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