eugene O'Neill and many other close-to-the-edge writers and artists. Danielle Ofri, the review's editor-in-chief and a doctor at Bellevue, believes scientists and doctors too often dismiss the power of language. Words, she tells Michael Bond, are a vital part of the healing process.

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.

A study that appeared in the New England Journal of Medicine in 1996 surveyed a large sample of Pennsylvania's cardiologists and cardiovascular surgeons to determine how the publication of those statistics affected the delivery of medical services.

The most disturbing finding, according to the authors, was that cardiovascular specialists believed that access to care for very ill patients had decreased due to the publication of these report cards. Fifty-nine percent of cardiologists reported that it had become much more difficult to find a surgeon willing to operate on the most severely ill patients. Likewise, 63 percent of cardiovascular surgeons reported that they were less willing to operate on the most severely ill patients.

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.

In the world of medical statistics, there are different ways to calculate survival. One is called absolute survival, a figure, usually cited as a percentage, that reflects how many patients receiving a particular procedure survive. The other, called "expected survival" or "risk-adjusted survival," takes into account a patient's unique characteristics -- such as underlying illness, age and lung function, for example -- that may affect his or her likelihood of surviving. Many experts believe surgery programs cannot be compared properly until all are viewed according to risk-adjusted criteria.

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.

To funders of medical care, the reliance on absolute survival statistics seemed to make sense. According to one Medicare official, when developing standards in the early 1990s agency staff felt that scarce organs should be given to patients who had the best chance of surviving surgery, and a center's absolute survival statistics would be an indicator of its quality. Medicare also did not want to compensate hospitals for undertaking high-risk surgeries. It looked skeptically upon risk adjustment, viewing it as a statistical manipulation to justify a program's decision to give an organ to someone who might die early.

But it can be done correctly. This requires proper data collection. Many cardiovascular surgeons participate in a program that does the risk adjustment.

Some hospitals that fared well on HCFA's list used the data in self-serving advertisements, so in the late 1980s, the VA and the Society of Thoracic Surgeons (STS) developed national cardiac databases to adjust outcome data for risk. More than 2.2 million cardiac patients have been entered into these databases, the largest undertaking of its kind in medicine. Approximately 450 of an estimated 700 cardiovascular practices nationwide participate voluntarily in the STS database.

The first step in this complicated process is to construct a model that predicts outcome. The most commonly used statistical method, logistic regression, produces a formula to calculate the probability of an outcome as influenced by "predictor" variables. Today, the VA database includes 10 predictor variables, while the surgeons' group database uses 25. A surgeon's adjusted death rate is calculated from these models and compared with his absolute death rate.

Michael Frank, a cardiovascular surgeon at Evanston Northwestern Healthcare in Illinois, says the STS computation has allowed him to take on the tough cases.
Early in his career, Frank said, he made an ethical decision to use his surgical skill to improve the lives of the sickest patients. Studies show that patients who have three narrowed coronary arteries (vs. one or two), poor contraction of the heart and diabetes have the most to gain from bypass surgery, but also the most to lose because of possible cardiac events during and after surgery. These patients make up more than half of Frank's practice, a larger share than most heart surgeons? Most young surgeons hesitate to operate on these very ill patients because too many deaths too early could impede their careers. A high mortality rate could make it hard for a surgeon to join reputable programs and it could increase malpractice insurance rates. Likewise, taking on tough cases could expose a surgeon to a greater risk of litigation.

Frank's two-year absolute mortality rate was on par with the national average. However, his risk-adjusted mortality rate indicated he was providing superior surgical care: His ratio of observed to expected mortality was 0.39. In other words, only a third of Frank's patients who, because of their risk factors, would be expected to die actually did so.

"A good report in the risk-adjusted category empowers me to continue taking on high-risk patients. It is positive feedback," Frank said.

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.

Liza Iezzoni, professor of medicine at Harvard and board member of the National Quality Forum, a public-private organization that focuses on improving the quality of health care, believes outcome data should be used constructively, not punitively.
"Outcome data is invaluable when it motivates physicians to be introspective and evaluate processes of care. But I am concerned when third-party payers use outcome data to punish health care providers, because this type of data does have inherent limitations."

All of the participants in the health care system -- HMOs and third-party insurers, physicians and patients -- require meaningful information about quality of care. If the data being collected and analyzed are incomplete, the conclusions are not meaningful, and can produce disastrous consequences. Entire patient populations can be left without options. Good doctors can make bad decisions to manipulate data that is not truly connected to quality.

A movement designed to protect patients and improve the quality of care can wind up having precisely the opposite effects.

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 Puzzling

Most States Are Cutting Medicaid Benefits, Study Says.

States facing tight budgets and growing Medicaid costs are cutting back on prescription drugs and dental care while increasing co-payments for people who use the program, an independent study released Monday says.

The study found that all states except Alabama have cut spending or plan to cut spending this year on Medicaid, the health insurance program that serves 42 million poor, disabled and elderly Americans. That includes 32 states that made cuts when the fiscal year began last summer and have found it necessary to cut yet again.

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?

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!

Food for thought

Many of us have made resolutions to lose weight, exercise more and eat healthier in the New Year, and while there are ample reasons to do so, discovering the right diet might be more difficult than getting three square meals or strictly following the Department of Agriculture's food pyramid.

There's little doubt that losing pounds can add years to one's life. According to a study published last week in the Annals of Internal Medicine, non-smoking individuals who are overweight (based on body-mass index) at 40 are likely to die about three years sooner than their slimmer counterparts, those who are obese at 40 are likely to die about six years sooner. Smoking cuts life spans just as much.

However, those of us trying to slim down by strictly following the food pyramid may be doing ourselves less good than we hope, according to Drs. Walter Willett and Meir Stampfer, chair of Harvard's Department of Nutrition and head of the Department of Epidemiology, respectively. In a thought-provoking article in this month's issue of Scientific American, they contend that the food pyramid is "grossly flawed," because it treats all carbohydrates as equally good and all fats as equally bad.

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:

Because the goal of the pyramid was a worthy one--to encourage healthy dietary choices--we have tried to develop an alternative derived from the best available knowledge. Our revised pyramid emphasizes weight control through exercising daily and avoiding an excessive total intake of calories. This pyramid recommends that the bulk of one's diet should consist of healthy fats (liquid vegetable oils such as olive, canola, soy, corn, sunflower and peanut) and healthy carbohydrates (whole grain foods such as whole wheat bread, oatmeal and brown rice). If both the fats and carbohydrates in your diet are healthy, you probably do not have to worry too much about the percentages of total calories coming from each. Vegetables and fruits should also be eaten in abundance. Moderate amounts of healthy sources of protein (nuts, legumes, fish, poultry and eggs) are encouraged, but dairy consumption should be limited to one to two servings a day. The revised pyramid recommends minimizing the consumption of red meat, butter, refined grains (including white bread, white rice and white pasta), potatoes and sugar.

Trans fat does not appear at all in the pyramid, because it has no place in a healthy diet. A multiple vitamin is suggested for most people, and moderate alcohol consumption can be a worthwhile option (if not contraindicated by specific health conditions or medications). This last recommendation comes with a caveat: drinking no alcohol is clearly better than drinking too much. But more and more studies are showing the benefits of moderate alcohol consumption (in any form: wine, beer or spirits) to the cardiovascular system.

Read their work, and study it. There is a test! Your health benefits from passing this test.

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!

We all know we should exercise. But we?re too busy and too tired. And we?re also increasingly confused: How much is necessary? Is it 60 minutes (gasp!) most days of the week, as the Institute of Medicine suggested last fall? Or 30 minutes? Three days a week or five? Running or mall walking? Researchers are attacking those questions and they?re delving even further into how physical activity affects our bodies at the molecular level. No matter how far the science goes, though, there?s one finding that will remain indisputable: any amount of exercise is better than none. ?Being active and fit is good for you whether you?re young or old, man or woman, tall or short, skinny or fat,? says Steven Blair, president of the Cooper Institute in Dallas, a health-research group.

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 where does the 60-minute recommendation fit in? When it was issued in September, the Institute of Medicine report seemed to fly in the face of the surgeon general?s guidelines, but the two may not be quite as incompatible as they seem. The 30 minutes is aimed at reducing the risk of chronic disease in the future. The 60 minutes, on the other hand, is paired with dietary recommendations and focuses on weight control in the present. Researchers found that among healthy people with a body mass index (a ratio of weight to height) of less than 25 (with 18.5 to 25 being desirable), 60 minutes of physical activity was necessary to maintain body weight and avoid excess gain. But the finding should not negate what the CDC recommends, says Dr. Ben Caballero, who was a member of the Institute of Medicine panel and is director of the Center for Human Nutrition at Johns Hopkins school of public health. The two ?guidelines, he says, ?are complementary.?

...

Any exercise program should also include resistance training for 20 minutes three times a week, using weights or exercise bands, or doing push-ups or squats. Weight training increases muscles and improves bone density?critical for baby boomers who?d rather bungee-jump than use a walker. ?There?s no other way you retain muscle mass and strength,? says William Haskell, an exercise specialist at the Stanford School of Medicine. Better strength also means fewer falls, which are the leading cause of death from injury in people older than 65. And new research suggests resistance training can even be good for the ticker, too: the Harvard runners study found that men who trained with weights for 30 minutes or more per week cut their risk of heart disease by 23 percent.

So when will you exercise this week. Make a plan and stick to it. You owe it to your body.

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.

Dr. Robert Atkins, the king of the high-protein and low-carbohydrate diet, and Dr. Dean Ornish, a staunch proponent of the low-fat lifestyle, have become the Norman Mailer and Gore Vidal of the diet industry, duking out their opposing views on television and in newspapers and magazines.

Now the battle between the doctors and their companies and products is spilling over into the advertising world.

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?

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

Of five types of brushes examined, only the "rotational oscillation" design of the Braun Oral-B device was clearly more effective than manual toothbrushes, the researchers concluded. Compared to manual brushes, that design removed about 11 percent more of the build-up on teeth known as plaque, and reduced by about 17 percent the development of gum disease, or gingivitis.

Thanks to overlawyered.com for this link. MDs will fly the coop rather than play chicken

Here is where the capitalist-bashing approach of the Democrats comes up against reality. The Democrats' assertion is that this crisis is illusory, that there has been no boom in malpractice judgments. The dollar figures say otherwise. In 1975, insurance companies paid out a mere $521 annually per doctor in judgments and defense costs, according to Americans for Insurance Reform. By 2001, that figure had risen to an astounding $7,232 per doctor. Even after accounting for inflation, payouts per doctor rose by more than 400 percent in a mere 26 years. If payouts had stayed flat, there would be no crisis regardless of how the stock market performed. But costs rose and premiums had to rise accordingly.

But did premiums rise by too much? A Star-Ledger editorial offered the very reasonable suggestion that New Jersey adopt a system similar to that in use in California. Any annual increase of more than 15 percent needs state approval in California.

Great idea. But before capping premiums, California first capped judgments, with a 1975 tort reform law that is the model for the nation. New Jersey Democrats reject that approach. They seem to be arguing that we can cap premiums without capping judgments. Can we? Fine, let's not wait until Thursday. Let's do it tomorrow.

That would take the doctors out of it and put the administration on a collision course with the insurance companies. If the Democrats are right, the companies will reduce their premiums and the crisis will end. If they're wrong, they'll create a mess similar to the car insurance crisis.

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?

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.

Why does a society provide good news with a grim face? No one appears to be the Minister of Fun around here because no one seems allowed to whoop with pleasure when a rather cheerful finding is published in the New England Journal of Medicine to the effect that moderate but relatively frequent drinking can reduce the risk of heart attack.

Well said; we should all celebrate (in moderation of course).

'Fat Land': Supersizing America is a book review.

Just since 1970 the proportion of American children who are overweight has doubled, a rate of increase that suggests the fattening of America has a specific history as well as a biology. ''Fat Land,'' a skinny book about this big subject, is the journalist Greg Critser's highly readable attempt to reconstruct that history.

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.

Critser doesn't put it quite this way, but his subject is the nutritional contradictions of capitalism. There's only so much food one person can consume (unlike shoes or CD's), or so you would think. But Big Food has been nothing short of ingenious in devising ways to transform its overproduction into our overconsumption -- and body fat. The best parts of this book show how, in the space of two decades, Americans learned to eat, on average, an additional 200 calories a day. In the words of James O. Hill, a physiologist Critser interviewed, getting fat today is less an aberration than ''a normal response to the American environment.''

When one reviews why 'agribusiness' has had such success, one starts to understand the problem. As usual we are the victims of 'unintended consequences'.

Now we find ourselves confronted with the unintended consequences of cheap and abundant food, foremost among them the epidemic of obesity. Critser takes us on a brisk tour, by turns funny and depressing, of a society learning to accommodate itself to its new dimensions: restaurants adding square inches to their seats; government agencies relaxing their weight, fitness and dietary guidelines; Seventh Avenue recalibrating clothing sizes to make for happier visits to the dressing room. Less amusing is what our weight is doing to our health, and Critser is sure-footed and clear in describing the science of obesity, especially the precise mechanism by which our diet has led to an epidemic of Type 2 diabetes. What used to be called adult onset diabetes now afflicts millions of children as well as adults, and costs America's health system billions of dollars a year.

As I wrote yesterday, the only answer is personal responsiblity. The book's author comes to the same conclusion.

George W. Bush has defined this as ''the era of personal responsibility'' and finally it is under this banner, so congenial to business, that Critser marches, seemingly in spite of himself and his best journalism. So instead of seriously entertaining any public solutions to what he has so convincingly demonstrated is a public problem, Critser ends by imploring us to eat less, get off our duffs and, incredibly, bring back gluttony as a leading sin. Personal responsibility is all to the good, but everything else in ''Fat Land'' suggests it is probably no match for the thrifty gene and the Happy Meal.

I suspect the book is even more sobering than the very well written review.

Marcus Welby Doesn't Live Here Anymore: How Bismarck and the Tooth Fairy created the health-care "crisis."

Interestingly, the rise in total outlays was not mainly because costs rose but for the quantity of medical care used. There is no other explanation: For Americans, consuming medicine and health has become a major pastime.

When politicians and policy makers meet now to talk about health care in America, they discuss it almost wholly as an interplay of economics, money and insurance. Theirs is a world of utilization rates, first-dollar coverage, provider profiles, outcomes and other such arcana. But for all the effort, if you look at the way we pay for health care today, there has been little real innovation around the subject in more than 100 years.

We live amid an unimaginable cornucopia of medical opportunities, but our relationship to the medical industry hasn't changed in its essential features since Otto von Bismarck mandated health insurance for Germans in the 19th century. We don't light our homes with kerosene anymore, but we still consume medicine the old-fashioned way: We buy some medicine from a doctor or hospital, who sends us a bill, which we or they send to someone somewhere else, and this someone somehow pays for whatever medicine we "bought."

For a hundred years this is the only thing in life that's been paid for by the Tooth Fairy--whether Medicare, Medicaid or private insurance companies. So how can it surprise anyone that the average American asks the Tooth Fairy to buy him, every year, more than $5,000 of medicine's wonderful products? Politicians may profess to be appalled, but surely no one is shocked that Medicare and Medicaid are crushing public budgets. Not a single consumer of medicine has the faintest clue what the "budget" for medicine is, and therefore no stake in using the system prudently.

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!!

There is no need to detail here the explosion in medical knowledge, pharmaceuticals and technology the past 40 years. It is one of the wonders of all history. Less noticed, I think, is what the suddenly marvelous world of medicine has done to create a culture of health. Before, we didn't think about it, until we got sick and went to see Doc Welby. Today we in the middle class think about our health all the time. It's still about life and death--but it's also a "lifestyle issue."

The author makes relevant points. We must change our thinking on this issue, as the old models really do not work.

Research Links Food Stamps and Obesity. If you have blinked twice on this story, join me. I really do not even believe the title!

Besharov said that how much people eat is directly connected to how much they?re given.

"When we give poor families food stamps instead of cash, we know that they will consume 20 percent more food," Besharov said. "That might be great at a time of hunger and malnutrition, but at a time of obesity, that?s a mistake."

The overeating epidemic is growing fastest among poor kids: 16 percent of low-income children are either overweight or obese, twice the rate of other children. That puts federally-funded school breakfast and lunch programs ? which are mandated to provide 60 percent of students? total daily caloric intake ? under the microscope.

Besharov thinks the government should continue to fund food programs but needs to change the emphasis from quantity and caloric intake to nutrition counseling and healthy eating habits.

I do not make up this stories - honest. People say and do these things.

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.

When Cure Is Worse Than Disease

I would have thought, naively I guess, that spending a lot of money on health care is a sign of success and wealth, a worthy priority. Where better to blow some money?

Last year, Drew Altman and Larry Levitt of the Henry J. Kaiser Family Foundation published a short paper that showed that no policies to contain health care costs have ever worked. From the initiation of Medicare and Medicaid in the 1960s, to wage and price controls in the mid-1970s, to Jimmy Carter?s ?Voluntary Effort? in the late-1970s, to managed care and the threat of drastic, Clintonesque reform in the 1990?s, nothing has held down health care costs.

Altman and Levitt suggest ?that the apparent failure of all approaches reflects the American people's uncontainable desire for the latest and best health care, and that what we will do in the future is try small things that will work at the margin, complain a lot, but ultimately pay the bill.?

And that?s okay. Unreasonable expectations and complaining are the American way.

So, as I have written previously, maybe rising health care costs are not a HUGE problem.

Diet Dispute

U.K.-based psychotherapist Susie Orbach, author of Fat Is A Feminist Issue, is planning a lawsuit against Weight Watchers on behalf of what she says are thousands of women and men who have paid out many hundreds of British pounds to the company, only to end up fatter than before they started the program. Orbach's main argument: diets simply don't work, and the dieting industry profits from the large number of people who come back to the program after they gain the weight back.

"I believe that it is the very 'problem' of recidivism that has made Weight Watchers its fortune," wrote Orbach in an editorial in London's Daily Mail last month.

Orbach has claimed that nine out of 10 Weight Watchers graduates fail to keep off the pounds they've lost, a figure the company disputes.

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

Proactivity

Being proactive means taking initiative, not waiting for others to act first, and being responsible for what you do. The opposite of proactive is reactive. Reactive people react to what goes on around them. Proactive people act based on principles.

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.

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

Investigations aside, why can't the Federal Government simply step in to aid consumers who are wasting billions of dollars a year on "remedies" that are ineffective at best, and occasionally harmful? The answer lies in the 1994 Dietary Supplement Health and Education Act, which was passed by Congress after extensive lobbying by the health food industry. Its passage was eased by the strong support of such medically illiterate politicians as Senator Tom Harkin (who believes in the healing powers of bee pollen), Senator Orrin Hatch (whose state of Utah is a hub for herbal manufacturers) and Representative Dan Burton (the most rabid Congressional opponent of vaccination). The act allows natural supplements to be marketed without any proof of their purity, safety or efficacy. Producers of these supplements are largely exempt from regulation by the Food and Drug Administration, which can take action against them only if they make claims about their products curing or alleviating disease ? or if, say, their customers start dropping dead.

Amen!

I have said this before. Here are more data in support of moderate alcohol. Drink Often, Heart Study Suggests.

Men who drank at least three days a week ? whether beer, red or white wine, or liquor ? had about one-third fewer heart attacks than did nondrinkers in a study being reported today in The New England Journal of Medicine. It made almost no difference whether they consumed half a drink or four.

Among those who drank just once or twice a week, the risk of heart attack fell only 16 percent.

Dr. Kenneth Mukamal of Harvard Medical School, who led the study, speculated that regular, moderate drinking is beneficial because it helps keep the blood thinned.

The researchers used data from a long-term study of 51,529 male health professionals. They set aside those who had stopped drinking in the last 10 years and those with histories of cancer or diseases of the heart or blood vessels. That left them with the medical histories of 38,077 men for their own study.

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.

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

But neither the Times nor the NHLBI told the whole story: Most of the cheaper-is-better rhetoric rests largely on the fact that there was a 40-percent increase in strokes in African Americans receiving ACE inhibitors instead of diuretics. And it turns out that the increase was a function of the study design: Heart specialists know that blacks are less likely to die of stroke on diuretics. Yet many blacks in the study received the ACE inhibitors first and were not allowed diuretics anyway, since the inhibitors were being tested against the other drugs. It is not a far stretch to say this study demonstrated the stroke benefit of diuretics by unfairly denying blacks optimal care. What would have happened if blacks had been treated appropriately in the first place?

Indeed, since combination therapy is crucial to superior outcomes, it's curious the study should have obsessed about the drug-to-drug face-off. The hypertension study found that in the first year, about 17 percent of all patients each were randomly assigned to a medicine had switched to another drug for reasons including such side effects as increased cholesterol or risk of diabetes. In the first year, at least 25 percent of all patients were taking one or more other blood-pressure drugs in addition to the one assigned to them in the experiment. By the end of the study ? the fifth year ? 40 percent of all patients were taking a combination of drugs that included beta blockers (which were not even evaluated in the head-to-head part of the study).

This analysis resembles mine at the time of the study release. The author is a bit more strident than me -

Large-scale trials should focus on comparing approaches to treatment ? not just drugs. As the study shows: Unless they compare all patients in all circumstances, trials tell us little more than what we want to hear. The NHLIB study must receive further scrutiny before the politicians and pundits begin attempting to dictate Medicare prescription-drug policy. To do any less would be to allow medical research to become a political tool, and to place life-and-death decisions in the hands of the New York Times and elected officials, not doctors and patients.

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!

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

Surgeons in West Virginia have gone on strike to protest the exorbitant cost of malpractice insurance. Good for them. Don't talk to me about the ethics of doctors going on strike. So long as they agree to treat emergency cases, they have as much right to strike as anybody else. The premise of a free market is that people can withhold their labor if they find the conditions under which they work intolerable.

Many doctors do. Many, especially those in the inherently risky specialties, such as surgery or obstetrics, have been forced out of business by malpractice premiums or hounded out by malpractice litigation. A totally irresponsible legal system, driven by a small cadre of lawyers who have hit the mother lode, has produced perhaps the most dysfunctional medical-liability system in the world. Juries hand out millions of dollars not just for lost earnings but also in capricious punitive damages in which the number of zeros attached to the penalty seems to be chosen at random.

Please read the entire piece. Krauthammer has nailed this subject!

The Institutue of Medicine has released 20 health care priorities - areas on which we should focus greater efforts. Ensuring World-Class Health Care

The priority areas, which were not ranked, are:
Asthma, doing a better job of supporting and treating those with chronic conditions.

Care coordination for the approximately 60 million patients with multiple chronic conditions.

Children with special health and care needs, particularly those with chronic conditions who require more than the normal level of care.

Diabetes, which can lead to high blood pressure, heart disease, blindness and other complications.

End-of-life care for people with advanced organ failures, concentrating on reducing symptoms.

Evidence-based cancer screening, which can reduce death rates for many cancers, including colorectal and cervical.

Frailty associated with old age, focusing on preventing falls, treating bedsores and improving advanced care.

High blood pressure. One-third of victims aren't aware of the disease, but left untreated it can lead to heart attack, stroke and kidney failure.

Immunization. "Every year diseases that can be prevented kill about 300 children and between 50,000 and 70,000 adults," the committee said. Major killers: flu and pneumonia.

Ischemic heart disease, also known as coronary heart disease. Efforts should focus on prevention.

Major depression, which currently has a much lower treatment rate that other major diseases.

Medication management to prevent errors.

Noscomal infections. These are infections acquired in the hospital and kill an estimated 90,000 Americans annually.

Obesity, which is blamed for as many as 300,000 deaths annually in the United States.

Pain control in advanced cancer.

Pregnancy and childbirth, especially improving the quality of prenatal care.

Self-management and health literacy, using public and private organizations to increase the level of health education.

Severe and persistent mental illness; improving mental health care in the public sector, including state hospitals and community centers.

Stroke, the third highest cause of death in America.

Tobacco-dependence treatment for adults.

Not a bad list in my viewpoint but let me add this disclaimer - I once served on an IOM panel.

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.

The major reason for the increase in health spending, Ms. Levit said, was an increase in the amount of medical goods and services purchased to care for an aging population.
"There was some increase in prices, but it was not as large as the increase in quantity," Ms. Levit said. The increase in quantity took many forms: more days spent in hospitals, more outpatient services, more diagnostic tests, more prescriptions and greater use of new technology, which has the potential to extend life and improve its quality.

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.

Democrats said the new data to supported their view that Medicare was more efficient than private insurance.

"Medicare increased payments to providers such as hospitals, home health agencies and nursing homes and still managed to keep overall spending growth to 7.8 percent in 2001," said Representative Pete Stark, Democrat of California. "Meanwhile, private insurance premiums went up 10.5 percent. Given these results, I cannot understand why Republicans continue to devise plans for turning Medicare over to private health insurers and H.M.O.'s."
But Republicans said that consumers had little incentive to shop for bargains in the health care market because they were insulated from most costs. Of every $100 spent on health care, consumers pay $14 from their own pockets, for co-payments and deductibles and items not covered by insurance.

Even though 41 million Americans are uninsured, the United States devotes more of its economy to health care than other industrial countries. In 2000, health accounted for 10.7 percent of the gross domestic product in Switzerland, 10.6 percent in Germany, 9.5 percent in France and 9.1 percent in Canada, according to the Organization for Economic Cooperation and Development.

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) -

U.S. health care spending grew 8.7 percent to $5,035 per capita in 2001. Total public funding continued to accelerate, increasing 9.4 percent and exceeding private funding growth by 1.2 percentage points. This acceleration was due in part to increased Medicaid spending in the midst of a recession and payment increases for Medicare providers. Prompted by sluggish economic growth and by faster-paced health spending, health spending?s share of GDP spiked 0.8 percentage points in 2001 to 14.1 percent.

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 -

I'm a physician in a college health center, so pharyngitis is one of those things I just have to love. In essence, I think we're just mostly out to lunch on the whole approach.

First, Group C strep can be just as painful and is just as common as Group A, but there's no rapid test for this one. Does penicillin decrease morbidity with Group C? Maybe, but nobody knows for sure. Why do we treat Group A infections with penicillin? To reduce the likelihood of rheumatic fever. How likely is rheumatic fever to occur in the West? It's become an incredibly rare complication. Thus,we're still trying to prevent something that just almost never happens, anymore.

The principle issue is one of comfort, not highly invasive disease. If we just had something great to help with the throat pain and the angst, no antibiotics and minimal testing would be necessary . A Mayo ENT study showed that a single 10mg tablet of dexamethasone gave substantial relief to anyone with a sore throat of any cause. Giving it did not cause any adverse events. We're conditioned against using systemic steroids in the face of infection, but I wonder if this isn't actually the most rational approach.

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.

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

Nonsmokers who were classified as overweight, but not obese, lost an average of three years off their lives. Obese people died even sooner. Obese female nonsmokers lost an average of 7.1 years, while obese male nonsmokers lost 5.8 years.

Scientists have long known that overweight people have shorter life expectancies, but few large-scale studies have been able to pinpoint how many years they lose.

"This study is saying that if you are overweight by your mid-30's to mid-40's, even if you lose some weight later on, you still carry a higher risk of dying," said Dr. Serge Jabbour, director of the weight-loss clinic at Thomas Jefferson University Hospital in Philadelphia. "The message is that you have to work early on your weight. If you wait a long time, the damage may have been done."

For smokers, the results were worse. Obese female smokers died 7.2 years sooner than normal-weight smokers and 13.3 years sooner than trim nonsmoking women. Obese male smokers lived 6.7 years less than trim smokers, and 13.7 years less than trim nonsmokers.

Sobering data, maybe this will stimulate some readers to start exercising and watching their diet.

Dr. Abigail Zuger writes in the New York Times - In an Age of Specialists, One Doctor Is Primary.

A jaundiced eye might read here a depressing postmodern portrait of what primary care has become: secretarial work with a little gatekeeping thrown in, certainly not doctoring in any traditional sense of the word.

Apparently all the standard medical care Robert gets these days ? the latest tests and treatments ? is provided by Doctors 1 to 5.

But if you ask Robert about Doctors 1 to 5 he shrugs, barely remembering their names. Ask him about No. 6 and a soft smile crosses his face. "I don't know what I would do without him," he says. "He's kept me alive all these years."

And there you have the continuing tangled contradictions of primary care medicine, an entity now so battered by market forces and reshaped by scientific changes that no one can quite figure out what it is anymore. Some experts are ringing its death knell, others are energetically reviving it ? and in the meantime it still somehow occasionally survives in its purest form.

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.

In a new book of oral history, "Big Doctoring in America" (University of California Press, 2002), 15 primary care providers from around the country describe what else is involved. They have little in common but an affirmation that primary care is "whole person care." One does his bit for the whole person in the executive offices of a managed care organization; another passes out blankets and mittens to the urban homeless. Several are not doctors at all, but nurse practitioners and physician assistants.

...

Primary care is "being a navigator," he said in an interview. "It's being a quarterback," knowing when to help, when to direct, when to pass. It's being "a team leader in an enterprise that's far more complicated and demanding than one person can do any more."

As policy makers scan the forest of health care, someone needs to be taking care of the trees ? it's being a "tree-type."

Or as Robert will gladly tell you, primary care is whatever it takes for any patient, even the sickest, to feel cared for.
It may actually need no definition because anyone lucky enough to stumble into it knows exactly what it is.

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?

Patient reporter: Our columnist goes under the knife. This reporter had significant supraventricular tachycardia (SVT). The cardiologists cured her. Read her story.

It's official: Unless Congress acts, Medicare physician pay will be cut 4.4%

"CMS recognizes that this will be the second year in a row in which physician fees will be affected by a negative update," CMS Administrator Tom Scully said. "Nothing would make us happier than to not be issuing this rule today."

Scully said the administration had no choice under the law but to issue the negative update, even though the agency believed a 1.6% increase in rates was appropriate.

"The reduction in physician fee schedule rates results from a formula specified in the Medicare law, and we believe that the formula is flawed and must be fixed," Scully said. "The administration has been, and continues to be, anxious to work with Congress to fix flaws in the formula as soon as possible. We want doctors and patients to see Medicare as a trustworthy partner in providing quality services."

The American Medical Association is urging lawmakers to put an update correction at the top of the new Congress' agenda in January.

"Last Congress, the House of Representatives passed two bills to help avert the cuts, but the Senate left Washington without fixing the Medicare payment mistake that is threatening access to care for America's seniors," said AMA President Yank D. Coble Jr., MD. "Now the next round of cuts is imminent on March 1, leaving just a tiny window of opportunity for Congress to stop the crisis when lawmakers return in January."

I certainly hope that Senate (the bottleneck on this issue) will act swiftly with Dr. Frist as Majority Leader.

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.

Obesity on trial Restaurants, food firms: Lawsuits wrongly blame their food

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?

Doctors Belong in Hospitals, Not Courtrooms

We doctors are now obsessed with the legal system. When I'm in the surgeons' lounge at my hospital, I don't feel like a doctor, given all of the legal jargon flying back and forth among my colleagues. Instead, it feels as if I'm in some sort of lawyers' confab. Rather than discussing medicine, we talk about which colleagues have retired early because their malpractice premiums hit six figures. It's the same at professional meetings. Instead of attending lectures on the latest advances in our specialties we sign up for the ever more frequent workshops on the finer aspects of tort law.

I went to medical school to become a doctor, not to become a moderately knowledgeable legal hack. I don't want to practice defensive medicine, ordering unnecessary tests out of fear of litigation. I don't want to evaluate new patients for signs of litigiousness instead of disease. I don't want to squeeze extra patients into my schedule just so I can pay down my malpractice premiums.

But the system is now compelling me to do all these things ? and I know many of my colleagues feel the same way. In some states doctors in the more high-risk specialities like neurosurgery and obstetrics pay as much as $200,000 a year for malpractice insurance. I have not been sued for malpractice (yet). But my insurance premiums increase each year anyway, forcing me to raise my rates, too. If I'm a good doctor, why do I ? and you ? have to pay for the errors of others?

Making it more difficult to file malpractice suits and imposing caps on excessive awards for pain and suffering, as the surgeons in West Virginia are demanding, is a start. But this won't get to the deeper problem: Mistakes do happen, and they have consequences, sometimes dire ones. Rather than focusing on rewarding victims and their lawyers, we should concentrate on creating fewer victims ? that means changing how we train doctors, track and correct errors and mete out punishment.

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.

Malpractrice insurance madness

But West Virginia, as readers of this editorial page know, is but one example of the festering national problem of lawsuits which are driving up insurance costs for conscientious doctors. The American Medical Association, for example, has listed West Virginia and Pennsylvania among more than 15 states whose health-care systems are threatened by or on the verge of crisis due to the proliferation of medical malpractice lawsuits.

It's long past time for responsible legislators on the state and federal level to say no to the excesses of trial lawyers and yes to responsible doctors and their patients.

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.

The LA Times has an interesting group of articles today (free registration required) - Five views on nutrition.

...we asked five of Southern California's leading dietary professionals what they recommend for weight loss. We also wanted to know if they practice what they preach, what dietary tricks they use and how they feel about the current nutrition debates (carbohydrates versus protein, for one).

Their advice -- and their core messages -- vary. One focuses on getting children off to a good start, another believes people's preferences must be factored into their diet, a third recommends radical wholesale changes -- and two others tout gradual modifications.

However, they did agree on three key points: We need to eat more vegetables. Regular exercise is essential. And healthy eating isn't just what you do before your next high school reunion -- it's forever.

The article has links to the five opinions. I will summarize my take on these articles.

• Fruits and vegatables should form the base of any food pyramid - not carbohydrates.
• Minimize refined carbohydrates and rather eat complex carbohydrates.
• Portion control is the key to life long healthy eating
• Everyone should get some form of regular exercise

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.

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 hopefu

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.

GE Workers Vow to Strike Over Health Care Health care costs are rising for a variety of reasons.

• Better, more costly technology
• Better, most costly medications
• Increased health care labor costs
• Defensive medicine (see the next rant)
• Our societal demand for the 'best' health care - regardless of price - for all (although society often demands the most costly even when it is not the best)
• Reimbursement which pays well for procedures and diagnostic tests, but poorly for office visits and thinking

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.

Increase in Physicians' Insurance Hurts Care: Services Are Being Pared, And Clinics Are Closing

"My sense is that in past malpractice crises there's been a lot of talk about a lack of availability of care, but that has largely been to serve political and financial agendas. But this time it seems more real," said Troyen Brennan, a professor of medicine at Harvard Medical School in Boston. "There's really no good empirical data, but I'm less suspicious this time. It's pretty widespread and spreading."

Twenty percent of hospitals have had to curtail services in some way because of rising insurance costs, and 6 percent have completely closed or discontinued some service, according to a survey by the American Hospital Association.

So who is to blame? What causes the malpractice crisis?

Doctors blame multimillion dollar jury awards and say the answer is limiting the amounts that juries can give plaintiffs. Lawyers blame insurance companies, contending they are raising rates -- not because of big jury awards but to make up for money they would be earning if the stock market were doing well.

"Insurers place profits over people and threaten the livelihood of America's doctors," said Mary E. Alexander, president of the Association of Trial Lawyers of America. "It's unfair to ask patients to give up their legal rights so the insurance industry can make higher profits."

One thing is clear: The cost of malpractice insurance is rising rapidly in many parts of the country -- with doctors in some areas seeing their premiums jump 80 percent in one year, according to the Medical Liability Monitor, an independent newsletter. Rates vary widely, and metropolitan areas such as New York, Chicago, Detroit and Miami tend to be hit hardest. But premiums are rising unexpectedly fast elsewhere, including Pennsylvania, West Virginia and Texas.

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!

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

Though White House officials are still working out details, Mr. Bush, like Dr. Frist, has said he wants to foster competition between the original fee-for-service Medicare program and private health plans. Such changes could eventually make Medicare look more like private insurance. Because of his long interest in the issue, Dr. Frist can explain and defend the Medicare proposals in a way that the previous Senate Republican leader, Trent Lott of Mississippi, never could.

Still, persuading Congress to enact major changes in the structure of Medicare, beyond the addition of drug benefits, will be an uphill struggle for Mr. Bush, even with help from Dr. Frist, because the program is immensely popular with older voters.

Administration officials hope that the changes would, over the long term, produce savings by keeping costs down. But they had no firm estimates for now.

The Democrats have responded in predictable fashion - Bush administration to propose Medicare changes

Still, Democrats said it is unwise to tinker with Medicare's foundation.

"Senior citizens have paid into Medicare all their lives and deserve a prescription drug benefit -- no strings attached," said Sen. Edward Kennedy, D-Mass. "Medicare should not be the price senior citizens have to pay for the affordable prescription drugs they deserve."

Kennedy, along with Democratic Sens. John Rockefeller of West Virginia and Bob Graham of Florida, sent a letter to Bush Friday asking him to reconsider his plans.

"The most important single step we can take to modernize Medicare and make it better is to provide the prescription drug coverage senior citizens need," the senators wrote. "We urge you not to divert the Congress from that critical task by insisting that partisan, controversial and potentially destructive changes in Medicare be the price senior citizens have to pay for the affordable prescription drugs they deserve."

An official with the AARP said it's too early for the nation's largest senior citizen lobby to declare opposition or support.

"Medicare does need to be brought into the 21st century and does need to have adequate prescription drug benefits," said John Rother, AARP's director of policy and strategy. But AARP also wants to see provisions that will allow "people who are perfectly happy with Medicare the way it's run today to stay put," Rother said.

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.

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).

W.Va. Surgeons Say Walkout Will Continue

A walkout by surgeons protesting high malpractice insurance costs will continue indefinitely because Gov. Bob Wise and the Legislature have not done enough to address the problem, a participating surgeon said Friday.

``No progress has been made,'' said Dr. Robert Zaleski, an orthopedic surgeon. ``I am pessimistic at present that the state and trial attorneys of this state will give such concessions to make West Virginia a more attractive place for new physicians.''

More than two dozen orthopedic, general and heart surgeons serving four hospitals in West Virginia's Northern Panhandle began 30-day leaves of absence Wednesday or planned to begin leaves in the next few days.

They want the state to make it harder to file malpractice lawsuits, a move they say would lower their premiums. They want a cap on pain and suffering awards, a board to review the validity of lawsuits before they are filed, and repeal of laws that allow suits to be filed twice in some cases, Zaleski said.

Most of the West Virginia surgeons are insured through a special program created by lawmakers last year, but even though the state recently cut rates for those policies, the premiums remain among the highest in the country.

``The only requirement for attorneys to file a lawsuit -- and I have been victimized at least a dozen times -- the only requirement is an attorney have an idea and $35,'' Zaleski said. ``The attorneys in West Virginia shoot first and ask questions later.''

But note that the surgeons have not abandoned the critically ill -

Surgeons have gone back on the job in when needed. Thursday evening, two came in without hesitation to operate in a life-threatening trauma case, he said.

Doctors and hospitals are losing income. All but one of the surgeons at Wheeling Hospital are independent practitioners, not salaried hospital workers. They continue to receive income from seeing patients in their offices and for surgeries they do in neighboring states, but lose money on surgeries that are not performed.

I do believe this walkout is principled. If the state does not resolve these issues expect few if any physicians moving to WVa.

Well said - When TV Commercials Play the Doctor.

Since the Food and Drug Administration relaxed its rules governing advertising of prescription drugs five years ago, I've seen a steady increase in the number of patients asking for certain expensive new medicines. Often these patients don't really know the purpose of these drugs or their risks or side effects ? they've just seen a nice ad on TV or in a magazine. While I've usually found that I can convince patients that they don't need these drugs (if they're inappropriate), it can be very hard to persuade patients to try pain relievers other than Vioxx and Celebrex, since often patients in pain are looking for anything that will help, and these drugs are effective and well known.

A recent report by the General Accounting Office estimates that every year at least 8.5 million Americans request and obtain specific prescriptions after seeing or hearing ads for particular drugs. In 2001 drug companies spent about $2.7 billion on such advertising, a 150 percent increase since 1997, when the F.D.A. loosened its rules on advertising. This is still less than the amount drug companies spent promoting their drugs to doctors (and I'll admit, I've listened to their talks and eaten their sandwiches). But most doctors, unlike patients, make their decisions based on clinical experience, and at least where I work, doctors usually greet these drug promotions with a dose of skepticism.

Perhaps the most unsettling finding of the accounting office report is that many of the prescription drug ads are misleading and are seen by millions before the government even considers stopping them. The F.D.A. is not required to review the ads before they hit the airwaves. Often, by the time the agency sends out letters telling companies to stop a particular ad, it has already run for months and been taken off the air.

...

Medicines aren't like shampoo or perfume. They're things people need to maintain health, not discretionary products a person can use or throw away on a whim. I'm all for educating patients so they can make informed decisions about treatment. But these ads aren't educational tools, they're sales pitches ? and as hard as we doctors try, it's tough to compete with the likes of Patti LaBelle and Dorothy Hamill.

Merck's Asthma Drug Joins Competition for Hayfever Patients

Merck & Co.'s blockbuster asthma drug, Singulair, has been approved to also treat seasonal hayfever, increasing competition among drug companies for allergy patients and likely boosting Merck's revenues.

...

"Singulair is a more expensive drug on a per diem basis," with wholesale prices about 20 percent higher than Allegra, Clarinex and Zyrtec, said Sean Brandle, a vice president at health care benefits consultant The Segal Company in New York.
With an over-the-counter nonsedating antihistamine now available, some businesses and other prescription plan sponsors are now "strongly considering" excluding all nonsedating antihistamines from coverage, Brandle said.
He expects companies that manage prescription benefit plans will set up systems where doctors prescribing Singulair will be called by pharmacists to see if the drug is medically necessary for a patient.

"They'll set up some hurdles that'll make it more difficult to obtain Singulair," Brandle predicted.

However, he said Merck's prediction of the 40 percent increase in singular sales is probably realistic.

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!

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.

On the other hand, subjects like medical malpractice are just a mess. It's true that fear of malpractice suits is crippling medicine. It's also true, though, that there's lots of malpractice that never generates any lawsuits at all, and the medical system doesn't regulate its own bad apples very well. Everybody knows who the bad doctors are, but they don't lose their licenses, or their hospital privileges, very easily. That's improved somewhat, but not nearly enough, in recent years.

On the other hand, though I'm a big fan of juries and I've served on a civil jury myself, I think that the trial lawyers are rather hypocritical in the way they sanctify the jury. Watch them change their tune in the face of proposals to strengthen juries in malpractice cases by, say, allowing the jury to call its own expert witnesses!

Malpractice suits don't play a significant role in preventing bad medicine, or in compensating injured patients -- given that most patients never sue, it's essentially a lottery. Sometimes a particularly bad physician is brought to account, but just as often it's somebody who made an honest and forgivable error of judgment, or who did nothing wrong at all. And in some truly dreadful cases, trial lawyers won't bring suit because there's no money in it; I can think of one in particular I know of that would curl your hair, but that a major plaintiffs' firm turned down because they weren't sure they could make money.

So the social value of malpractice suits is overrated: if you wanted to compensate people who were hurt by bad doctors, or if you wanted to police bad doctors, you wouldn't have a system like this one, where profitability to plaintiffs' lawyers -- which is at best only roughly correlated with severity of harm, and even more roughly correlated, if at all, with severity of malpractice -- is the major determinant of what cases get brought and what cases don't.

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!

Lawyers Vs. Doctors. Robert Prather rants about a Wall Street Journal piece on tort reform. His opinion -

I usually agree with the Wall Street Journal's editorial page and do favor tort reform, but having Congress pass tort reform for medical malpractice would be unconstitutional in my view. Their only vehicle for doing this is the Interstate Commerce Clause and medical procedures generally don't involve commerce in more than one state. Besides, if a state wants to run its doctors off, let it.

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.

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.

This nation is in the midst of an expanding epidemic of excess weight, the consequence of overconsumption and underactivity that has resulted in a chronic net increase in caloric intake over expenditure. About 60 percent of American adults are overweight or obese, including about 3 percent of adults who are morbidly obese, weighing 100 pounds or more above their ideal weights.

Despite a false start with an intestinal bypass operation that initially gave weight-loss surgery a bad name, modern versions of so-called bariatric surgery are safer and more effective, and they are becoming increasingly popular among the largest Americans.

The American Society for Bariatric Surgery estimates that in the year now ending, 63,100 weight-reduction operations will have been performed, up from 23,100 five years ago.

Surgery is a final option. It is a last resort. Surgery has significant risks.

Surgical weight reduction is now limited to those who are extremely obese, with a body mass index, or B.M.I., of 40 or more, or 35 for those with medical complications caused by obesity. The B.M.I. can be calculated in several ways: in one, a person's weight in pounds is divided by height in inches squared, then multiplied by 703.

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.

The operation, even though sometimes done through a laparoscope, is hardly a minor procedure. Like all operations, it has risks and complications, including blood clots, wound problems and death. About 15 percent of patients experience complications, and 0.5 percent to 1 percent die because of the 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.

But the benefits are profound. In addition to durable weight loss, bariatric surgery can rapidly reverse Type 2 diabetes, improve cardiac function and blood lipid levels, correct breathing problems like sleep apnea, reduce blood pressure, improve the quality of life and lower health care costs, disability and the risk of premature death.

Many patients whose weight had kept them from working or taking part in physical and other activities are able to go back to their jobs, exercise regularly and maintain active social lives.

Sexual interest is often restored and women who were infertile because of hormonal problems are able to conceive. In addition, there are the emotional benefits of extreme weight loss: an improvement in self-image and self-esteem and lifting of depression.

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.

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.

• I will continue to use the stairs rather than the elevators at work (average of 5 flights)
• I will continue to workout (either weight training or cardiovascular or both) at least 5 days each week.
• I will work at minimizing refined carbohydrates

So there you have my resolutions.

Now for something slightly different - New Year's goals!

• I will reduce my waist size from 35 to 34 over the next 3 months.
• I will do an unassisted pull-up during the same time peroid
• I will run at least 30 minutes at an 8 minute/mile pace within 3 months

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!!!

Obesity, Diabetes On Rise In U.S. What we have here, unfortunately, is a 'dog bites man' story.

The researchers found the nation's obesity rate climbed to 20.9 percent in 2001 from 19.8 percent the year before, and the rate of diagnosed diabetes rose to 7.9 percent from 7.3 percent.
The study appears in Wednesday's Journal of the American Medical Association.

...

The study's findings are based on telephone surveys with a nationally representative sample of 195,005 adults.

The study used self-reported data to calculate body-mass index, a height-to-weight ratio. A BMI of 30 or higher was considered obese in the study.

Researchers believe the real rates are even higher, partly because people tend to underestimate their weight when asked.
The study confirmed previous findings that Mississippi is the state with the highest rate of obesity and Colorado the lowest. The highest rate of diagnosed diabetes was in Alabama; the lowest was in Minnesota.

Pa. doctors drop boycott threat

Doctors in eastern Pennsylvania who were threatening to walk off the job Wednesday because of high malpractice costs will work as usual, thanks to a $220 million bailout proposal by Gov.-elect Ed Rendell.

...

Under the proposal, Rendell said he will cut doctors' payments to a state insurance fund by two-thirds, and have insurers pay into the fund. He said health insurance companies would finance the bailout through a one-time surcharge on their reserves, and insurers will not be allowed to make up for the expense in the form of higher insurance premiums.

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.

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.

In the study in question, Dr. Eric Westman of the Duke University Medical Center looked at both. He followed two groups of 60 dieters each, one on a high carbohydrate diet and one on the high-fat, low-carbohydrate Atkins diet. He reported that the Atkins group lost twice as much weight during the six-month study period as did the high-carb group. But this is both unsurprising and meaningless.

Gary Foster of the University of Pennsylvania co-authored a study conducted in virtually the same manner as Westman's. Foster, whose work will soon appear in a major medical journal, provides a simple explanation for the Atkins weight loss. The regimen "gives people a framework to eat fewer calories, since most of the choices in this culture are carbohydrate driven," he says. "Over time people eat fewer calories."

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.