I have heard this idea bandied about. Apparently, the idea has caught the fancy of some in Britain. Should junk food be taxed?

A ban on marketing fatty, salty and sugary products at youngsters is one of the options supported by the study from the Food Commission campaign group.

It also backs those calling for a nationwide promotion of healthy foods and a possible "fat tax" on junk food advertising.

The report, which has been published by the Consumers' Association watchdog, urges firms to limit the use of salt, sugars, artificial flavouring and colouring in products aimed at children.

The remainder of the article is really a commentary from BBC readers. The comments are familiar and telling. Some are greatly in favor; some are strongly opposed; some are conditionally in favor of the tax. Should we be having the same debate in the US.

While I blog about medicine 99% of the time, I cannot resist this link. Zell Miller has nailed this one. Living most of my life in Virginia (growing up in the mountains of Southwest Virginia), and Alabama, I understand Senator Miller's points. For us Southerners this is a hot button issue. Stereotyping, That Is Mr. Moonves, call off your hillbilly hunt.

Illinois doctors stage insurance protest But this one has a twist

Premiums across-the-board have been rising because some insurers -- who entered the market during good economic times with low premiums -- are leaving the business or being forced to raise prices in the wake of bad times and rising jury awards in malpractice cases, protest organizers said.

Tom Pliura, a physician and lawyer from LeRoy, Illinois, headed up Wednesday's rally, said "No one single thing is going to kill this beast. We need to work with the insurance industry to identify patterns, recurring episodes of negligence, to educate and train physicians and to train patients on how to avoid negligence.

"We need need educational systems set up and a data collection repository. We need the help of trial lawyers to understand that this is a problem that affects everybody," he said in an interview.

He added that some proposals, such as the limit on punitive awards being discussed in Congress, have no impact in states like Illinois, which have already done away with them in health care cases.

This problem reflects some of the problems that I have ranted about. Apparently they have proposed some remedies which jas caused our friend (and frequent adversary) the Bloviator to go ballistic. (again, he needs to make rants linkable - but in that absence - go to his page on scroll down to Wednesday). Ranting aside, this crisis will have major adverse effects on health care delivery. We must find creative solutions which protect individual patients and protect the health care system in general.

A long time reader wrote to me asking whether the second heart lung transplant done at Duke was "ethical". This article addresses that question directly! Transplant teen suffered brain damage before second transplant, doctors say

Doctors acknowledged Tuesday that Jesica Santillan had suffered brain damage after her botched heart-lung transplant and defended their decision to go ahead with a second operation.

A Duke University Medical Center ethics committee deemed the second transplant worthwhile after tests showed the brain damage was potentially reversible, hospital officials said.

"The feeling was that she may have had some mild degree of neurologic injury, but in our best opinion, it was not irreversible injury," said Dr. Ira Cheifetz, one of the doctors who cared for Jesica.

I find it difficult to argue against that logic. We all see significant reversals at times. I support their process of involving the ethics committee. Trying to second guess, without having seen the patient, is always hazardous.

A long time reader wrote to me asking whether the second heart lung transplant done at Duke was "ethical". This article addresses that question directly! Transplant teen suffered brain damage before second transplant, doctors say

Doctors acknowledged Tuesday that Jesica Santillan had suffered brain damage after her botched heart-lung transplant and defended their decision to go ahead with a second operation.

A Duke University Medical Center ethics committee deemed the second transplant worthwhile after tests showed the brain damage was potentially reversible, hospital officials said.

"The feeling was that she may have had some mild degree of neurologic injury, but in our best opinion, it was not irreversible injury," said Dr. Ira Cheifetz, one of the doctors who cared for Jesica.

I find it difficult to argue against that logic. We all see significant reversals at times. I support their process of involving the ethics committee. Trying to second guess, without having seen the patient, is always hazardous.

Study finds ethnic differences in metabolic syndrome

Metabolic syndrome affects about 22 percent of U.S. adults, or at least 47 million Americans. Symptoms often include high blood pressure, poor cholesterol levels, high blood sugar and a disproportionately large waist.
Researchers analyzed data from a 1988-94 national health survey and found that prevalence ranged from 27 percent of Mexican-American women to 14 percent of black men.

The percentage of black and white women affected was 21 percent and 23 percent respectively. Among men, the rates were 21 percent for Mexican-Americans and 24 percent for whites.

The disparities are probably due to genetics, though there may be some unknown environmental factors that the study did not measure, said Columbia University's Dr. Steven Heymsfield, a co-author.

Fascinating - but I do not understand it.

Patients pay extra for better service.

But a boutique practice, reserved for patients who would pay a hefty extra annual fee, is exactly what this venerable medical group of 280 doctors on the Peninsula is considering. For an organization as large and established as PAMF to consider such a move speaks volumes about the state of health care in America -- and how the doctor-patient relationship is changing.

Frustrated by declining payments from insurance companies, managed-care red tape, and appointments limited to 10 minutes, a small but growing number of doctors are choosing to ``live off the grid,'' eschewing insurance for either yearly retainers, immediate cash payment, or both.

Such moves often mean better conditions for doctors, who say they can drastically reduce the number of patients they see from thousands to hundreds. Doctors who have made the leap say they are able to spend more time with their patients and improve quality of care while maintaining their income.

We know this story. I have written often about this phenomenon. Let me share a bit more financial data to frame the movement.

Druker, however, defends the proposal as one that could help the Palo Alto Medical Foundation better serve its 150,000 to 180,000 patients. The group loses $1,000 annually on each Medicare patient because government reimbursements are low; the retainers could help subsidize such patients, he said.

The foundation already has toyed with the pay-more, get-more approach, charging a $60 annual fee for e-mail consultations with a doctor.

They lose $1,000 per Medicare patient!!!! The system is broken - and very expensive. We do need to reform health care insurance. The problem is finding a solution that really benefits patients and physicians. As I have stated (and see yesterday's link to Medpundit's excellent essay), a national health program is unlikely the correct answer.

Genes May Draw Your Road Map, but You Still Chart Your Course. Read this excellent article that Jane Brody published in today's NY Times. She discusses the importance of genetics.

Meanwhile, most of us have to contend with a complex set of genes that may or may not predispose us to ailments, ranging in seriousness from superficial skin cancer to premature heart disease. And a genetic predisposition is just that: it is not destiny, but rather a tendency that can be encouraged or discouraged to express itself by how we live our lives.

Some experts estimate that about 30 percent of longevity is determined by genes; the rest is up to us.

Read those words again. "... a genetic predisposition is just that: it is not destiny, but rather a tendency that can be encourage or discouraged ... by how we live our lives." She continues with examples (some very personal) on genetic predisposition and life style decisions.

This article emphasizes an important concept. Genes generally predispose, but we can modify genetic tendencies by lifestyle decisions. Eating right (especially keeping one's weight controlled), and exercise can overcome many predispositions. So beware of your tendencies, but do not give in to those tendencies.

By now, many readers have seen news reports on this NEJM "pre-release" study. Safe Therapy Is Found for High Blood-Clot Risk. We should carefully understand the patient population included in this study to better place the results into perspective.

The study included 508 patients at 52 hospitals in the United States, Canada and Switzerland who were at high risk because they had already had blood clots, for no known reason. They were followed for an average of 2.1 years, some as long as 4.3 years. Half got low doses of warfarin, and half got placebos. Of the 253 on placebos, 37 developed blood clots, as compared with only 14 of 255 on the drug. The risk reduction was 64 percent.

The treatment was safe, the researchers said. Although more patients on warfarin had hemorrhages (five versus only two in the placebo group), the difference was not statistically significant. One patient had a stroke caused by a brain hemorrhage, but that person was in the placebo group, not on warfarin.

So what is low dose warfarin? The study had a target INR of only 1.5-2.0. This is indeed modest anticoagulation.

How much benefit did they find? The Washington Post article provides more data - Common Drug Cuts Risk of Clots

Researchers had planned to study 750 people for seven years, giving half the patients about half the dose of warfarin usually used and the remaining subjects a placebo. But the study was terminated Dec. 4 after only 508 patients were enrolled at 52 sites in the United States, Canada and Switzerland. They were followed for an average of only two years because the protective effect was shown to be so dramatic and safe.

Of the 253 patients who received a placebo, 37 suffered another clot, compared with 14 of the 255 patients who received warfarin. The low dose of warfarin did not boost the risk for bleeding.

Many clinicians like to convert such data into Number Needed to Treat (NNT). The placebo group averaged 7% recurrences each year, while the warfarin group averaged 2.5% each year. This gives a benefit of 4.5% each year or a NNT of 22/year. Putting this back into English, on average 1 out of each 22 patients treated will have a recurrence prevented when taking warfarin. The article gives the NNT for a 3 year period as 10.

These are dramatic results, especially when one considers the morbidity from DVT (and possible subsequent pulmonary embolism). You can read the article - Long-Term, Low-Intensity Warfarin Therapy for the Prevention of Recurrent Venous Thromboembolism and the accompanying editorial - Warfarin for Venous Thromboembolism -- Walking the Dosing Tightrope. The editorial raises questions about the best dose to use for such patients.

In summary, this is a very important article. Patients with truly idiopathic DVT should now receive low dose warfarin (assuming no major contraindications). I am certain we will see more such studies as newer anticoagulants become available.

I left out a question and an answer yesterday. After some research, I feel ready to address the question. Spending most of yesterday setting up a new computer, I have lost the original question. The reader had had a CRP level measured and wanted an interpretation.

The current guidelines suggest that levels less than 1 are desirable; levels between 1 & 3 are average risk; levels above 3 predict high risk of coronary artery disease. Because CRP is an acute phase reactant, levels above 10 should raise the question of an independent inflammatory process - especially infection.

Our colleague, MedPundit, has nailed it. Read her rant - Bad Medicine . Please read this!!!

Lawyers revise obesity lawsuit against McDonald's

In the revised complaint, attorney Samuel Hirsch accused McDonald's of "deceptive practices in the advertising, processing and sale of foods, including Chicken McNuggets, Filet-O-Fish, Chicken Sandwich, french fries and hamburgers."
Hirsch asked for class-action status for the suit on behalf of "hundreds of thousands of New York state residents under the age of 18" who suffer health problems as a result of eating McDonald's food.

In the 46-page complaint, Hirsch alleged that McDonald's does not make its nutritional information "adequately available" and said numerous claims made by the fast-food chain are misleading and untrue.

While a McDonald's nutritional booklet claims the fish in a Filet-O-Fish is "100 percent cod with a pinch of salt to taste after cooking," the list of ingredients for the sandwich includes modified corn starch, dextrose, cellulose gum, citric acid and an anti-foaming agent called dimethylpolysiloxane, the complaint alleges.

The suit also alleges that while McDonald's claimed in advertisements that its beef is nutritious and leaner than beef purchased in a supermarket, the levels of saturated fat and cholesterol would not make the beef nutritious. The United States Department of Agriculture has also found that meat used in fast-food outlets was generally fattier than retail meat purchased in grocery stores, the complaint said.

In a statement McDonald's called the new lawsuit "senseless" and accused the plaintiffs of "focusing on only one food organization."

I can only ask why. These lawsuits give the legal profession a bad reputation. They do not address the underlying problem. Parents must take responsibility for teaching their children good eating habits. Why does our culture allow such suits?

Now official, we will receive a slight increase for each patient visit in 2003. Physicians win Medicare payment relief: With an increase secured for 2003, the AMA will focus on preventing a cut next year.

Physician groups already have begun a push to modify the way payment updates are calculated each year. Sara Walker, MD, president of the American College of Physicians--American Society of Internal Medicine, said additional changes in Medicare policy would be needed for payments to keep pace with increases in practice expenses.

"We look forward to working with the Centers for Medicare & Medicaid Services on implementing the beneficial changes approved by Congress, as well as other changes in Medicare payment policies that may be required," Dr. Walker said. "The goal must be to assure that Medicare patients have continued access to physician services by guaranteeing that Medicare payments will keep pace with the rising costs of delivering care."

Physician groups have urged CMS to exclude the cost of outpatient prescription drugs and clinical laboratory tests covered by Medicare from its calculation of the spending targets for physician services. Physicians argue that they have no control over the price of those drugs and should not be penalized for the rampant inflation in drug costs in recent years.

So this story will continue, but today's chapter has a decent ending.

I have used personal trainers for 18 months. While they do cost significant money, I doubt that I would have achieved my current conditioning without a trainer. This article describes the benefits well - Friendly persuasion that works. The article discusses many pros but adds this "con" -

So, was it worth it? Absolutely. But it is also true that two months, no matter how intense, is not enough to get into great condition. It's a start, I hope, to a more regular workout.

If there is any room for complaint, it would be that for three days a week, there was no room for flexibility in my early schedule. I also should probably have taken much more care about diet so that I could shed more pounds.

I disagree about the flexibility comment. Having a fixed time to workout is a major advantage. Since prioritizing working out, I never miss these workouts unless I am traveling. Working out is too important to allow flexibility. Flexibility makes not working out too likely. Most of us need the discipline of scheduling.

Does tea have health benefits? Some studies suggest this might be true. Steeped in science.

"I pay attention to the health benefits from tea. It's medicinal," said Emmerich, who lives in Los Angeles and is a student of Ayurvedic medicine. "I quit drinking caffeinated coffee three years ago. Then I went to decaf coffee. Then I went to tea." No one is saying that tea is a cure-all or that you should drink it daily for good health, said Jeffrey Blumberg, a tea researcher at Tufts Nutrition Center in Boston. "The evidence is compelling that something is going on," he said. "But I wouldn't call it definitive."

Many researchers expect that to soon change. They're pushing ahead with studies that should answer whether tea can help prevent certain diseases.

The belief that tea improves health began with epidemiology, observations that certain tea-drinking cultures have a lower incidence of disease. For example, the Japanese, who drink tea with most meals, have much lower rates of heart disease than Americans, who are not big tea drinkers.

Such observations are obviously not proof -- the English, who practically bathe in tea, show no special protection against heart disease -- hence, the need for better research.

"There has been a lot of epidemiology looking at tea, and it's, at best, sort of mixed," says Dr. Ken Mukamal, an internist at Beth Israel Deaconess Medical Center in Boston. "Some studies have found striking beneficial effects, and others really haven't shown that; so there is this area of controversy."

Recent research has focused on biomarkers, measurements of specific substances or chemicals in the body, that can reveal what is happening -- such as whether tea consumption lowers cholesterol or kills harmful bacteria in the stomach. (Studies show tea does both.)

Still to come are large clinical trials in which people are assigned to drink a certain amount, and quality, of tea in a controlled setting over long periods of time. The tea drinkers' rates of disease will then be compared with the rates of those who don't drink tea.

Back to questions and answers. I have several themes to discuss today. I hope to shed more light than heat - but you never know.

 DB, I fear your editorializing has overstepped your great capacity for logic. The plan does not require that insurance companies reform their rate-setting practices. Therefore, at best, it offers an extremely limited possibility of a solution.

But what do I know? I'm just an illogical lawyer. :)

First, thanks for providing the answer within your comment. Second, I do like the lawyerly technique of starting with flattering and then smashing me hard!

I admit to not being an expert on rate-setting practices. Lawyers seem to continually focus on this issue when malpractice rates are discussed. I assume that like political parties, someone gave all lawyers a set of "talking points" to use when the malpractice issue arises. Another comment on this rant shared this point.

In the state of Pennsylvania, for every $1 in premium collected, insurance companies have paid out $1.38. So they left the state. As long as legal expenses continue to rise, so will premiums.

Blaming the insurance companies is a smokescreen.

We obviously have a Mars/Venus thing going on here. I am certain that malpractice rates are having, and will have a negative effect on health care. If we do not develop a solution, we will have less physicians in many areas. It will impact the decision to enter medical school (remember it takes from 7 to 11 years after entering medical school before you start paying those rates). The malpractice crisis raises costs (defensive medicine) and damages the doctor patient relationship (from the doctor's side). We need lawyers to help us find a solution, but alas I see only talking points.

WOW...I thought it was my imagination about the generic. I unlike others am paying less for the generic, but then again, my insurance company isn't paying that much for the Prilosec so therefore, the generic in my case is far cheaper. I am also experiencing some major reflux symptoms when a friend swears that the generic has ALL the same ingredients, anyone else on my side???

I certainly get many of these comments and queries. Generic omeprazole is taking the blame for everything short of Saddam Hussein. I can find no studies of generic omeprazole. I refer to last week's research on the FDA web site. Someone should do a double blind crossover study. One problem occurs that everyone should consider - the placebo effect. In drug studies, placebos have many side effects. We tend to blame changes in how we feel to linked temporal events (like switching to generic omeprazole). It may or may not be the cause.

If one is really concerned, I suggest and N-of-1 trial. In such a trial, one would keep a notebook and go through periods on the trade name drug, alternating with the generic drug. The key here is blinding. Somehow, you must not know which one you are taking! That could prove to you whether the generic in some way caused your symptoms. I would bet against it - but then I am a betting man.

Spreading the pain around or one more deep pocket to pick? I generally am not sympathetic to HMOs as one who has too many times ended up with the short end of the stick in my dealings with them. All the same, this seems like a judgment that is a lawyers' relief act, making open season on a class of defendants that are particularly unsympathetic (which the trial lawyers will like) and which until now have escaped civil accountability under arcane federal law loopholes. That being said, nothing comes without a price. I expect that the underwriters for the HMOs will be busy recalculating their premium schedules to account for their newly affirmed exposure. So raise the premiums. And expect new HMO contracts to contain stiff arbitration agreements, hold-harmless clauses and other terms that place doctors who do business with them at risk for the HMOs' acts. One more reason not to do business with them, if you ask me. How will this pass as the Bush administration tries to tie prescription drug benefits to managed care contract enrollment?

Well said, and it spurs a few comments. I, like many physicians, have felt great frustration with HMO decisions about medical care. They could make seemingly arbitrary decisions about what I could or could not prescribe or what test I could order. This decision makes them accountable and balances the scales a bit.

I agree that not doing business with managed care organizations makes a lot of sense. Given today's health care climate, I suspect increasing numbers of physicians are taking that step. I see the reign of HMOs on the wane. It does raise significant questins about a prescription drug benefit plan.

It is about time there were some teeth put into the resident workweek limits. As one whose surgical internship year had quite a few 120+ -hour weeks, I couldn't recommend that experience to anyone as something beneficial. Setting aside the usual self-denying surgical machismo that wants to shout "wimp" at complaining co-residents, the hard truth is that not much extra learning takes place for that 50% increase in the workweek (over the 100% increase from the rest of the world!). And it isn't safe, not least for the patient. At the time of my residency, a decade ago, the only specialty organization to have done a legitimate study on resident performance and workweek and shift length was anaesthesiology. Their study prompted them to limit shifts to 24 hours. No other specialty wanted to repeat a similar study for their residents, perhaps for fear of knowing the truth. It also isn't safe for the resident, chronically in sleep debt. I know of my own microsleep episodes driving at speed on the freeway home, and the automobile accidents of my internship classmates (thankfully, none injured). These were responsible, hard-working people pushed beyond their limits of safe endurance, who unfortunately worked for an employer--in this case, the United States Navy--that just didn't want to know the truth.

Not much to add here. We have had the goal of an 80 hour work week in internal medicine for the past 5-6 years. It does help. Watching how residencies deal with change this summer should be very interesting. Hopefully, it will improve the personalities of many residents.

The MSNBC article said "DEPRESSION WILL affect about 10 percent of women and five percent of men sometime during their lives." These numbers seem low to me (no pun intended). Perhaps a Sunday Q and A re: this? 

Ask and ye shall receive. I believe these numbers for clinical depression are fairly accurate.

I glanced at Alex's site at one point concerning this topic and appreciate the different point of view. I don't know how it is for other people, but for me, antidepressants have literally been a life saver. I've been on them for years and every time I have tried to stop them, I end up in the same frame of mind. Merely reducing the dose causes a relapse. Clearly they don't work for everyone. I'm glad they work for me.

This comment reflects my clinical experience. I do not have access to the entire Lancet article, but I did find the summary. Their summary makes sense.

Antidepressants reduce the risk of relapse in depressive disorder, and continued treatment with antidepressants would benefit many patients with recurrent depressive disorder. The treatment benefit for an individual patient will depend on their absolute risk of relapse with greater absolute benefits in those at higher risk. Further trials are needed to establish the optimum length of therapy and should include patients who were not well represented in these trials, including those at low risk of relapse.

Well that is it for this week. Next Sunday's Q&A will appear late (travelling most of the day from California). Keep those excellent comments and questions coming!!
 

Another Dr. wrote this rant - it is a good one - Regulation of Dietary Drugs Is Long Overdue. A few important quotes:

It is quite remarkable that although the American Medical Association recommended a ban on ephedra and the Defense Department halted sales of ephedra products in military commissaries, the federal government ? acting through the Federal Drug Administration ? has still not taken decisive action to protect the American public from the well-recognized dangers of this herbal drug.

The reason for its inaction is clear: in 1994, Congress removed the F.D.A.'s power to take effective action against dangerous botanical products by passing the Dietary Supplement and Health Education Act. This fatally flawed legislation declared herbs to be dietary supplements, which most assuredly they are not. In doing so, Congress shifted the burden for proof of safety away from the manufacturer and to the F.D.A. Under this law, the F.D.A. must prove ? after the fact ? that a dietary supplement presents significant or unreasonable risk of injury.

Even where overwhelming evidence of such injury exists, the F.D.A. lacks the staff and resources required to document its case in a court of law. Meanwhile, the public remains exposed to a dangerous dietary supplement.

Also, manufacturers of dietary supplements are not required to report serious adverse effects caused by their products to the F.D.A. Thus, the manufacturer of Metabolife ? an herbal remedy taken by 2.5 million Americans wanting to lose weight, and which contains the potent combination of ephedra and caffeine ? was within its legal rights in withholding the more than 14,000 reports of adverse reactions the company received over several years. In contrast, prescription drugs ? whose therapeutic effects have been documented in controlled clinical trials ? are promptly removed from the market when serious adverse effects occur. For herbal medicines, such action rarely occurs.

Read those lines again. I find this situation totally unbelievable.

Medical decision rules can help us combine clinical signs and symptoms to improve our decision making. The Ottawa Ankle Rules use three physical examination findings to select a patient group who do not need Xrays (their exam excludes fracture).

One problem with decision rules comes from the statistical processes used to develop them. Some initial reports are too optimistic - generally due to overanalyzing the data. Prior to adopting a decision rule for general use, we need studies to validate that rule at varying sites. A report in this week's BMJ shows that the Ottawa Ankle Rules "travel" well. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review .

Conclusion: Evidence supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30-40%.

For those who want to read the rules - The Ottawa Ankle Rules

Depression Study Backs Long Drug Therapy

A review of 30 years of studies, which is to be published today in the British journal The Lancet, suggests that this is the wrong approach. In the analysis, led by researchers at Oxford University in England, patients who stayed on antidepressants were half as likely to have another bout of depression as those who stopped taking medication.

The 31 studies reviewed in the new research involved a total of 4,410 patients who had done well on short-term antidepressant therapy and were then randomly assigned either continued drug treatment or fake pills.

Now we need to figure out how we can get the patients to continue the drugs once they are feeling better.

This rant is a first for me. I was invited to rant about Bechler's death at Off Wing Opinion (a sports blog). I have a different introduction there - On Steve Bechler's death. If you like sports, please frequent his blog - he does a wonderful job.

For many years, I have taken advantage of athletes' deaths to make teaching points. For example, Flo Hyman (the world class volleyball player) died of Marfan's Syndrome and subsequent dissecting aortic aneurysm. Hank Gaithers died from an arrythmia secondary to hypertrophic cardiomyopathy. Walter Payton died of cholangiocarcinoma secondary to primary sclerosing cholangitis. Each of these athletes' deaths raise important teaching points. By understanding why someone died, we can often learn lessons which might prevent future deaths or injuries.

When I first heard that Bechler had died, I started wondering what had happened. I saw the same news reports that you had. He did not die suddenly, this "rules out" most cardiac causes. Cardiac deaths occur in young athletes, but they die almost immediately. He on the other hand made it to the ICU.

The next information that I heard was that he had had a heatstroke. This information came along with information that the ambient temperature was only 81 degrees. Heatstroke is well recognized as a cause of death in athletes, but I generally associate that cause with August football in Texas (temperatures in the 100s). But then I remembered the Corey Stringer story. At that point I wondered what Bechler had taken.

I also wondered about his underlying health. Did he have any unknown diseases? His autopsy gave some clues. Varied Factors Caused Pitcher's Death

The autopsy performed yesterday on the Baltimore pitcher who died of heatstroke produced a portrait of a young man with an assortment of potentially dangerous medical problems who was also desperately trying to lose weight. An accompanying investigation revealed that the pitcher, Steve Bechler, was using an over-the-counter weight-loss supplement containing an ingredient that has been linked to heatstroke.

Now I understood. He was not in good shape, was trying desperately to lose weight, and probably had underlying disease.

The use of Xenadrine added to the risk factors that were present, Perper said, explaining that heatstroke was "brought about by the convergence of a number of factors."

He listed those factors as an enlarged heart, abnormal liver functions, borderline hypertension, an overweight condition, use of Xenadrine and dieting.

I blogged earlier today on my site about the idiocy of Ephedra - Ephedra - PLEASE DO NOT TAKE!!! . Let's look at what he was taking. SUPPLEMENT FACTS: XENADRINE® RFA-1. The dangerous ingredient is "Ma Huang?335mg - (plant)(standardized for 20mg Ephedrine)". The problem comes from dosing. Many athletes take too much, and as the dose of Ephedrine increases, so do the problems.

The article that I cited this morning explains how Ephedra can cause heatstroke.

Ephedra can promote heatstroke in three ways, according to Neal L. Benowitz of the University of California at San Francisco. It speeds metabolism and thus creates extra heat. It constricts blood vessels in the skin, preventing the body from cooling itself efficiently. And by making the user feel more energetic and less fatigued, it keeps him exercising longer.

Since the recommended dose is 4 capsules a day, the dose of ephedrine is large enough to cause problems. Ephedrine (at these doses) is the single supplement with the most reported problems (again please read my earlier rant).

So why would an athlete take this stuff? Why would anyone 'bet his life' on a supplement? I guess this is really a stupid question. We all know that athletes will do anything to succeed. They rarely consider the potential consequences of drugs or supplements. Rob Dibble, the former Reds relief pitcher, writes eloquently about this attitude today - For The Love Of The Game? I highly recommend reading his confession and shuddering. He share an attitude which prevails. Here are some of his thoughts

While I don't condone the use of potentially harmful supplements, I can honestly say that during my playing days, I would have done the same thing if I were in Steve's position. Despite cringing at the mere thought of what I put my body through, for the chance to play professional baseball, I wouldn't hesitate to do it all again.

And for further proof that my hypocrisy knows few boundaries, if I could take a pill that would allow me back in the game today, I'd gladly take it. I wouldn't even consider the ramifications, because they wouldn't matter. I'd want it that badly.

That mindset -- that drive, motivation, and perhaps stupidity -- doesn't exist in everyone. But it's common among professional athletes. And with the exception of a few rare specimens who are blessed with superior genes, the desire to succeed is only heightened by the extraordinary demands that go along with their chosen occupation.

So, when a player like Steve Bechler shows up to spring training out of shape and a few pounds overweight, his desire to shed a few pounds will override any potential warning signs or dangers to himself. Despite a family history of high blood pressure and heart disease, he was willing to risk his own health to succeed in the game.

In Steve's case, the results were catastrophic. But for every fatality, there are many others who won't deal with the repercussions until much later in life, maybe never. And unfortunately, many athletes are willing to roll the dice and play the odds. They cling to a notion of immortality and an "it won't happen to me" attitude.

So they willingly play 'You Bet Your Life'. But unfortunately, this problem does not just exist in professional sports. Our teenagers and young adults take supplements almost willy nilly. And they know that their heroes take them. They see the ads in magazines.

I rant about supplements often. I tell patients and friends not to take supplements unless they can be certain of the potency, safety and efficacy. Since the 1994 law on supplements, we have no real protection. The FDA does not approve supplements, nor are they regulated. Yet they can kill and injure. If Steve Bechler's death influences Congress to reconsider their stance on supplements, then we will have some redemption. Otherwise, we just have another teaching case. And dammit, I have too many teaching deaths already.

Cancer group tries to link fat, cancer in public mind. The goal is laudable. The American Cancer Society is beginning a campaign which will educate the public on the health risk of obesity. They estimate that 1/3 of cancer deaths are related to diet and inactivity. We should follow this campaign carefully. I suspect that they will eventually influence policy.

Currence said the society wants to keep the goal very simple, much like the Smokeout's goal of having smokers quit for the day.

"Weight management is a complex activity, so we tried to pick one thing that you could do," she said. "Here, the call to action is to take your body mass index. If you take that one step, perhaps that will trigger other factors."

The society wants to reach several million people. That's a small minority of America's 290 million-plus population, but the Smokeout also started small and grew. By 2002, 60 percent of the population was aware of the Smokeout and 19 percent of smokers participated, she said. The Smokeout asks smokers to quit for the 24 hours of the event, hoping one smoke-free day will lead to another.

The Weigh In is a step in the right direction, Manson said, but it will take a lot more to reduce America's weight and raise its activity levels.

For instance, one of the reasons that antismoking programs have been effective is that they can have the force of law -- for instance, people can't smoke in many buildings, Manson said. Something similar could be done with food, such as reducing prices of healthier food and placing higher taxes on fattier ones, she said.

I like this. Health Official Considers Bid to Raise Cigarette Tax to $2

Tommy G. Thompson, secretary of health and human services, said today that he was considering whether to support an increase in the federal cigarette tax to $2 a pack, from the current 39 cents, as recommended by an advisory committee.

Last week, the Health and Human Services Department's Interagency Committee on Smoking and Health approved a plan for the steep increase in the tax. Half the money raised would be allocated for initiatives to help people stop smoking.

This initiative would have an effect. Cigarette prices do effect purchase, especially in teenagers. Thus, we have a proposal with a two pronged positive effect. The price would deter some (or at least decrease the number of cigarettes smoked). Moreover, we would have money to help patients stop smoking.

Smoking is the greatest health evil. The ravages of cigarettes fill our hospitals. Lung cancer is the poster child - but at least it kills you relatively quickly. Chronic obstructive pulmonary disease (chronic bronchitis and emphysema) destroys one's quality of life. It leads to multiple hospitalizations. On good days, patients breath somewhat comfortably when sitting still Cigarettes remain a major risk factor for coronary artery disease.

Doctors rant about cigarettes constantly, because we hate to see patients with preventable disease. Especially diseases that the patient could prevent by choosing a healthier lifestyle.

I hope they adopt this tax. If it prevents some teenagers from starting; if it convinces some adults to finally quit; then it will represent good health policy.

Some rants are tiring. Some seem repetitious. Nonetheless, readership changes, and this issue demands overkill. Be wary of supplements. Do not take ephedra. Despite the Danger Warnings, Ephedra Sells

But what is clear, experts said yesterday, is that ephedra can be dangerous. They said no other dietary supplement on the market had stirred as many warnings and frightening medical histories as ephedra. It has been linked to deaths, to strokes, to heart arrythmias and even to psychotic episodes.

Why does the FDA not protect us? This stuff is a natural supplement. How can they sell something dangerous?

Ephedra, like other herbal supplements, can be legally sold over the counter under a 1994 law that allows their sale unless they are shown to be unsafe. In contrast, drug makers must prove to the F.D.A. that their drugs have benefits that exceed any risks before they can market them.

Dr. McClellan, of the food and drug agency, said it was "assessing what the proper way to handle ephedra is." It has commissioned a report by the Rand Corporation, to be delivered by spring, he said.
Then, Dr. McClellan added, "you should see some prompt further action from us." If the agency identifies serious risks with the product, he said, it could insist on warning labels or even remove the supplement from the market.

Wes Siegner, a lawyer for the Ephedra Education Council, an industry group, said clinical trials had demonstrated that the substance was safe when used as directed. "You can't use these individual cases to raise more than a question," he added.

I have ranted previously on this ridiculous 1994 bill. Alternative works for music not for medicine . We have an industry that is out of control and without controls. That industry sells chemicals which they claim are natural, and thus do not require FDA approval. They claim medical benefits, yet are not required to show efficacy - only lack of harm. They have no quality control standards. This would be funny, if lives were not at risk.

A variety of research studies have called attention to ephedra's dangers. The most recent is to be published next month in The Annals of Internal Medicine and is available now on the journal's Web site (www.acponline.org). In it, Dr. Stephen Bent of the University of California at San Francisco and his colleagues report that ephedra is the most dangerous herbal product on the market.

The researchers, who have consulted for lawyers suing ephedra makers on behalf of injured consumers, say that 64 percent of all reports of adverse reactions to herbal supplements in the United States involve ephedra. Yet products containing ephedra represent only 0.8 percent of all herbal products sold.

"The sale of ephedra as a dietary supplement should be restricted or banned to prevent serious adverse reactions in the general public," they write.

For those interested in the data - The Relative Safety of Ephedra Compared with Other Herbal Products. Congress has shown irresponsibility in allowing companies to sell ephedra. The industry clearly has no scruples - just check out their advertising. Tell everyone you know - do not take ephedra. It can kill.

Later today I will rant here and on Off-Wing Opinion about Steve Bechler specifically.

The Digoxin study published several years ago continues to provide useful information. This report describes a new data analysis which suggests that we aim for a much lower digoxin level than previous targets. Beware High Serum Digoxin Concentrations

This post-hoc analysis evaluated data from 3,782 men enrolled in the DIG trial from August 1991 to December 1995 who had a left ventricular ejection fraction of 45% or less. At one month, serum digoxin concentration (SDC) in men randomized to digoxin therapy was 0.5 to 0.8 ng/mL in 572 men, 0.9 to 1.1 ng/mL in 322 men, and 1.2 ng/mL or greater in 277 men; 2,611 men were randomized to placebo.

All-cause mortality at a mean follow-up of 37 months was 29.9% for SDC 0.5 to 0.8 ng/mL, 38.8% for SDC 0.9 to 1.1 ng/mL, and 48.0% for SDC 1.2 ng/ml or greater (P = .006 for trend). Compared with men receiving placebo, men with SDC 0.5 to 0.8 ng/mL had a 6.3% lower mortality rate (95% confidence interval [CI], 2.1 - 10.5%), but men with SDC 1.2 ng/mL or higher had an 11.8% higher mortality rate (95% CI, 5.7% - 18.0%).

After multivariable adjustment, SDC was still linked to mortality risk. Hazard ratio was 0.80 for SDC 0.5 to 0.8 (95% CI, 0.68 - 0.94), 0.89 for SDC 0.9 to 1.1 ng/mL (95% CI, 0.74 - 1.08), and 1.16 for SDC 1.2 ng/mL or greater (95% CI, 0.96 - 1.39).

"Given that no study has demonstrated any substantive clinical benefit for higher SDCs, prudent practice would support an SDC of 0.5 to 0.8 ng/mL as a revised therapeutic range," the authors write. "Only a randomized controlled trial can confirm this recommendation; however, we believe our data provide sufficient grounds for consideration of lower target SDCs for men with stable heart failure and left ventricular dysfunction."

To reiterate, when you use digoxin for CHF (and it does improve quality of life for severe CHF), use a modest dose.

Evolution eventually defeats antibiotics. As one studies genetics and mutations, one learns that given enough bacteria and enough time, they will generally develop a method for resisting a succesful antibiotic, and then propagate according to the precepts of evolution. Effectiveness of
Cipro declining: Study blames overuse of popular antibiotic

THE RESEARCHERS examined data on infections in hospitalized patients in 43 states and Washington, D.C., from 1994 to 2000. Ailments included respiratory and urinary infections caused by a variety of bacteria.

Many germs had grown resistant to fluoroquinolones, a class of antibiotics that includes ciprofloxacin, known by the brand name Cipro.

In 1994, Cipro was effective against 86 percent of the bacteria samples analyzed, but that dropped to 76 percent by 2000, the researchers found.

This study (in today's JAMA) has no surprises. We have seen this story play out with antibiotic after antibiotic. Evolution is too powerful to defeat. We can delay resistance by using antibiotics more intelligently. But eventually evolution will win.

Medical residents limited to 80-hour week. I ranted often about this subject last summer. This article and decision are not a surprise. Our program has already made the necessary adjustments to call schedules so that we can accomodate the necessary changes.

Doctors-in-training in the United States -- who work marathon shifts and 120-hour weeks that critics say lead to medical mistakes -- cannot work more than an average of 80 hours a week, a body that accredits medical residents said Tuesday.

Under new rules approved by the nonprofit Accreditation Council for Graduate Medical Education, medical residents must also get one day off out of seven and a 10-hour rest between being on call and working a shift. The rules, which schools must follow to be certified, take effect July 1.

The vote by the council's board of directors means the standards "go from being a should, to a must" in order to pass muster with the accrediting body, said Julie Jacob, a spokeswoman for the group.

Working with internal medicine residents, we have had the 4 days off each month rule for the past 5 years. While it sometimes seems like an inconvenience, it is a very good rule. Since initiating this rule, I see much less housestaff depression and burnout. We often arrange for housestaff to get the entire weekend off (on the golden weekend - the weekend when the team is on call Thursday night and Monday night). Having a long weekend allows for mini-vacations which greatly improve ones mood.

Medical residents and the consumer group Public Citizen prefer federal standards, saying a private group lacks teeth to enforce the rules. But the government rejected a petition to a federal agency on that front last year.

The Committee on Interns and Residents, a union that represents 12,000 residents in the United States, said the move "is going in the right direction, but the weakness is enforceability," according to executive director Mark Levy.

Another flaw are loopholes that allow residents to extend for example, the 24-hour shift limit by six additional hours, Levy said.

I beg to differ with Mark Levy. Enforceability will work, because the ACGME has the ultimate threat - discontinuing the residency program. Some programs might try to cheat - but they will be caught. They will also quickly lose the yearly battle for interns. Medical students find out who complies and who does not. They will not choose cheating programs.

I strongly disagree with the 24 + 6 rule. This is the single part of the new guidelines causing the great compliance problem. We have developed a unique solution that I believe will work.

The problem here is continuity of care. We all worry about the "pass off". What happens to patient care when you change physician responsibility? The "pass off" represents the danger in these rules. We have spent much effort developing a plan to insure that the responsibility stays within a team structure. Our solution looks good on paper, but we will know the flaws when we start this process soon. We are planning to do several trials of our new system over the next few months. And then we "go live" in July, with new interns. I plan to be ward attending in July. I will try to remember to rant as things work or do not work.

A nice feature of our new system is a decrease in overnight call. Our interns will generally stay overnight in the hospital every 8th night rather than every 4th night. A downside is the necessity of a night float system. We have avoided the night float (making us a minority program) for many years. I hope we can make that system work well.

Most important I hope that patient care and education do not suffer. These are the two standards which one should use to judge these changes. I believe that the ACGME has acted too aggressively, without carefully studying the impact of these new rules. But they did not listen to widespread criticism. They acted unilaterally, and we will play ball by their rules.

Vitamin link to heart failure

They compared 54 patients with chronic heart failure with 34 healthy people, and found that vitamin D levels were up to 50% lower in the blood of CHF patients.

And the more severe the vitamin D deficiency, the worse the symptoms of heart failure appeared to be.

The researchers now plan to check whether giving CHF patients vitamin D can help to improve their condition.

We should all be careful. Remember the drill. This is a hypothesis generating study. Until we have clinical trials showing a benefit, then we only have informed speculation. However, this is certainly an interesting research line.

Some Urge Type of Pap Test to Find Cancer in Gay Men

An anal Pap smear, which involves taking a swab of cell tissue from the rectum, is similar to the Pap tests that women receive to screen for precancerous cells in the cervix.

Cervical and anal cancers can be fatal if they are not caught early enough. The cancers ? as well as cell abnormalities called dysplasia, which can progress to cancer ? are linked to infection with the human papillomavirus, or HPV.

"This is something we really need to be paying attention to," said Dr. Joel Palefsky, a professor of medicine at the University of California at San Francisco.

"We've decided as a society that it's important to spend billions of dollars to test for and treat cervical dysplasia before it turns into cancer," Dr. Palefsky said. "And we should also be testing for and treating anal dysplasia in high-risk populations."

I learned about this a few years ago when reading a paper by Dr. Sue Goldie from the Harvard School of Public Health. A quick google search found this reference, which includes her cost-effectiveness study of screening. Beyond the Anal Pap Smear. If you care for men who have sex with men, you should consider this test as a reasonable screening procedure.

This question is personal. I have had a PSA, albeit over my modest protestations. My internist believed that it was good medical care. But is it? Questions Outnumber Answers on P.S.A. Test

In an article published in December in The American Journal of Medicine, researchers from the University of North Carolina and the University of Massachusetts in Boston noted that screening men for prostate cancer had become popular even though it had not been shown to be lifesaving in a randomized clinical trial.

There is "a disconnection," these researchers maintain, "between the degree of enthusiasm for screening and the quality of the evidence supporting it."

On the other hand, cancer experts in favor of screening point out that prostate cancer death rates among American men have dropped decisively in the last decade, following the introduction of the P.S.A. test. The National Cancer Institute last year documented a "dramatic decline" in the prostate cancer death rate per 100,000 men ages 50 and older since 1992; before 1992, the rate had been rising steadily.

I have talked over the years with several experts in this field. They remain confused, and stress that we have no clear evidence that screening helps men. I must face this decision again this year, and I remain confused. If you will face this decision, read this article carefully. It may help a bit.

A Court Expands the Rights of Patients to Sue H.M.O.'s

A federal appeals court has expanded patients' rights, ruling that consumers can sue a health insurance company for injuries resulting from the company's refusal to authorize medically necessary treatment.

The ruling, issued last week by the United States Court of Appeals for the Second Circuit, in New York, said that health maintenance organizations and their medical directors could be sued for medical malpractice when they made decisions about the treatment of a patient.

In the past, courts have often rejected such claims, saying they were precluded by the federal law on employee benefits. But the appeals court said those precedents were no longer binding because the Supreme Court had established a new framework for analyzing the issue in a 2000 case, Pegram v. Herdrich.

The Supreme Court held then that some decisions involved both an interpretation of an insurance contract and the exercise of medical judgment about how to diagnose and treat a patient's symptoms. The appeals court said H.M.O.'s could be held accountable for such "mixed eligibility and treatment decisions" under state standards of medical malpractice.

While I always have mixed feelings when the legal system gets involved, I applaud this decision. Insurers have put physicians in an awkward position. We cannot just recommend the best therapy, rather we must ask permission. Patients do need some protection from insurers and medical directors. How do we achieve the appropriate balance between cost and efficacy?

This decision (and the problem it addresses) raises a very important problem in health care. How do we proceed once we admit that we have limited resources? Who makes the decisions about rationing health care? And make no mistake, all systems eventually will lead to rationing. We are very uncomfortable with the thought of rationing, yet to not ration means ever increasing costs which our society will not willing pay.

Congress will once again consider malpractice reform this session. Medical liability crisis: Tort reform bill goes to Congress

The legislation -- the Help Efficient, Accessible, Low-cost, Timely Healthcare Act of 2003, or HEALTH Act -- also would hold physicians responsible for only their portion of damages, impose a three-year statute of limitations on when most medical malpractice cases could be filed and limit punitive damages to whichever is greater, two times the economic damages or $250,000.

The bill is nearly identical to tort reform legislation that the House passed 217-203 last year, but that the Senate never considered.

The new bill drew immediate support from the American Medical Association, the Federation of American Hospitals, the American College of Physicians--American Society of Internal Medicine and other organizations that claim that excessive jury awards have led to increased insurance premiums.

Those groups and the Bush administration favor legislation that includes a cap on pain and suffering awards because they say similar legislation passed in California more than two decades ago has helped keep insurance rates stable there.

"It brought a crisis state of 1975 to a state of stability," said AMA President-elect Donald J. Palmisano, MD. "The HEALTH Act will go a long way toward bringing common sense back to our liability system."

The bill, which Republicans generally support and Democrats generally oppose, is expected to pass the House again. On Feb. 10, a House subcommittee held a hearing on medical liability insurance in Greenwood's district in Bucks County, Pa. The legislation has already received support from key House members, including House Judiciary Committee Chair F. James Sensenbrenner Jr. (R, Wis.), Majority Leader Tom DeLay (R, Texas) and House Speaker J. Dennis Hastert (R, Ill.).

This bill has so much logic behind it, that only trial lawyers can argue against it. And they are arguing against it, and therefore their buddies (the Democrats) will argue against it.

This very interesting research suggests a possible preventive measure for diabetic retinopathy. With the increase in diabetes mellitus, all complications of diabetes have major implications on health care. Could this research line provide major hope? Drug Prevents Eye Disease in Tests on Rats

A synthetic form of vitamin B1 that is used in Europe to treat nerve problems has been found to prevent the most common form of diabetes-related eye disease in rats.

Diabetic rats treated with benfotiamine for 36 weeks did not develop any of the retina damage found in a similar group of untreated rats, according to a research team led by Michael Brownlee of the Albert Einstein College of Medicine in New York.

Brownlee said he hopes to begin a clinical trial to determine whether a similar result would occur in humans once an effective dose for the drug in people is determined. That could happen in as soon as a year, he said.

"We can't say it works in humans because there has never been a double-blind clinical study" of it, Brownlee said.

The new findings are published today in the online edition of the journal Nature Medicine.

This is very interesting research. I hope the human studies work as well as the rat studies.

You keep posting great comments and questions. Some comments deserve this stage and I will have little to add.

This, I think, is the area most neglected by physicians in their practice. I have personally experienced, and been told of experiences, in which the patient or the patient's family were treated as troublesome, stupid, interfering nuisances who dared to question, disagree, discuss or otherwise impune the 'wisdom' of the white coat.

While waiting in the closed door, windowless examining room, I have felt that I am in an assembly line. When I have waited more than 20 minutes, and dare to query staff on this delay, I am treated as if I spoke against a GREAT SPIRIT and am seldom given any relevant information about the delay.

I have been seen by specialists who seem to forget that the body part or function in which they are interested is part of a whole person. I have had my 'story' ignored, while the physician rushes through her or his mental list of rule-outs, data sets, and hypothesis checks. Yet, often, it has been the 'story' that contains the reason(s) for the problem.

Advances in medical technology, basic sciences, and other arenas provide wonderful tools and treatments. But, there always is a complex, integrated, mind-body person who comes seeking a partner in finding health.

This comment beautifully should remind us about doctoring. Doctoring is not just knowing a lot. It is not just making diagnoses or prescribing medications. Doctoring requires engaging the patient to develop an approach to diagnosis and treatment. Patients recognize good doctoring. Payors do not.

Maybe. Then again, it is possible that another scenario will prevail: large groups that use not medical doctors but nurse practitioners and physician assistants as the principal providers, with smaller numbers of doctors acting as supervisors and consultants.

Several reasons lead me to see this as one way things will go: the model has been tried in institutional settings for several years--the military, for one-- and nurse practitioners have already obtained considerable practice latitude and independence, even forming practice groups independent of doctors. Cost controls will be a relentless requirement, and even if the sway of graduate training interest again turns more favorably toward generalist physician training, there still has to be a way of paying for that kind of primary care. More likely there will be a greater split between high and low option services, with primary care services provided by well-paid internists enjoying a less stressful practice schedule being available only to those able and willing to pay for that quality of service.

The definition of primary care holds the key to this problem. What is primary care? Can physician extenders provide it? If primary care means 'simple care', i.e., care for minor episodic illness, hypertension control and preventive examinations, then the comment makes sense. If one uses the original Institute of Medicine definition - "accessible, comprehensive, coordinated and continual care", then I do not believe that physician extenders will suffice. Once the patient has multiple diseases, then physicians make a major difference. Take our average VA patient with diabetes mellitus, hyperlipidemia, coronary artery disease and worsening renal function. This patient needs a good generalist.

I do believe the pendulum will shift, and I do not think that we can or should replace physicians.

As the Pima study indicates (if not proves) exercise and diet will cut down on obesity. But as it also shows, some are not much helped even by that.

Should we patients try diet/exercise/lifestyle changes? Certainly! For many it not only works, but can be satisfying in itself.

Even if there were a med that would magically take off weight, losing that weight - in any manner - might encourage lifestyle changes as well.

Let me make few comments about this well stated comment. First, we should not fear research into the genetic bases of weight control. Some people seemingly have no difficulty with weight control, while others have a life long battle. Understanding the genetic bases will allow us to better treat those with a genetic predisposition to obesity. I suspect that we will see increasing research and results in this area.

Even when we succeed with genetic understanding, we will still have diet and exercise as important subjects. Many can not blame their weight on genetics. When I become a couch potato, I can easily become a size 38. With diet and exercise, I am a size 35 (and hopefully soon a size 34). My genetics have not changed, my attention to lifestyle has. Almost everyone improves their health (or at least odds at good health) when they eat smart and exercise. I believe that genetic understanding will help those people with major genetic influences (like the Pima Indians) to succeed with normal efforts. Remember, a fit overweight person does much better than a deconditioned overweight person.

Alas, Dr Centor .. you miss the point. Canada spends a fraction of what we spend on healthcare as a percentage of GNP. Their current problems stem from their decisions to limit healthcare spending in this way ... not from the structure of their system.

Their system - with a structure to rationally make decisions about healthcare spending (rationing?) nearly eliminates the ~25% administrative overhead that we have in this country. We spend 25 cents of every healthcare dollar on administration. They spend 4 cents. They insure the whole country with that extra 21 cents .. and they STILL spend much less per capita than we do.

Health plan administrators make an average of $175,000 .. and insurance company investors bring home their dividends ... These are clearly $$ that flow INTO the thealthcare system .. yet go out in a form that has rather little to do with the provision of healthcare. In Canada, since there are no such beasts .. the $$ that go IN .. are devoted to providing the services.

Today I saw 22 patients. 4 of them had no insurance. While Canadians may wait .. at least they can get care. Last week, I cared for an uninsured patient with a kidney stone in the office. Our system requires me to reach right into my own pocket and provide services, medications, etc .. for our patients without the means to pay for it themselves. Sure .. I can do this once in a while .. But I can't do it too often . or I won't be able to pay the nurses or the rent or pay for my kids braces.

No .. I dont' drive a Mercedes. I drive a 1993 Saturn. We're not in this business to make lots of money .. but should we really support a system that puts us (and our patients) in this uncomfortable position?

A combination fo the Canadian style STRUCTURE .. with the funding levels that we currently dedicate to healthcare could significantly improve the quality of care for all Americans.

This comment comes from a blogger - Family Medicine Notes. I do respect the passion of the argument, but I still cannot agree with the conclusion. If we have a universal health care plan, the government will play a role. They will ultimately determine the budget. Congress always controls the budget. And that scares me a lot. I see the decisions made in the VA system. I see the decisions made concerning Medicare. The Canadian system has continual struggles. The British system has serious problems.

We do need to develop a better plan for treating the uninsured. I just fear more governmental control.

The answer to this question brings a moment of truth. If doctors leave because of hostile practice climates, then all in the affected community will bear the consequences, including those with no vote and hence no voice in the debate. We aren't just talking about local bond issues for road expansions and other typical issues of local governance. Poor specialist coverage may mean some people will die who might otherwise not in better-served communities, given the same circumstances. Are we prepared to accept these consequences? Personally, I think it is morally and economically bankrupt of any society to allow the ruinous, selfish, greed-driven litigation industry such as we have, to squander the human capital in our medical system. Remember, when you drive off the doctors you have, you won't necessarily get replacements.

I agree with this comment. For context, I ranted about an editorial urging state experimentation with differing malpractice reforms. I am in favor of a national solution. This is a national crisis, thus it requires a national solution. If legislators in one state make bad choices, what will that mean for the health care of their citizens. And when will some enterprising lawyer sue the legislators for decreased access to medical care, caused by increasing malpractice premiums. If the legislators (and Governor) of that state do not 'solve the problem', are they not responsible to citizens having decreased access to care.

This is a major national issue. Lawyers do not seem to understand, perhaps because their business follows capitalistic rules. Our 'business' has controlled pricing (or at least reimbursement) and uncontrolled costs (nice combination). We have no method of passing increased insurance costs on to patients (unlike most businesses who pass their increased costs on to consumers). Hopefully, Dr. Frist will lead the charge here. Will the Democrats filibuster on this issue?

This is very relevant to my job in CCU. As patients get sicker and sicker, more and more specialists are brought
on the case, until the 'generalist' who actually admitted the patient in the first place can barely keep up with what the other 5 are doing.

I've lost count of how many times the pulmonologist has ordered or dc'd antibiotics without telling the I.D. MD, who then comes in at 8pm and rants at the nurses for not notifying them of the change. I'm not sure what a good solution would be. We need both generalists and specialists, but the missing link is communication... and common
sense (Why consult ID if you're not going to abide by their recommendations, or even chat with them about concerns before just blatantly dc'ing their orders? Oh yeah.. because the surgeon consulted ID... not pulmonology....Does pulmonolgy even know that ID's on the case?). That's just one example. Sometimes it seems like people feel as though they've had their toes stepped on.

This wonderful comment comes from Geena at code blog - tales of a nurse . She understands. Fortunately I am rarely called a gatekeeper anymore. I have always preferred the concept of the generalist as the conductor. I must understand all the parts, especially when several consultants become involved. Someone has to direct traffic and decide amongst competing recommendations. The generalist has great value, even in the ICU. And he (or she) is probably the least financially compensated.

Thanks again for all the comments and questions. I apologize if I ever insult anyone. I like the banter, the arguing and listening to all sides of an argument. I hope you do too.

Thanks to Overlawyered.com for this link. Cash Diet: When medicine can't produce a miracle, there's always litigation. This case becomes my poster case for malpractice reform. I am so angry, that typing becomes difficult.

The volcano inside Lawrence Smith's chest erupted on June 8, 1999. The LTV shipping supervisor crumpled to the plant's floor, dead of a heart attack. But as abruptly as his life ended, it's surprising he lived to age 54.

At 6 feet 2 and 260 pounds, the beefy Smith treated his body less like a temple than a tool shed. He'd hit the bad-health trifecta: too much smoking, too little exercise, and a poor diet, the last triggering high cholesterol and diabetes. He'd felt stressed since becoming supervisor, a job he got after the previous foreman suffered a heart attack a year earlier.
Smith visited Dr. Franklin Price almost two dozen times in the five years preceding his death. In between badgering his patient to swap the cigs for a salad fork, Price guided his treatment for prostate cancer. The doctor ran regular cholesterol tests and six EKGs to gauge Smith's cardiac health. Price's records also suggest he told Smith to see a cardiologist two months before he collapsed.
Last August, Smith's widow asked a Cuyahoga County jury to decide who to fault for the seizure -- her husband or his doctor. Maggie Smith brought a wrongful-death suit against Price in common pleas court, where her lawyers argued that he missed billboard-sized warning signs of heart disease. They asserted that even if he had made the cardiologist referral -- documents were hazy on the matter -- it should have come years earlier, after Lawrence Smith's first heart test in 1994. Price's attorneys countered that the physician did everything to help a man who did next to nothing to help himself.

Jurors blamed Price. On a 6-2 vote, they awarded Maggie Smith and the couple's two adult children $3.5 million; a judge later added $1.2 million in prejudgment interest.

In a written summary, the jury claimed that Price failed to provide "ordinary, reasonable care." Yet insofar as Lawrence Smith preferred french fries to Fitworks, it's fair to ask if the same charge should have applied to him.
"A doctor can advise and give counsel to a patient," says Dr. Kevin Geraci, president of the Northern Ohio Medical Association's Cleveland branch. "But it's still up to the individual to do what he has to do. We can't guarantee immortality."

This judgement makes no sense. Read the rest of the article, but consider taking a benzodiazepine first. I must quote one of the jurors.

The jury's two dissenting members believe Smith's vices claimed his life -- along with Price's reputation. One of them, Morris Blatt, wrote to defense lawyers, alleging that the other six jurors let their emotions obscure the evidence and that Smith "abused himself."

A judge denied Price's request to include the note in his pending appeal. But malpractice attorneys say it's the first time they can recall a juror attempting to enter written frustrations into the court record. Allyson Cooley, who sided with Blatt, says she was tempted to follow suit. "[Smith] didn't try to change. He didn't fix his diet, he didn't exercise, he started smoking again. But the widow was looking to place blame, and Dr. Price was the closest one."

In his closing argument, John Martin, Weinberger's co-counsel, suggested Smith bore no liability for his death: "It's absurd for anybody to come into this courtroom and say, Lawrence Smith would be alive today if he stopped smoking, if he had lost weight . . . The doctor let him down."

Following a week-long trial, the Smith jury took only two hours to deliver a verdict on a Friday afternoon. Blatt and Cooley contend other jurors rushed the decision to avoid returning to the courthouse on Monday. "Their whole thing was 'Let's get out of here,'" Cooley recalls, adding that none bothered to so much as scan the case's numerous exhibits. "They just said, 'Her husband's gone, give her the money.'"

AAAAARRRRRRRGGGGGGGGHHHHHHHHHHHH!!!!!!!!!!!!!!!!!!!!!

When ALLHAT first appeared, I ranted and cautioned readers mostly about data interpretation. I had a gut feeling (which I did not recognize or verbalize) that the study did not deserve the hype and press conferences. This week I again ranted after the Australian study appeared - seemingly contradicting ALLHAT. I was browsing Medscape (which is free and a great resource) and found this article which appeared in the Journal of Hypertension (free registration at Medscape required) The ALLHAT Report: A Case of Information and Misinformation. This article supports my rants - thus I like it. The article does a nice job of discussing the study in depth and showing the warts. ALLHAT provides much interesting data. It does have the simple bottom line that a diuretic should be either the first or line antihypertensive. We need not switch patients who are already well controlled on an ACE inhibitor.

FDA Approves New Heart Attack Test

On Friday, the FDA approved a simple blood test that, when added to heart checks, could greatly improve doctors' ability to rule out a heart attack and send those patients home sooner. The $30 test, made by Ischemia Technologies Inc. of Denver, uses the metal cobalt to hunt changes in a blood protein that occur during a heart attack.

Today, two tests are standard for heart-attack detection: an EKG to measure the heart's electrical activity, and a blood test that detects troponin, a protein present in the blood after a heart attack.

In a study of 200 patients, doctors were 50 percent accurate in ruling out a heart attack using just an EKG and troponin test. But when they added the new test, doctors accurately ruled out a heart attack 70 percent of the time, FDA said.

How does the test work? A blood protein called albumin undergoes changes in its structure during a heart attack and certain other illnesses. In 1995, a Denver emergency room physician discovered that when cobalt was added to a blood sample, more of the metal would bind to normal albumin than to the changed albumin of a heart-attack victim, said Robin Daigh, vice president of Ischemia Technologies.

This news surprised me. I try to keep up to date on cardiology, as we care for many cardiology patients on the VA wards. I scouted around and found the companies web page - Ischemia Technologies - Completed Studies. They have several publications. I look forward to reading subsequent clinical studies on the utility of this new test - which goes by the name - Albumin Cobalt Binding (ACB®) Test. If independent investigations confirm the initial studies, we may be able to decrease unnecessary admissions for chest pain.

Both Rangel and I ranted on this subject last week. The ACP-ASIM expands our discussion significantly. Taking a tough stand on nonbillable care

Many of the new policies, like discouraging phone consults in favor of office visits, can improve patient care. But for many physicians, the driving force behind their efforts has as much to do with boosting revenue as enhancing care.

"Any time physicians extend liability or incur expense, they should bill for it," said Joseph A. Leming, MD, a primary care physician in Virginia. "Either the time is right for patients to bear more costs of services, or it's time to go out of business."

The article discusses in depth the following issues: copies and forms, phone calls and no shows, prescription refills, drug switches, drug reps and sample, and finally email. While I understand all of these initiatives, I still believe that some flavor of retainer medicine should be our solution. Then the patient will have prepaid for all these services. Either that or we may have to learn from the lawyers and start counting billable minutes.

Mending Malpractice Mania . Read this interesting essay which concludes:

President Bush proposed a $250,000 nationwide ceiling on pain and suffering awards to clip insurance premiums and staunch the hemorrhaging of doctors from high-risk specialty practices. And Congress is holding hearings on medical liability. But discovering the most enlightened balance between compensating injured patients, deterring irresponsible care, and arresting the cost of medical treatment is an art, not a science.

Experimentation in 50 state laboratories is urgent to gather empirical data. If the nature and severity of the medical malpractice problem varies from locality to locality, then so should the answers. Moreover, states are more alert to correct medical malpractice infirmities because inertness will precipitate physician flight to warmer professional climates in sister jurisdictions. In other words, our system of federalism fosters competition in good government when an issue is left undisturbed with the states. The federal government should thus silence its monopolistic voice. It squelches experimentation where, as with medical malpractice, states are actively considering and enacting varied reforms in searching for the superior solution.

Is the author right? Should we allow some states to fail and others to succeed? Is that just?

It makes sense. Jenner used this principle to start the smallpox vaccination ball rolling. Apparently a harmless virus can slow HIV progression. Scientists Link Harmless Virus to Slowing of H.I.V.'s Effects

Infection with a common harmless virus seems to slow the progress of H.I.V. and prolong the survival of AIDS patients, according to new evidence reported by American scientists at a meeting here today.

Swedish scientists reported a study supporting the link between the harmless virus, known as GBV-C, and H.I.V. But the Swedish and American authors disagreed about whether GBV-C could cause the apparent benefit or whether it was simply an indicator of something else ? as yet undetected ? that might account for the variability of H.I.V. infection.
The Swedish and American authors agreed with other participants at the 10th Conference on Retroviruses and Opportunistic Infections that much more research was needed to determine the importance of the link before it could have any effect in AIDS care.

They also agreed that more testing is needed to determine factors such as: how often GBV-C infects people; the frequency with which people recover from infection; how the virus is transmitted; and the age at which most people become infected.

Limited testing has shown that up to 2 percent of blood donors in the United States and 3 percent in Sweden are actively infected with GBV-C. More testing has shown that 12 to 15 percent of Americans and Swedes have been infected in the past.

Who knows where this research will go? This report is classic early hypothesis generating research. We should not get excited over this report, rather we find it interesting and look forward to subsequent studies.

I have many medical friends who decry our health care system. We do have 40 million uninsured patients. We have patients who cannot afford their medications. Advocates of universal health care (a euphemism for socialized medicine) point out how unfair our system is. They rant that health care is a right (and one wonders why not legal care, why not a nice house, why not a nice suit). Then they often point to the Canadian system.

I too would like a better solution to insuring the uninsured, but please do not change the system so much that we have a Canadian like system. Long Lines Mar Canada's Low-Cost Health Care.

Waiting times have also increased because an aging population has put more demands on the system, while the current generation of doctors is working fewer hours than the last.

Waiting can occur at every step of treatment. A study by the conservative Fraser Institute concluded that patients across Canada experienced average waiting times of 16.5 weeks between receiving a referral from a general practitioner and undergoing treatment in 2001-2002, a rate 77 percent longer than in 1993. The recent Senate report noted that waiting times for M.R.I., C.T. and ultrasound scans grew by 40 percent since 1994.

"Waiting lists are the hornets' nests that are jeopardizing the system," said Dr. Tirone E. David, professor of surgery at the University of Toronto. He noted that Ontario residents needed to wait an average of two months to see a cardiologist unless it was an emergency, queues for angiograms took four to six weeks, and waiting times between initial examination and micro-valve repairs could take as long as six months.

"It wasn't that way 15 years ago," Dr. David added. "It does not alter the ultimate outcome, but there's an anguish and uncertainty when a person feels their life is in a holding pattern for up to a year."

What are the real consequences of changing our health care system? Would it influence how hard physicians work? Would it effect who becomes a physician? Would you have to wait?

New Study Stokes Blood Pressure Debate. This lead article in the NEJM asks the question of the best initial BP medicine and gets a different answer. In this article the ACE inhibitor (enalapril) outperformed the diuretic (hydrochlorothiazide). The greatest positive effect occurred in the men (all patients in this Australian study exceed 64 years).

But a large study from Australia, published Thursday in the New England Journal of Medicine, found that ACE inhibitors are somewhat better at preventing heart attacks -- at least in men.

The new study is unlikely to end the debate, however -- partly because of differences in the two studies, but also because the question is more complex than which drug is better. Many patients, in fact, need two or three drugs to control blood pressure.

For nearly two decades, the question hasn't been ``is drug A better than drug B. The question is: Do you have to use A and B, or A, B and C to control blood pressure?'' said Dr. James Reed of Morehouse University, a participant in the U.S. study.

As I was saying when I criticized the ALLHAT study, the monotherapy question may not be the right question. I could say from the previous study that diuretics were better than ACE inhibitors. I cannot say from this study that ACE inhibitors are better.

Thus, I stand by my previous rants. Diuretics are an excellent choice for monotherapy when the patient has no specific indication for another class. When one starts with and ACE inhibitor, and does not achieve excellent BP control, then one should add a diuretic. Fortunately, we do not have to choose between ACE inhibitors and diuretics, rather we often appropriately use them together. Once again we do not have data on the combination, but can only assume that the synergistic effect on BP control leads to a synergistic effect on outcomes.

In the 1980s we taught medical students and residents not to use beta blockers in CHF (because of the negative inotropic properties). In those days we thought of CHF as a contractile disorder first and a hemodynamic disorder secondary. These days we understand CHF first as a neurohormonal disorder and then a hemodynamic disorder. Research increasingly supports using beta blockers for chronic heart failure. A study in today's JAMA documents the safety and benefit of beta blockers in patients with severe CHF - who are euvolemic . Let me stress that one more time, they did not start beta blockers until patients became euvolemic.

Effects of Initiating Carvedilol in Patients With Severe Chronic Heart Failure   describes the outcomes of starting CHF patients with ejection fractions of less than 25%.

Results

The carvedilol group experienced no increase in cardiovascular risk but instead had fewer patients who died (19 vs 25; hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.41-1.35); who died or were hospitalized (134 vs 153; HR, 0.85; 95% CI, 0.67-1.07); or who died, were hospitalized, or were permanently withdrawn from treatment (162 vs 188; HR, 0.83; 95% CI, 0.68-1.03). These effects were similar in direction and magnitude to those observed during the entire study, and were apparent particularly in the 624 patients with recent or recurrent decompensation or a very depressed left ventricular ejection fraction. Differences in favor of carvedilol became apparent as early as 14 to 21 days following initiation of treatment. Worsening heart failure was the only serious adverse event with a frequency greater than 2% and was reported with similar frequency in the placebo and carvedilol groups (6.4% vs 5.1%).

I find these stunning results. Carvedilol less often than placebo worsened CHF. They decrease mortality or hospitalizations. We assume this is a class effect (although we are waiting for a study comparing carvedilol and metoprolol currently underway). We should all remember to use beta blockers in these patients. We do this regularly on my inpatient service, without clinical difficulty.

I believe that it helps if physicians are not judgmental. Many patients rebel from a judgmental attitude. How can we get patients to tell us their sexual habits (and often that is important information) if we appear judgmental?

I suspect that many physicians fit into a libertarian philosophy. So I have written this introduction to justify this link. Actually, I do believe that the 'struggle' between a liberatrian and conservative philosophy has important implications for medicine. I favor the libertarian side. I found this editorial very well considered. Sex, Drugs and Rock 'n' Roll: Libertarians have more fun--and make more sense.

While I do not agree with this entire editorial, the editors have clearly thought about the issues. Short-term malpractice fixes push partial cure. This editorial focuses more on finding a fair method for compensating patients who are victims of medical errors. The difficulty is in defining errors as opposed to unavoidable bad outcomes.

I still believe that the problem is the tort system. Lawyers often make the case (check out some comments I have received) that few cases are lost. However, malpractice costs are not just related to lost cases. Each prepared case requires significant resources to defend. Each physician victory still costs and drives up. Settled cases cost money, and insurance companies often choose to settle.

So most physicians work in a financially regulated industry (insurance companies determine how much a visit or procedure gets reimbursed), without a regulated overhead. Trial lawyers and the USA today editorial always worry about compensating the injured party (but who determines if there is truly an injury rather than an unusual undesirable outcome). We worry about health care generally. How does the malpractice industry influence health care, health care costs, and the doctor patient relationship? How do we reconcile the classic conflict between individual rights and societal rights? What is fair?

I believe we should not use the tort system to answer these questions. No commentary from a trial lawyer has convinced me. The problem is not compensation for truly injured patients. The problem is not who wins in court. The problem is the process - the arbitrariness of the process.

Fat: Is it all in our genes? Simply put, genetics contribute, but we can modify the genetics. We all know people who seem to eat anything and everything yet stay slim. We know others that constantly fight their weight.

Why the sudden change in weight-loss philosophy? It?s simple. Scientists have learned that while willpower is important, much of what, when and how much we eat is dependent on our genes. In addition, the urge to exercise may also be related to the DNA we inherit.

When it comes to losing weight, we?re fighting against a body regulatory system that has evolved over hundreds of thousands of years to keep us functioning no matter how sparse food becomes. And, scientists have been learning, this genetic influence is stronger in some people than others.

As a prime example of the role of genetics, researchers point to two groups of Pima Indians, one living in Arizona and the other in Mexico?s Sierra Madre Mountains. The Pimas in Arizona have long been known for high rates of obesity, diabetes (almost 50 percent suffer from this disease) and high cholesterol.

The Pimas in Mexico, where food is more sparse and manual labor more common, tend to be lean and have a much lower rate of diabetes than those in Arizona. But despite their healthier lifestyles, the Mexican Pimas still have higher rates of obesity and diabetes than the general population, a finding that leads researchers to point to genes as the culprit.

Should we give up because genetics influence weight? I say no. We will not have specific therapies based on genetic understanding for some years, nonetheless, some patients do have success in weight control Patients should strive towards a healthy lifestyle; physicians should recommend healthy choices.

?At present, we?re at least five years away from having any therapeutic applications based on genes,? says Thomas Wadden, director of the Weight and Eating Disorders Program at the University of Pennsylvania School of Medicine in Philadelphia.

Wadden is one of the weight-control experts who?s changed his mind on surgery.

?I used to think it was barbaric,? he says. ?Now I think it?s underutilized. If you?re extremely overweight, you should explore it.?

For those like Syrnick, who are overweight but not morbidly obese, the only options available now are calorie counting, exercise and the current generation of medications that make it a little easier to pass up that extra slice of cake.

Thanks to Bloviator for this link. Higher Medicare Payments Approved

Congressional negotiators agreed yesterday to increase Medicare payments to doctors by nearly $49 billion over the next 10 years, avoiding a scheduled March 1 pay cut that some feared could drive thousands of physicians out of the program.
The action, which was lobbied for intensely by the American Medical Association, rolls back economies in the Medicare program dating to the 1990s. It also provides a taste of the enormous pressures building for more federal health care spending, even as huge federal deficits return.

Hospitals outside urban areas in almost every state will also collect $600 million more in Medicare payments through next September. Other health care providers, ranging from skilled nursing homes to medical facilities in Puerto Rico, are clamoring for similar relief.

Primary care physicians and their professional groups bemoan the decreased interest in the field. Some blame the medical schools for not producing more primary care physicians. Some discuss strategies for convincing students to select primary care residencies. They miss the point.

Specialty selection remains an economic decision. I do not mean that money is the sole factor in the decision making. Rather I believe that students make these complex decisions considering money, lifestyle and difficulty of residency training as much as their love of the subject matter. I suspect that most educated people with options consider all these factors in varying degrees as they choose jobs. Why should physicians be any different?

You could not pay me enough to be a radiologist. I would miss the patient interaction, the history taking, the patient education. I do not find the subject matter that interesting. While I love making diagnoses, I get more pleasure from thinking through the problem, designing first the diagnostic strategy, and then designing the therapeutic strategy. Finally, I love to explain the process to the patient, to work with the patient to refine the plan to fit his or her view of the world.

Fortunately, medical students have different personalities and different needs. Some will become family physicians regardless; some are born surgeons; some could choose amongst many specialties. This latter category responds most to the marketplace.

Paul Ginsberg has addressed the economics in an Annals of Internal Medicine editorial - Payment and the Future of Primary Care . He makes some very important points.

Primary care has been on a roller coaster. It was pushed to the forefront in the mid-1990s by managed care, and as a result its scope and authority increased (1). But the backlash against managed care and its transformation to a less restrictive model with less emphasis on primary care dealt a serious setback to primary care. It is most timely that Annals is publishing this supplement examining primary care's future (2).

As an economist who has been systematically studying changes in the financing, organization, and delivery of health care, I believe that a key factor in the future of primary care is how its services are paid for. To augment the valuable contribution of the papers in this issue to our thinking about the future of primary care, I have set out my thoughts about the likely developments in physician payment and how they will shape primary care. I first discuss recent developments and the outlook in the overall level of payment for evaluation and management services in relation to procedural services. I then examine the extent to which traditional fee-for-service payment will support the directions for primary care sketched out in the papers in this supplement.

As I said yesterday, I believe that increasing signs suggest a change in primary care payment. While many decry retainer medicine, and use prejorative terms like concierge or boutique medicine to describe this concept, I believe they are missing the underlying point. This movement is occurring in response to market forces. As I blogged yesterday, physicians are leaving primary care much faster than students are choosing primary care. Thus, I conclude that the system is broken, and market forces (albeit slowly) will fix the system.

The mechanism of payment for primary care services can be a substantial impediment to achieving the vision of the primary care of the future. Fee-for-service payment is not evolving in the same way that the practice of medicine is. Primary care practice now involves more telephone and e-mail communication with patients and time spent on management and coordination of care. Payers have resisted paying for these services. They are concerned about paying for something that is already being done without payment and difficulties in adequately documenting the time and effort spent on such services.

Relate this paragraph to my Q&A from Sunday. Ginsberg makes my point beautifully.

A few years ago, I expected that increased use of capitation would resolve these problems. Primary care capitation allows practitioners to use services not recognized under fee-for-service payment without disproportionate penalty. Global capitation, in which the payment goes to an organization such as a large physician practice or a hospital system, provides these organizations the flexibility to use salaries with incentives or to innovate with fee-for-service payment to physicians. But, at least for now, the use of capitation is declining sharply (8), in large part because of increased resistance from hospitals and physicians to this payment mode. This history of expansion and now decline in the use of capitation is probably delaying the emergence of alternative mechanisms for adapting fee-for-service payment to changes in medical practice.

But there are mechanisms short of capitation that could address the mismatch between fee-for-service payment and the envisioned evolution of primary care practice. Primary care physicians could be paid a case management fee for each of their patients. This fee could cover e-mails, telephone calls, care management, and other services, while visits and procedures would be paid on a fee-for-service basis. Many Medicaid programs already pay a case management fee. If Medicare, which has the resources to invest in developing payment tools, took the lead here as it has done in the past, private insurers might follow.

In conclusion, those concerned with payment for primary care must work to sustain past gains while pressing to make the payment system more supportive of the primary care practice of the future. The Medicare reform of physician payment has raised payment rates for evaluation and management services at the expense of procedural services. Holding on to these gains will depend on maintaining the accuracy of the Medicare relative value scale. Making the payment system more responsive to the trend toward spending more time on management and coordination of care will be a more formidable challenge. It will probably involve either increased use of capitation, which would be a reversal of today's trend, or development of payment models that blend fee-for-service and capitation.

So he proposes a case-management fee - or in my words a retainer . I truly believe this is an idea worthy of further consideration. We need to think outside the box. Given appropriate retainers (and therefore limiting patient volume), primary care physicians could deliver higher quality care. At this same time, they could enjoy higher quality lives. And physician lifestyle is very important. Happy physicians are better physicians (at least in my not very humble opinion).

Doctors in state fleeing HMOs: Consumer advocates alarmed by trend

In numbers that are alarming consumer advocates, doctors are closing their practices to new HMO enrollees and dropping out of "preferred provider" insurance contracts that offer discounted rates for patients. A recent UCSF survey found that only 58 percent of California doctors were accepting new HMO patients.

Doctors are experimenting. Some limit their practices to patients who pay cash up front; others are requiring hefty retainer fees of a smaller group of patients happy to pay extra for more personalized care.

Some are simply giving up. For Palo Alto physician Dr. Richard Lenon, quitting medicine was "the only honorable solution."

The 58-year-old internist, tired of the paperwork and low fees from health insurance plans, is closing his 24-year-old practice this month, and plans a solo bicycle trip to Chicago.

"Doctors have been trying to get out from under the yoke of what managed care has done to them, and to their sense of professionalism," said Dr. William Andereck, a San Francisco physician who was among the first to embrace HMOs -- and among the first to leave them.
The increasing turmoil in the medical world does not bode well for patients in search of a doctor in a seller's market.

This article tells us several things. First, we are developing a supply and demand mismatch. We clearly see this in Birmingham. More patients need generalists than our current supply of generalists supports. Moreover, less physicians are becoming generalists. So what will happen?

We will soon see a pendulum shift. Income and lifestyle are the keys to attracting medical students to residencies. As the supply demand mismatch accelerates (and I predict it will), conditions for generalists will have to improve. Generalist's incomes will increase for simple economic reasons. Then students will choose generalist fields, and internal medicine residents will more often become generalists rather than specialists.

Given the supply demand mismatch, generalists will redesign their practices to the benefit of their lifestyle. Insurers will start to court generalists once again. This will also occur for some specialities which currently have an undersupply of physicians.

The marketplace will adjust, albeit a bit slowly. Should we have to rely on the marketplace for these adjustments? Apparently we have no choice in an economically free society. Is this good for health care? I do not think so. I think we have too few generalists in the pipeline, because the economic forces turned the pendulum several years ago. But it is about to turn - or so I predict.

It is Sunday, the evil virus has subsided (I was able to make rounds this morning), and it is time for Q&A. I have collected the comments from this past week. Some comments are not exactly questions, nonetheless, I can still rant. So here goes my selection of interesting topics.

Every year millions of men go in for a psa for the prostate. Almost without exception the Dr will say come in in a couple weeks so we can go over your test. I just had mine and it was 2.1 I told the nurse this is what is helping to run the medical costs up.As long as their is not a problem a simple phone call would suffice and probably save my insurance co $50.

I had blood work done and had to go to the Drs.office for him to tell me everything is perfect.Once again a phone call would take care of it.

So,everything is perfect.I want to see you in 3 months.For what?To ask me if everything is alright. Another $50. I left the office saying to myself Doc you will see me when I have a medical problem. If we were trying to treat something that would be different.I could see coming back.Don't ask patients to come back for no reason. If everyone would use a little common sense medical costs could be lowered considerably. Enough of that.

This is a long comment, but very relevant. When should we see patients back in the office. When does a phone call suffice? How about email of results?

While this seems straightforward and easy, let me suggest the following complications. First, phone calls are not simple. They take physician time (and unlike lawyers we do not bill for our time, just visits). Moreover, the patient does not always answer and you may start a game of telephone tag.

Sometimes the visit helps reinforce a treatment plan. Sometimes the news is 'bad' and we do not feel comfortable having the discussion over the phone.

All that being said, the comment has validity. We need a system of contacting patients and communicating other than the office visit. If we had a modest retainer fee from each patient (paying for the time necessary for all the calls and email) then perhaps we would embrace these alternate methods. The system is not running smoothly.

Well stated! I'm happy to see that at least one doctor shares my viewpoint, that the biggest issue here is the way creationists reject science.

I like flattery. I also like her post - Loxosceles on evolution

I too was asked to switch to Omeprazole instead of Prilosec. I fear that it will not be as effective. Does anyone have similar negative experiences with omeprazole?

This question appears in many forms. I have done some research. According to the FDA there should not be any problems. Omeprazole ratings - omeprazole generic gets and AB rating - which means "(2) actual or potential bioequivalence problems have been resolved with adequate in vivo and/or in vitro evidence supporting bioequivalence. These are designated AB." For those interested in checking any generic - Electronic Orange Book

Referring to herbal remedies - If you want the view from the other side read this.
Understand, I'm not saying you're wrong, but sometimes just being right isn't enough.

This is an interesting read. I have the following problems with herbal intake. First, there are no controls on potency. While many herbal preparations seem harmless, who knows. We do not really know what we are taking. Second, the championing of herbal preparations does somtimes delay prompt medical care. If you are not really sick, then I have no problem, but if you are sick, you need a diagnosis. The person behind the counter at the health food store is unlikely to make an accurate diagnosis. Third, herbal preparations can have adverse reactions including interactions with prescribed drugs.

I understand why patients gravitate towards herbals, but I will and must rant against them.

Love your blog - it's nice to see someone in the medical field unafraid to throw out such strong opinions :) Congratulations on the 10 pounds gone!

What is your take on the Food Pyramid? Opponents say that it's too heavily loaded with sugars and carbohydrates and is nothing more than marketing materials. My nutritionist gave it to me and basically told me to treat it as a bible (which I don't do).

I have written about the pyramids recently and clearly favor the Willett pyramid. Check these two rants and associated links - Sorting out the pyramids and What to eat?

Will there be a vaccine developed to prevent men from contracting HPV?

Great question! I have had several related to this question., HPV is not just a problem for women. I have seen proposed strategies for immunizing all adolescents. Once a vaccine becomes available, I would bet that both sexually active men and women should get vaccinated.

Very interesting. This makes me feel better about having fired the general surgeon who was originally scheduled to treat my hyperparathyroidism. I asked him how many times he had done this operation. He said about fifty. I figured that he probably inflated the figurte by a factor of two or so, and I had the adenoma removed by a surgeon who specialized in endocrine surgery.

I can only say amen! Patients needing complex or unusual surgery should find a expert who does the procedure often. As the initial rant stated, practice generally helps. This is actually especially true for parathyroid surgery!

Speaking of colonoscopy - This was the most painful test that I have ever had. I will NEVER have this done again.Colonoscopy should not cause pain in 2003. Most gastroenterologist use sufficient medications so that you have amnesia for the event and have sufficient pain control. I wonder whether the reader had a sigmoidoscopy without sufficient pain medications. I have sent many patients for colonoscopy. They only complain about the prep, not the procedure. I have had my own colonoscopy, and do not remember a minute of the procedure. It may have hurt, but I do not know that.

I have been on Zocor for about two years. Also, I have been doing weight machine exercises on a regular basis for about the same length of time. I have gained some strength but my muscles remain flabby. Could Zocor be the cause? My age is 73. This is a difficult question, because I do not know what flabby means. I have researched this question on Medline and can find no relevant reference. I suspect that Zocor is not 'the problem'. If you are gaining strength at 73 you are to be commended. This is important for you overall health. I cannot speak to the aesthetics.

Drink some fluids and get some rest. I hope you feel better in the morning.

I did and I do!

I have a few more comments that may turn into rants this week. Please keep the questions and comments coming. I love the interaction and love the challenges to my rants! For now, I will plan to do these Q&A rants each Sunday.
 
 

db is lying in bed all day with some evil virus. Not enough energy to blog. Hope to return in the morning.

db

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose. This is a grade I recommendation. (See Appendix Table 1 for a description of the USPSTF classification of recommendations.)

The USPSTF found good evidence that available screening tests can accurately detect type 2 diabetes during an early, asymptomatic phase. (See Appendix Table 2 for a description of the USPSTF classification of levels of evidence.) The USPSTF also found good evidence that intensive glycemic control in patients with clinically detected (not screening detected) diabetes can reduce the progression of microvascular disease. However, the benefits of tight glycemic control on microvascular clinical outcomes take years to become apparent. It has not been demonstrated that beginning diabetes control early as a result of screening provides an incremental benefit compared with initiating treatment after clinical diagnosis. Existing studies have not shown that tight glycemic control significantly reduces macrovascular complications, including myocardial infarction and stroke. The USPSTF found poor evidence to assess possible harms of screening. As a result, the USPSTF could not determine the balance of benefits and harms of routine screening for type 2 diabetes.

The USPSTF recommends screening for type 2 diabetes in adults with hypertension or hyperlipidemia. This is a grade B recommendation.

The USPSTF found good evidence that, in adults who have hypertension and clinically detected diabetes, lowering blood pressure below conventional target blood pressure values reduces the incidence of cardiovascular events and cardiovascular mortality; this evidence is considered fair when extrapolated to cases of diabetes detected by screening. Among patients with hyperlipidemia, there is good evidence that detecting diabetes substantially improves estimates of individual risk for coronary heart disease, which is an integral part of decisions about lipid-lowering therapy.

Screening for Type 2 Diabetes Mellitus in Adults: Recommendations and Rationale

I have discussed screening for type II diabetes in the past. I believe that this will develop in to a major public health thrust over the coming decade. We know that we can decrease the probability that pre-diabetes becomes clinical diabetes with exercise, diet and medications. These guidelines are cautious, but do support screening patients who may have the 'metabolic syndrome', i.e., patients with hypertension or hyperlipidemia. While we wait for definitive studies, we should probably become more aggressive at identifying patients at risk and teach them how they can decrease their chances of developing diabetes. Posted by at 11:30 AM | Comments (0) | TrackBack (0)

How To Fix the Medical Liability System

NEWSWEEK?s Jennifer Barrett spoke with Dr. Donald J. Palmisano, president-elect of the American Medical Association, about the current crisis and what physicians hope can be done to fix it.

NEWSWEEK: How serious is the medical malpractice insurance problem?

 Donald Palmisano: We believe the medical-liability system is broken, that the amount of awards has escalated dramatically in recent years and that there is no statistical correlation between actual negligence and payment of claims, but that there is a statistical correlation between payment amounts and disability.

     Medical liability insurance has reached crisis proportions in 12 states: Washington, Oregon, Nevada, Texas, Mississippi, Georgia, Florida, Ohio, West Virginia, Pennsylvania, New York and New Jersey. Only seven states are stable: California, Colorado, Indiana, Louisiana, New Mexico, Wisconsin and Hawaii.

 How do you define crisis?

We look at many factors: the fact that women can?t find a doctor to deliver their babies, the closure of a Level One trauma center, the early retirement of physicians, the limitation of practice by certain specialties and the movement of physicians to other states with more stable liability climates. Those meet our definition of crisis.

Yes, we do have a crisis. The crisis does come from a broken tort system.

10 pounds lighter, and safely past Super Bowl

The results haven't been bad: 10 pounds lost. Down to 214.

I would have liked to lose a bit more--12, 15 pounds--and probably could have had I suffered more. But I'm deliberating trying to long haul this process. I've been on those diets where you wake up hungry in the middle of the night, gazing greedily at the clock, waiting until the second hand sweeps the 12, ushering in feed time. It's hard to keep that up.

I did skip all starches for the first week--no bread, no potatoes, no nothing. I stuck to what could be called a modified Atkins--lots of steak, breakfast, lunch and dinner. It was fun eating so much steak. I was never hungry and I lost seven pounds. But I felt weird--almost a buzzing in my ears. After the weight-loss needle stuck for three or four days in a row, I figured, rather like a struggling radio station changing format, it was time to shift from All Meat All the Time to a more pleasing mix of other foods.

That's how it's been for the last 20 days. Lots of salads. Small meals--a glass of grapefruit juice for breakfast, a power bar for lunch. Even those vile Slim-Fast drinks. Going is slow, and the hard part is not to let disappointment sap my resolve. What trips people up about dieting, I believe, is how long it takes. They gain weight over months and years, and then want to strip it off quickly because dieting is such a chore. I've struck on two helpful metaphors I want to pass along.

The first came early in the month. I had lost a good amount of weight in a short time, then realized, sadly, that I still had a long way to go. "It's like walking to New York,'' I thought. "You head off at a good clip, make 25 miles a day, and a week later you're still in Indiana.''

We should all understand life as a marathon, rather than a sprint. Lifestyle changes only occur one day at a time. As I have attacked my New Year's Goals, I understand that I will need time to succeed. We succeed when we can delay gratification of our final results and revel in our small successes.

Repetition makes best surgeons, studies find.

A growing body of research is pinpointing the surgeons most likely to cause harm or death during operations, creating powerful benchmarks for obtaining safer medical care. A simple question posed to surgeons, the research shows, can often separate the talented from the average: How often do you do this?

The work builds on earlier research that established that busy hospitals generally deliver better care. But it adds a new level of precision, citing the specific risks patients face in the hands of low-volume surgeons, who don't frequently and regularly perform certain procedures.

These surgeons become most dangerous, the studies found, during AIDS treatments, carotid artery blockage surgery, pediatric heart surgery, as well as surgeries for cancers of the lung, pancreas, esophagus, rectum, and prostate. These are complex procedures, often requiring precise cuts and scrapes near the nerves and arteries of gravely ill patients.

Practice makes perfect. Well maybe not perfect, but certainly practice makes better. We all know that. I am a better blogger than I was last May when I started. We all benefit from concentrated experience.

How do we apply this concept to our health care system? I would argue that we generalists should know when to care for a patient alone, and when to ask for help. And we need to know who to ask for that help. The wise generalist knows when to consult. We must not have ego when it comes to patient care.

Interestingly, some procedures do not show this effect - the more routine, less complex procedures.

Dr. Colin Begg, epidemiology chairman at New York City's Memorial Sloan-Kettering Cancer Center, has conducted several of the studies establishing the high-volume pattern, and though his work focuses on cancer, he strongly suspects his results can be applied to many complex surgeries.

Begg said, however, the pattern probably does not hold for less complex surgeries. It did not turn up, for example, in studies of hip fracture repair and knee replacement, considered less technical than procedures on tumors or delicate organs.

This article should make us think carefully about medical care. We should understand the practice effect and determine how and when to use it.

As I have been ranting. Those dang unintended consequences. Access hurt in liability crisis states

I have received several very positive comments on the Q&A format I used on Sunday. Therefore, I plan to do that again. This is a formal invitation for questions or general challenges to my rants. Please let me know if you want credit or wish to remain anonymous.

db

I remember ward attending in 2000 when the NEJM published an article showing that acetylcysteine (Mucomyst), could decrease renal damage in chronic renal insufficiency patients having dye contrast studies. We used the new treatment that month, based on a single study. I likened the data to chicken soup - it might not help, but it couldn't hurt.

Further studies have confirmed that original study. The latest appears in JAMA this morning - if you subscribe - Acetylcysteine for Prevention of Acute Deterioration of Renal Function Following Elective Coronary Angiography and Intervention  

Participants

  Two hundred Chinese patients aged mean (SD) 68 (6.5) years with stable moderate renal insufficiency (creatinine clearance <60 mL/min [1.00 mL/s]) who were undergoing elective coronary angiography with or without intervention.

Intervention

  Participants were randomly assigned to receive oral acetylcysteine(600 mg twice per day; n = 102) or matching placebo tablets (n = 98) on the day before and the day of angiography. All patients received low-osmolality contrast agent.

Main Outcome Measures

  Occurrence of more than a 25% increase in serum creatinine level within 48 hours after contrast administration; change in creatinine clearance and serum creatinine level.

Results

  Twelve control patients (12%) and 4 acetylcysteine patients (4%) developed a more than 25% increase in serum creatinine level within 48 hours after contrast administration (relative risk, 0.32; 95% confidence interval [CI], 0.10-0.96; P = .03). Serum creatinine was lower in the acetylcysteine group (1.22 mg/dL [107.8 µmol/L]; 95% CI, 1.11-1.33 mg/dL vs 1.38 mg/dL [122.9 µmol/L]; 95% CI, 1.27-1.49 mg/dL; P = .006) during the first 48 hours after angiography. Acetylcysteine treatment significantly increased creatinine clearance from 44.8 mL/min (0.75 mL/s) (95% CI, 42.7-47.6 mL/min) to 58.9 mL/min (0.98 mL/s) (95% CI, 55.6-62.3 mL/min) 2 days after the contrast administration (P<.001).The increase was not significant in the control group (from 42.1 to 44.1 mL/min [0.70 to 0.74 mL/s]; P = .15). The benefit of acetylcysteine was consistent among various patient subgroups and persistent for at least 7 days. There were no major treatment-related adverse events

So there you go. We have a cheap medication that works to prevent a major complication of contrast dye studies. While questions remain about the true benefit seen here, even a skeptical editorial recommends using this inexpensive therapy.

The Doctor Is Out in New Jersey. The Times tries in this editorial to balance the controversy. They miss entirely. They miss the point.

I was talking with an obstetrician yesterday. We discussed malpractice premiums. I mentioned an article I read about a Wyoming obstetrician being charged $160,000 for the privilege to deliver babies. (I pulled that number from memory and cannot verify it). He shared that he received approximately $1,800 per delivery and probably did around 100 each year. You can do the math.

Why do we have a malpractice crisis? Do we have a physician malpractice epidemic? I believe that trial lawyers have created a culture which encourages a lawsuit for any bad outcome.

This culture does not just occur with physicians. You can read about excessive lawsuits at Overlawyered.com. In medicine, bad outcomes are too often blamed on the physician.

Several solutions seem apparent, but unlikely. First, we need to curb the true beneficiary of malpractice lottery - the lawyer!! The contingency fee arrangement encourages the "exploratory" lawsuit. Who knows? You might get a settlement just to prevent further legal proceedings. Second, we need to have better definitions of pain and suffering. Having each jury decide makes the system too random. Third, we need a different concept than punitive damages. If a physician needs punishment, then the courts can recommend such to the state board. State boards do a much better job than many think.

We cannot continue providing excellent health care under the current legal atmosphere. Our system is broken. But will anyone willingly fix it? Or will 2003 go down as the year of doctors' strikes.

New guidelines stress first colon screening. The data have seemed overwhelming for several years. Colonoscopy not only provides excellent screening for colon cancer, but it also provides therapy. When the colonoscopist finds premalignant polyps, and removes them, the likelihood of subsequent colon cancer plummets.

Doctors currently recommend that everyone get a colonoscopy at the age of 50. The exam can find early signs of colon cancer -- the third biggest cancer killer in the United States.

Tiny polyps in the colon that can become tumors if left to grow can be removed at the time of the examination, done while the patient is sedated but not unconscious.
Patients are usually told that if they get a polyp removed, they should return for repeat checks every three years.

But new guidelines issued by the U.S. Multisociety Task Force on Colorectal Cancer say the first screening detects the largest, most dangerous polyps.

Writing in the February issue of Gastroenterology, the journal of the American Gastroenterological Association, the task force says follow-up colonoscopies after three years may not be terribly useful because polyps do not grow that fast.

"Colonoscopy allows us to visualize the entire colon, and to detect and remove polyps in one procedure. It's invaluable in patients who are at high risk of developing colorectal cancer," Dr. Douglas Rex of the Indiana University School of Medicine, one of the task force members, said in a statement.

The American Cancer Society predicts that 105,000 Americans will be diagnosed with colorectal cancer this year and 57,000 will die of it.

You know what they say about colonoscopy. It certainly is good to have that test behind you.

Picking a Bone With Vitamin A: High Levels, Weak Bones Linked Again

A study published last month in the New England Journal of Medicine linked high levels of vitamin A to bone fractures, echoing findings of two other studies published in the last year.

While this study is not considered conclusive in linking high intake of vitamin A to increased risk of osteoporosis, the developing body of research is leading some experts to advise consumers to be more vigilant about abiding by federal intake guidelines for vitamin A and the degree to which foods fortified with it can increase risk of poor bone health.

In an editorial published with the study, Paul Lips of Vrije Universiteit in Amsterdam wrote that "vitamin A supplementation and fortification of food with vitamin A may be harmful" in well-fed populations where osteoporosis is growing.

The latest study, conducted by Karl Michaelsson and colleagues at the University Hospital in Uppsala, Sweden, followed 2,322 men over 30 years and found that those with the highest level of serum retinol, or vitamin A in the blood, suffered the highest number of bone fractures.
The group with the highest level of serum retinol had 1.6 times more fractures of all sorts than the middle group. The men who broke hips were 2.5 times more likely to come from the high-retinol group than from the middle group.

The study found no connection between bone fractures and beta carotene, a nutrient found in fruit and vegetables and vitamin supplements, which turns into vitamin A in the body.

For those who subscribe to the NEJM, the original article - Serum Retinol Levels and the Risk of Fracture

Many residents love the ICU. The units (housestaff slang) have action, rapid decision making and the aura of life and death. One can compare the units to police work - except in the units you are more likely to have a stressful situation each day. Not everyone likes the units. Trial by Fire, and by Fear, in the I.C.U. This article has poignancy. I truly emphasize with the resident. No excerpt will do this piece justice. Read and feel his pain and frustration and fear.

Herbal Remedies: Natural Does Not Mean Safe. I rant about this so often that I have become redundant. Read the article, discourage friends, relatives and patients from using 'natural remedies'. Believe in science.

Behind Walkout by Doctors, Chronic War With Lawyers

Mindy Cohen lives a reclusive life marked by fistfuls of painkillers and the drone of daytime television.

A former school psychologist who lives in Randolph, Ms. Cohen, 47, has been largely bedbound since 1997, when doctors were forced to remove a portion of her thigh after a liposuction procedure went awry. The unceasing pain, the narcotic-induced fog and the crushing depression, she said, make mundane activities nearly impossible.

"I desperately miss being out in the world," said Ms. Cohen, who took part in a news conference last week featuring several medical malpractice victims. "I'm just a shell of a person."

I must consider several points here. Liposuction clearly represents an elective procedure. It has clearly defined complications. Did Ms. Cohen have expected complications or did the physician do something clearly wrong? This question is our point. All outcomes are not good, even if the physician does everything right! We do not always understand why patients have poor outcomes. Apparently trial lawyers assume that any bad outcome must result from physician error.

Dr. Elliot Kaplan, a thoracic surgeon in Morristown, endures a different sort of anguish, one brought on by what he and his colleagues describe as a malpractice insurance crisis in New Jersey. He was forced to stop working for a month after malpractice insurers in the state, calling his specialty a magnet for litigation, refused to issue him a policy. When he finally found one last January, his annual premium, $60,000, was 40 percent higher than the previous year's for just a third of the coverage.

With reimbursements from health maintenance organizations and Medicare holding steady or falling, Dr. Kaplan, 44, wonders how much longer he can keep working in New Jersey. "I'm very anxious because I love what I do," he said. "But if there are any more increases, I won't be able to remain in practice."

Is he exaggerating? How many surgical procedures does he do just to pay his insurance? Where is the middle ground?

Insurance experts and consumer advocacy groups say that focusing solely on huge awards further muddies a complex problem that requires more than just a $250,000 limit on pain-and-suffering awards, the goal sought by doctors in New Jersey. The entire insurance industry, these experts say, suffers from a chronic malady stemming from the way malpractice insurers invest their premiums, a business model that turns customers into cash machines during economic downturns.

The National Association of Insurance Commissioners counters that insurance companies are prudent investors. A study by the association found that only a quarter of insurance companies' assets were invested in stocks in 2001.

The consumer groups say that the rush to cap awards ignores the problem of medical negligence in America, which accounts for 44,000 to 98,000 preventable deaths a year, according to a 1999 study by the Institute of Medicine, part of the National Academy of Sciences. "The so-called crisis with medical malpractice is another symptom of a health care system that is broken and out of control," said Dena Mottola, acting director of the New Jersey Public Interest Research Group. "There's a lot of misinformation out there, but whether or not you agree with the numbers, until we fix the underlying problems, nothing will change."

For the moment, medical professionals in New Jersey are united in their belief that aggressive lawyers and greedy patients are to blame for the spike in premiums. Many doctors see their fight against large malpractice payouts as part of a noble stand against freewheeling litigation, an issue that riles many Americans. "It's more than just a medical problem, it's a societal problem," said Dr. Donald Allegra, an infectious-disease specialist in central New Jersey, who said he planned to treat only the most gravely ill patients on Monday. "I've never seen doctors so galvanized by an issue."

Again, the Institute of Medicine errors study is being used as an argument against the profession. The study has fundamental errors (surprise) and very likely markedly overestimates the problem. Does that mean that we have no problem?

Health care is often complex. No simple algorithm works for each patient. As we can do more, each medical situation requires more complex decision making. One must balance risks and benefits.

How does one establish a fair tort system? Clearly, the current malpractice lottery game is not fair. How does one protect our health care system and maintain protection for individual patients?

We clearly need caps. We also need a much better system of judgement. How can one distinguish between bad outcome and negligence? I cannot believe in a jury system making consistently good decisions. I have no faith in the randomness in awards.

This crisis has done something very unusual. It has united physicians. It has united us, because we understand the unintended consequences . We understand the current malpractice system threatens the entire health care delivery system. If physicians leave New Jersey, can patients sue malpractice lawyers for inadequate availability of medical care?

I thought I would try something different today. I receive many questions each week. I hope the answers I give are helpful to more than just the questioner. Please give me some feedback - should I make this a weekly feature?

Doesn't generic mean lower prices? How can it be just as expensive as the brand ppi's?

This question addresses the economics of pharmaceuticals. As I remember Econ 101, many factors determine price. Companies factor in production costs, development costs, and a variety of other costs. Then they price the drug according to some estimate of supply and demand. While I do not understand the details here, the general concept is all we need at this time.

When a drug loses its patent, then a different company can apply to produce a generic - e.g., the generic name for Prilosec is omeprazole. When the first generic company gets approval, they have a 6 month exclusive. Thus, that company will generally not dramatically lower the price, rather they try to get as much profit as possible over that 6 month period. Only when several generic companies produce the same drug does competition and price lowering come into play. Thus, generally prices start to go down after the 6 month protected window.

Why is there a rare likelihood of rheumatic fever and glomerulonephitis (added by me) in the West? Could it be due
to the fact that we DO treat Group A Beta Strep?

This question has no simple answer (few questions do). I suspect our antibiotic availability does make a difference, however, other possibilities exist. Our living conditions (generally less crowded than 3rd world countries) probably have changed our susceptibility to streptococcal epidemics. We still occasionally will read reports of small epidemics. As I understand, rheumatic fever is strain dependent. It can still occur even without a symptomatic sore throat. Perhaps we (physicians) have changed the flora with our treatment. Clearly we have an impact to community spread (treating an infected patient decreases the chance of spread).

Interestingly, we have no evidence that antibiotics prevent glomerulonephritis. Glomerulonephritis is such a rare complication that we will never have a study that shows an antibiotic protective effect. Moreover, most glomerulonephritis comes after skin infections, not sore throats.

On a different note, I'm wondering how DB finds enough hours in the day to exercise, attend to his medical duties, write his blog, and listen to college lectures on tape (among other activities, I'm sure). If he has some kind of "time warp" gizmo, I want in on the action. 

We all have enough time to do those things that we value. Blogging takes around 1 hour a day. I find it relaxing and educational. I start most days at the computer surfing the net for health news and medical articles. This procedure helps me keep up to date. I prioritize exercise each day - trying to schedule an hour if possible. As I am considering the coming week, I have already started planning when exercise fits. I listen to the tapes in the car, driving to and from work (a 20 minute commute). I have not time warp gizmo, just priorities and planning.

I have been on Prilosec for quite a while and found it to be very effective. A week ago, when renewing a prescription, my doctor substituted Omeprazole. Now I am starting to experience low-level reflux symptoms. Is it possible that Prilosec works but Omeprazole might not?>

I am not aware of any such difference. The FDA does regulate the bioavailability of generic drugs. Many generics are made by the same company. There should not be any difference between generic and trade name drugs (except in rare circumstances). If you notice a difference, you should contact your physician. Two possibilities exist, one that there is a rare difference, but more likely that your reflux symptoms will now require a higher dose (a well known phenomenon in GERD).

Has anyone experienced long-lasting side-effects of Zocor after discontinuing the medicine?

I have not seen this reported anywhere. I rarely see side effects from the statins (Zocor, Lipitor, Pravachol). The most common side effects relate to muscles.

Thanks to all the questioners. I hope these answers stimulate some thought and actually are responsive to the questioners.
 

Bush to Seek $16 Billion for Epidemic of AIDS in U.S.

Just days after announcing a major initiative to fight global AIDS, President Bush turned his attention today to the domestic epidemic, saying he will request $16 billion for AIDS prevention, care and treatment when he submits his 2004 budget to Congress on Monday.

At the same time, Mr. Bush announced that federal health officials had cleared the way for doctors and public health workers to have easy access to a new test that can detect infection with H.I.V., the AIDS virus, in as little as 20 minutes.

We should invest in addressing the AIDS epidemic. Money just might make a major difference.

Mona Charen writes on malpractice this week. Malpractice: By lawyers . I could almost quote the entire article, but let me choose some snippets.

... But doctors have been driven to this attention-getting extreme by an out-of-control malpractice system. To quote the old movie "Network," they're "mad as hell and they're not going to take it anymore."

The doctors are outraged because the malpractice lottery has made the practice of medicine a combat zone. It is making a few lawyers very rich but driving up costs, causing good doctors to abandon medicine, and souring the relationships between physicians and patients.

..

... Obstetricians are paying a heavy price because most malpractice suits in America are not about bad medicine, they are about bad outcomes. In obstetrics, more than in other fields, a certain number of disabled children and bereft parents is unavoidable. But trial lawyers seize upon every tragedy as an opportunity to enrich themselves.

...

The trial lawyers argue that malpractice suits improve medicine by going after the few bad apples in the medical profession and holding them accountable. But as the Harvard Medical School study of 30,000 New York City cases demonstrated, more than 80 percent of the lawsuits filed were without merit -- i.e., no malpractice was found.

As Peter Huber, a tort reform advocate has pointed out, about 20 percent of the suits did not even involve an adverse event -- yet these tended to be settled for an average cost of $29,000. (Fifty-seven percent of medical malpractice premiums pay for lawyers' fees.) The presence or absence of actual malpractice had nothing to do with the likely outcome of the case. Insurance companies settle with plaintiffs all the time in order to avoid the expense of litigation.

Read the entire piece. Then say ... Amen!

Surgical Strike Read this short piece highlighting quotes from West Virginia surgeons.