Tomorrow is the big day. Tomorrow the rules change. Tomorrow our residency changes - and we really do not understand how it will impact either resident education or patient care!

My current resident expressed her concern clearly this past week. Our current system involves "team call". With team call, the resident and 2 interns take call for 24 hours, then resolve issues the next day. Teams develop working collegial relationships. Teams allow for appropriate increases in responsibility at all levels.

Starting tomorrow we have a hybrid system. Sunday through Thursday nights, the resident and one intern will leave around 8 p.m. The "float resident" will work with the remaining intern on all new admissions. A "float intern" will handle all cross cover issues until the next morning.

At 7 a.m., the team and the float resident will convene with the attending to present the admissions from after 8 p.m. By 8 a.m. the float resident should go home.

This may work splendidly, or it may lead to "discontinuity" problems. I hope that this system does not adversely effect patient care. I also hope that the learning which results from team call is not hindered by this new system.

I will rant periodically about the new system. It start tomorrow. My team takes call on Wednesday. Thursday morning will be different.

I blog constantly about primary care. This opinion piece from the AMA news captures many points well - Primary care physicians being stressed to the max

Some have recognized low morale in primary care physicians, but not enough has been written from our perspective about what is causing the problem. Often, low morale is attributed simply to "loss of autonomy," but I believe the reasons are more complex. To advocate for ourselves, we need to better state the cause of our grievances and make them clear to outsiders.

To clarify the reasons for frustration among primary care physicians, I have created the following list. It's the reality we live with but it reads like a how-to manual for anyone interested in maximizing stress in the work environment.

Please go read her list. If you are not a primary care physician, please try to understand our perspective. She finishes with words that all should read.

The pressures facing primary physicians are not as much about money as they are psychological -- Catch-22 situations (coding, for example), arbitrary punishments (our current tort system), increasing amounts of uncompensated work and so on.

Physician advocates need to do a better job of making this clear to the public and to policy-makers. Unless major improvements occur in working conditions for primary care physicians, Americans will have growing difficulty in obtaining access to primary care services. (Medical students are getting the message about poor working conditions -- internal medicine and family practice residency applications have fallen dramatically).

Some changes that could help alleviate this situation include reimbursement by time (the real canvas of primary care) rather than the current coding system; major tort reform; countersuing frivolous lawsuits (perhaps organized medicine could set up a fund for this); and a public education campaign to inform Americans of the above issues.

Certainly there are intrinsic rewards in providing primary care. Those rewards are the major reason dedicated people enter the field in the first place. But as current pressures increase, these rewards will become increasingly overshadowed. Unless major improvements are achieved in the primary care environment, both physicians and the American public will pay the price.

The AMA news has this piece today - Study outlines deficiencies in American health care. If you have been reading Medical Rants, you know the gist of the story. I want to highlight this commentary from the AMA news article:

James Mold, MD, a director for the Oklahoma City-based Oklahoma Center for Family Medicine Research, said that although he has problems with the study's assumption that all people of a certain age or condition require the same interventions, the results are what he would have predicted and are worthy of further study.

"Primary care practices currently do not have the systems in place to make sure that all the effective treatment options are at least considered for every potentially eligible patient," Dr. Mold said. "However, until the health care system moves from a disease-oriented model to a person-centered, goal-directed one, it will be impossible to do any better."

Dr. Kilo called for better use of information technology and a different way of financing health care so that primary care gets the attention it deserves. "The primary care we have today is not the primary care we need," he said, adding that it is impractical to think that primary care physicians can properly address the health needs of the 2,000 to 3,000 people they see each year in short office visits.

"Primary care is continually devalued," he said. "As long as that continues to be the case, we will not solve either the cost or the quality problems."

I believe that quality medical care requires a quality financial investment. We complain all too often about the cost of health care, not understanding that you really do get what you pay for. With regards to generalists and primary care, we have undervalued their services and we are getting the predictable outcome.

Nonetheless I suspect that the study markedly overestimates the problem.

In response to my post on Friday - the "whole pie" - Donald Johnson of Business Word entered 9 questions as comments. Here are my responses:

1. Do you agree hospitalists improve the quality of patient care and reduce costs?

This question - which implies the answer - assumes as true a series of suggestions from observational data. We do not really have a good prospective study determining the value of hospitalists.

Let me define the problem. We would have to have random assignment of large numbers of patients to two systems - a hospitalist system and a non-hospitalist system. We would have to compare overall outomes and expenses. This study may not be achievable.

We cannot look at the published studies, as they only look at hospital expenditures. Moreover, they look at convenience samples, often at academic centers.

Logically, we should expect a physician who cares for hospitalized patients to spend a minimum amount of time on hospital work. I question what the right amount of time is.

2. Do hospitalists consult more or less frequently on difficult cases than other docs, and how does this affect quality and costs?

I doubt that we know the answer to this question. We would like all physicians to consult exactly the right amount (neither too often not too infrequently). This question (while an interesting one) again is likely unanswerable. I suspect that some hospitalists are close to ideal. I suspect that some general internists (here I imply the internist who practices both in the office and in the hospital) are close to ideal. Is one group generally better than the other? I do not know.

3. Has medicine become so complex that mastering all the information that internists are supposed to command is impossible, or just difficult?

What a wonderful hypothetical? The problem with this question is that the answer is irrelevant. Many general internists do have outstanding command of much information. The great internists know what they know, and know when to ask for help. I would argue that we have no good alternative. The patient often does not know which subspecialist to contact. Moreover, if the general internist has a challenge with knowing the breadth of the material, he/she generally knows more about the various subspecialties than each subspecialist knows about the other various subspecialties. Let me try to expand this concept more clearly.

You have chest pain. Do you go to a cardiologist, a pulmonologist or a gastroenterologist? If you see the cardiologist, in general he/she will consider whether or not you have a cardiac cause for your chest pain. (One of my favorite sayings comes to mind - when the only tool a carpenter has is a hammer, everything looks like a nail). The cardiologist generally (and one can only generalize here) will not consider the breadth of non-cardiac causes as completely as the general internist. If the cardiologist does cardiac catheterizations, then the patient may well have a catheterization - just to be complete. In medicine, we often observe this phenemonon. The generalist, regardless of practice site, will probably more often consider the breadth of possibilities prior to assigning a diagnosis.

General internal medicine is broad, difficult but not impossible. This question applies both to hospitalists and other general internists. I believe that I do have a good handle on the breadth of internal medicine. I suspect that I am no different than many internists in this country.

4. If you agree with the Rand study that physicians follow recommended procedures some 50% to 55% of the time, does that suggests they are spread too thin, trying to cover too much ground?

First, please read my post earlier this week on the Rand study. Then read Medpundit's post from today. Now I will comment further on this study.

Practicing medicine is not equal to being a car mechanic. We know the interval for changing oil, oil filter, air filter, et cetera. Medicine is not, and cannot be, cookbook. Let me give a few examples.

The patient is a 64 year old man who had a heart attack 3 years ago. I tried a beta blocker after his heart attack, but he had reproducible bronchospasm, and could not tolerate the drug. Thus, I am no longer treating him with a drug that has an absolute indication after a heart attack.

When you review my chart over the past year, you see no evidence of beta blocker use, nor any discussion of why I am not prescribing a beta blocker. As one analyzes this patient, one could argue that I have not met a guideline. But I may be practicing good medicine.

Patient care involves complexity. We (physicians) must juggle competing problems, side effects and even financial considerations.

Studies, like the Rand study cited, which use chart reviews, are prone to underestimation. As I stated in my previous rant: We must stop sensationalizing statistics on quality, but rather start researching the reasons for less than perfect quality. These studies must look at quality in new ways. Some guidelines have greater importance than others. We need to prioritize our research and our report cards.

My colleagues at the University of Alabama at Birmingham developed a method called ABC - the Achievable Benchmarks of Care - A new quality improvement tool is being developed for deriving benchmarks of clinical care

This method considers the underlying chaos of patient care and patients, and sets achievable goals. Studies like the Rand study sensationalize, but do not really add to the quality debate. We all want better quality, but we must understand quality not as an arbitrary standard, but rather as an achievable standard.

5. Is there a possibility that officists and hospitalists may follow recommended procedures more often and practice more evidence -based medicine than internists who practice both office and hosptial medicine?

Anything is possible. This question must be meant rhetorically. It is unanswerable.

6. Is it possible that officists are more customer and people oriented entrepreneurs and hospitalists are more institutional and bureaucratic, and they may get more satisfaction from being round pegs in round holes 100% of the time instead of 50%?

See the previous answer.

7. I've been told hospitalists often burn out after a year or so, and I'll bet a lot of officists are burned out, how do current trends affect burnout?

Many physicians currently are either suffering burnout, or will soon develop burnout. Medical practice requires reflection. Good practice requires time to read and discuss. Our current practice environment - both inpatient and outpatient - is not conducive to developing healthy happy physicians.

This problem is neither a hospitalist nor an officist problem. It is a problem of expectation and reimbursement. Until we value time in a better fashion, we will have rampant burnout. We need a system that allows physicians to spend time with patients, and the journals and colleagues. This question does raise an interesting question which I should rant on separately later this week.

8. Do you feel more specialization will improve or hurt the quality and cost of care?

I like this question, because it asks for my opinion. I dislike this question because it is so nebulous.

I believe the combination of a generalist (in both outpatient and inpatient settings) with appropriate subspecialty consultation leads to the best care. If you have diabetes, coronary artery disease, hypertension, hypercholesterolemia and chronic obstruction pulmonary disease, I would argue that you need an excellent generalist who can coordinate your care, obtaining subspecialty help as problems arise. This care will surpass the care the patient would receive from 3 subspecialists. The patient needs a generalist to consider him/her as patient with many medical problems.

9. Any feel for what percentage of internists feel the way you do, and what percentages would like to be officists or hospitalists?

I suspect that most internists would like to balance inpatient and outpatient practice, but not in our current system. We have many residency graduates who specifically seek such jobs. They exist in smaller cities.

I believe that practicing in the hospital makes me a better outpatient doctor, and vice versa. Many graduating residents believe that also.

I hope these answers help somewhat. I will specifically ask Don Johnson to respond. At the risk of boring readers, I will probably continue this discussion for several days. Perhaps through this interaction - and the comments of RangelMD - we can all better crystalize our thoughts.
 

I am getting ready to make rounds. Sometime later today, I plan to respond both to this post and to the 9 questions posed on my post from Friday. My greater blogging pleasure occurs when I stimulate passionate thought. Read Rangel's counterpoint to my rant - Are hospitalists a threat to general internal medicine? While I disagree, one should consider his points. Hopefully I can find time for a careful rebuttal later today. Now off to make rounds with my team.

I often blog about the business of medicine. I also blog about many other issues. This site includes many news stories (with some commentary) that effect the business of medical care. The Business Word. I am adding it to my blogroll. You just might find it a worthwhile resource!

This column is published in this week's SGIM Forum. You can get a pdf version online - SGIM Forum - open the May issue - pdf file. Here are my thoughts on general internal medicine:

ACGIM COLUMN

THE WHOLE PIE-ON THE FRAGMENTATION OF GENERAL INTERNAL MEDICINE

Robert Centor, MD

The field of general internal medicine has become sick. Division chiefs all see this. Amongst many threats (including reimbursement rates and articles belittling generalist physicians), the latest threat to general internal medicine, in my opinion, is the hospitalist movement.

I must provide these disclaimers. First, I spent a year doing renal research (after residency) and quit my renal fellowship. Second, by almost any criteria, I am an academic hospitalist (5 months attending on the VA wards each year). Third, I spoke at the recent Society for Hospital Medicine (SHM formerly NAIP) meeting in a "Meet the Professor" session.

General internal medicine is a wonderful profession. Unfortunately decreasing numbers of practicing general internists agree with that sentence.

As I have said often in public (see my address in the July Forum), general internal medicine leaders wisely embraced the concepts of primary care, but allowed the field to be mislabeled as primary care internal medicine. The problems that the primary care label has caused are not our doing. I doubt that many in our field could have anticipated these problems. Nonetheless, we are left to address the current state of affairs.

The thesis that I proposed is that general internal medicine includes the provision of primary care for patients, but is more than primary care alone. Primary care currently has an unfortunately narrow definition (at least from insurers and other payers). The dictionary defines primary care-"The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system." Nowhere in this definition does the comprehensive nature of general internal medicine fit.

The April SGIM Forum in an article titled, "The Future of General Internal Medicine," addresses this issue. "Recommendation 2: The domain of general internal medicine should continue to be both deep and broad-ranging from providing or supervising uncomplicated primary care to delivering continuous care to patients with multiple, complex, chronic diseases. As the principal provider for adults, general internists need to have skills in gynecology, dermatology, orthopedics, otolaryngology, psychiatry, and the internal medicine subspecialties."

General internists traditionally have treated both inpatients and outpatients. They provide comprehensive, complex care, involving subspecialists as necessary for specific consultation. General internists specialize in understanding the spectrum of disease and the interactions amongst multiple diseases, thus providing comprehensive care-from first contact care to general prevention to complex disease management. Most general internists chose our field because of its comprehensive and complex nature. As residents, we enjoy the spectrum of internal medicine-from the outpatient setting, to the hospital, to the ICU.

As payment for office visits has deteriorated-forcing either markedly reduced income, or unacceptably short visits-so have the pressures on outpatient practice increased. Many general internists find providing both outpatient and inpatient care a financially unacceptable luxury.

Out of this conflict between outpatient and inpatient care, the hospitalist movement has arisen. The hospitalists have filled a void in health care. Hospital care has become more complex and time consuming. Hospital administrators and insurers like the logic and economy of hospital care specialists. Graduating residents often like the lifestyle that hospital medicine offers. They also see the hospitalist as a natural extension of their residency experience. With these forces acting, the hospitalist movement has expanded and thus the outpatient practice option has become a reality for many internists.

SHM has encouraged this new dichotomy-specialty defined by location. While I understand why we are moving in this direction, I continue to worry about the implications for the field. Who are the true general internists: the hospitalists, the officists, or the decreasingly common hybrid practice, which all practicing internists had in previous decades?

I worry about how this fragmentation will affect general internal medicine. Most GIM divisions include all three practice options. As division chiefs struggle with varied faculty practice patterns, these changes are redefining general internal medicine. How do we unite these disparate practices? What signals are we sending to residents? I wonder whether this role fragmentation is contributing to the malaise in our field. Why would residents choose general internal medicine, when we have such difficulty defining the field? I see three different practice patterns confusing trainees. Many larger communities almost force one to choose between hospital and outpatient practice.

We are struggling with redefining general internal medicine training. However, we should first consider how their practice will look when they finish training. As we allow the redefinition of general internal medicine, ones view of the field becomes hazy.

Both ACGIM and SGIM are considering this problem. I hope that we can preserve and define the field. Perhaps we cannot resist the economic, medical and political forces causing these modifications. I hope that we can maintain the practice balance that general internists want and desire. I still love general internal medicine; I love the whole pie, not just a small piece!

I think we all really know this, it did make the NEJM - Outpatient Prednisone Reduces Relapses in COPD

Daily prednisone for 10 days reduces the relapse rate for patients with chronic obstructive pulmonary disease (COPD) treated and discharged from the emergency room, according to the results of a randomized controlled trial published in the June 26 issue of the New England Journal of Medicine. The editorialist suggests that because of modest benefit and potential risks, this regimen should be considered an option rather than routine care.

I think this is already routine care.

Sometimes we are our own worst enemies. Medicine has developed the knowledge to improve care. We have guidelines to help us provide high quality care. For varied reasons, not all physicians follow all guidelines in all patients.

I am involved in several research projects which are investigating this phenemon and learning how to help busy practicing physicians provide higher quality care. While I find the article which informs this newspaper piece interesting, the "spin" about the article may not help our progress - Study: U.S. Doctors Ignoring Guidelines

Poverty or lack of health insurance are far from the only barriers to good medical care -- even people with good insurance and doctors they like often don't get all the care they should, a researcher says.

Doctors around the country fail to take nearly half the recommended steps for treating common illnesses such as high blood pressure and diabetes, indicating that U.S. health care is worse than people thought, Elizabeth McGlynn wrote in Thursday's New England Journal of Medicine.

Treatment guidelines, many written by medical specialty groups, outline recommended approaches to many common ailments, ranging from painkillers and exercise for arthritis to surgery for breast cancer.

The study by McGlynn, a researcher with the Rand Corp. think tank, documents a broad range of lapses in treating and preventing run-of-the-mill illnesses. For instance, patients studied did not get one-third of the recommended immunizations, one-third of the standard medicines for heart disease or half of the recommended care for diabetes.

The report underscores the importance and extent of a problem which physicians have been discussing for more than a decade, said the immediate past president of the American Medical Association and the presidents of two other major physicians' groups.

The AMA's Dr. Yank Coble, Dr. James Martin of the American Academy of Family Physicians and Dr. Munsey S. Wheby of the American College of Physicians all said better and less costly electronic records are needed to keep track of dozens of guidelines and hundreds of recommendations -- and which patient needs which of them.

This study looked at 30 medical conditions, plus preventive care. All of those guidelines added up to 439 actions, recommendations or other steps.

``The days of everyone being able to keep it all in your own head is long gone,'' Martin said.

Martin and Wheby also said more attention from both patients and their doctors is needed to ensure that patients get the best medical care possible.

Quality takes time. One cannot shorten patient appointment times and provide the highest quality medicine.

Martin also noted that a recent article in the journal Public Health estimated that if the average doctor did everything recommended for annual health exams, the checkup would last 90 minutes instead of 15 to 20.

We must stop sensationalizing statistics on quality, but rather start researching the reasons for less than perfect quality. These studies must look at quality in new ways. Some guidelines have greater importance than others. We need to prioritize our research and our report cards.

I also would urge more studies on how to improve quality, and less studies which highlight this challenge.

Wheby said most doctors want to do the right thing for their patients, but he added: ``It's a matter of time, a matter of effective systems of reminder, at times knowing the correct guideline or the correct procedure.''

Alice has commented about my depression post. Read her post for more texture concerning this important issue - Depression. Because the link goes to blogspot, you may have to navigate a bit to find the right story.

I ranted about this earlier this week. Here is the same story from Medscape. Anemia Increases Risk of Death in Patients With Severe Heart Failure

"Anemia occurs with increased frequency in severe HF," Dr. Dariush Mozaffarian, of the VA Puget Sound Health Care System in Seattle, Washington, and colleagues observe. "However, few studies have examined the impact of anemia on mortality in this population."

The researchers prospectively examined the association between baseline serum hematocrit and the risk of all-cause mortality among 1130 patients with severe HF. The patients had a left ventricular ejection fraction of less than 30% and New York Heart Association functional class IIIB or IV, and were being treated with angiotensin-converting enzyme inhibitors, diuretics, and digitalis.

Over 15 months of followup, there were 407 deaths. After adjusting for potential confounders-including diabetes, smoking, and HF etiology-patients with the lowest hematocrit (25% to 37%) had a 52% greater risk of death compared with those with the highest hematocrit (46% to 59%). Each 1% decrease in hematocrit was associated with an 11% higher risk of death (p < 0.01).

When different causes of death were evaluated, a significant association was observed between a lower hematocrit and death from progressive heart failure, Dr. Mozaffarian and colleagues note. "If this association is causal, normalization of [hematocrit] in this population would be expected to reduce mortality by approximately 33%," they conclude.

A few months ago I ranted on the initial press release from the COMET study. This story posts this important study into more context. Study finds one beta blocker better at saving lives in heart failure

A large head-to-head comparison of two widely used heart drugs known as beta blockers found one significantly superior in prolonging the lives of people with chronic heart failure.

Some experts, however, said the results might be different depending on the formulation of one of the drugs used.

Prognosis for chronic heart failure is poor, with around half of patients dying within three to five years -- a death rate similar to that of lung cancer.

In the largest such study to date, scientists estimated that those taking carvedilol, also known as Coreg in the United States or Dilatrend elsewhere, lived nearly 18 months longer than those taking metroprolol, another beta blocker.

The study, paid for by F. Hoffmann-La Roche and GlaxoSmithKline, marketers of carvedilol, and conducted by a committee of European heart failure experts, was presented Monday at a European heart failure conference in Strasbourg, France.

"Carvedilol's significant survival benefit could mean thousands of lives saved each year. The results will have a major impact on clinical practice," said lead investigator Dr. Philip Poole-Wilson, professor of cardiology at Imperial College in London.

However, Dr. Michal Tendera, European Society of Cardiology heart failure spokesman, gave a cautious interpretation of the results.

"This is most probably related to the drug, but it may also be due to the different formulation of the metroprolol used in this study compared to other studies of metroprolol," said Tendera, a professor of cardiology at Silesian School of Medicine in Katowice, Poland, who was not connected with the study.

The study used a short-acting generic metroprolol. Key research that established metroprolol as an effective beta blocker used the long-acting version known as Toprol XL and that research indicated the drug was as effective as carvedilol or other beta blockers, although there has never been a head-to-head comparison, Tendera noted.

This study should change practice at this time. I have used generic metoprolol in lieu of carvedilol for my CHF patients, because of the significant cost difference. This study did test the hypothesis relevant to my practice. I can no longer justify metoprolol as being as good as carvedilol. The slow release metoprolol - Toprol XL - does not have the price advantage, thus I had not been using it. I will choose carvedilol now, unless and until further research changes our understanding.

Mixed Results for Drug Used to Prevent Prostate Cancer

A drug that doctors had hoped might prevent prostate cancer has been found to be both more effective and potentially more dangerous than expected.

After giving a daily dose of the drug, finasteride, sold by Merck under the brand name Proscar, to more than 4,300 healthy older men for seven years, researchers found that the men's chances of getting prostate cancer were 25 percent lower than for those of a like-size group of men who took placebos, according to a report released online yesterday by The New England Journal of Medicine.

But 280 of the men who took finasteride, or 6.4 percent, ended up with especially aggressive cases of prostate cancer, compared with 237 in the placebo group, or 5.1 percent.

Whether or not a man should take finasteride to prevent prostate cancer is "an individual decision for a man and his physician," said Dr. Charles A. Coltman Jr., chairman of the Southwest Oncology Group in San Antonio and a leader of the nationwide study.

Men who stand a particularly high risk of developing prostate cancer ? blacks and men with close relatives who have had the disease ? might consider taking the drug as a preventive measure, Dr. Coltman said. In the study, the drug proved to be as protective for high-risk men as it was for others.

But Dr. Peter T. Scardino, head of urology at Memorial Sloan-Kettering Cancer Center, in New York City, who wrote an editorial about the study for the Journal, said most men should not take finasteride, because the possibility of developing a more aggressive form of cancer appeared to be too great.

"The 25 percent reduction in cancers is quite impressive, and I think this study opened an enormous area of research," Dr. Scardino said. "But when doctors look at this carefully, I don't think they're going to prescribe Proscar to people to prevent prostate cancer."

Dr. Coltman said the National Cancer Institute ended the 10-year study 15 months early, not because it concluded that finasteride was dangerous but because the results had already conclusively demonstrated the drug's mixed effects. "More information wouldn't have changed the outcome," he said.

The men who took finasteride experienced a greater number of sexual problems, including reduced libido and erectile dysfunction.

So we have an intereting research dilemma. Finasteride decreases the incidence of prostate cancer, but increases the incidence of more aggressive cancers. Since many men die with prostate cancer rather than from prostate cancer, we should focus on the aggressive cancers. While the absolute difference in aggressive cancers is small (1.3%), this finding would dissuade me from taking finasteride. I cannot recommend it to patients at this time.

Loyal readers know my healthy obsession with fitness. Now the American Heart Association is encouraging all physicians to adopt a healthy lifestyle. They just may be on to something important. Physicians Urged to Promote Exercise to Patients, and to Set an Example

As well as recommending regular physical exercise to their patients to prevent and treat cardiovascular disease, physicians should "personally engage in an active lifestyle," according to a new report from the American Heart Association.

Writing in the June 23 rapid access issue of Circulation, a group of experts led by Dr. Paul D. Thompson of the Hartford Hospital in Connecticut note that people who get a lot of regular exercise appear to have half the risk of atherosclerosis as sedentary people.

In addition, regular exercise appears to lower the chances of a host of other chronic conditions, such as diabetes, depression and certain types of cancer.

Consequently, Dr. Thompson and his team suggest that doctors follow recommendations issued by the U.S. Centers for Disease Control and Prevention, which support at least 30 minutes of moderate exercise, such as a brisk walk, on most or all days of the week.

As the title says - Do as I do!!!!!

For Depression, the Family Doctor May Be the First Choice but Not the Best. As I have come to expect, this title misleads. Family doctors and internists make most depression diagnoses. We also manage the majority of depressed patients. One must consider several factors.

Many patients do not want to see a psychiatrist or psychologist. Many health care plans do not allow appropriate mental health referrals. We can manage much depression in our offices. For many patients, the generalist is indeed the best (and sometimes only) choice.

A subset of depression does need more advanced care. These patients clearly need a psychiatrist or psychologist who specializes in depression. Even patients with those needs may or may not agree to see a mental health professional.

Generalist programs are spending more time considering depression diagnosis and management every year. The residents that I work with are clearly better at considering the diagnosis of depression than their predecessors from 5-10 years ago. They also are becoming more comfortable with pharmacotherapeutic options.

What few generalists can do is spend enough time for significant psychotherapy. We do have significant time restraints. We do spend a small amount of time counseling patients within our time constraints.

The NY Times article is worth reading. Depression is very complicated. I think we should concentrate on helping generalists do a better job, rather than criticizing the soldiers on the front lines.

An article in the Journal of the American College of Cardiology (June 4, 2003) adds to a growing body of knowledge about anemia and CHF mortality. In this study (a reanalysis from a prospective randomized controlled trial) the investigators found that in patients with severe CHF, progressive anemia leads to increased mortality.

Accumulating evidence suggests that anemia may be an independent risk factor for mortality among patients with HF. Additionally, clinical studies among small numbers of HF patients (n = 26 and N = 32) indicate that treatment of anemia with erythropoietin and iron improves symptoms and the ejection fraction (EF) and decreases hospitalizations and the need for diuretics, suggesting that anemia may be a modifiable risk factor in HF with a causal role in clinical outcomes. However, few previous studies have characterized the impact of anemia on HF mortality, such as the magnitude of risk, threshold of risk, or associations with different causes of death, and only one previous study has examined patients with severe HF, the population at highest risk for both anemia and death.

In this study, mortality starts to increase as the hematocrit is below 38%. These results are consistent with previous results (as noted in the quoted section from the article's introduction).

These data are consistent with growing data from the renal literature. While patients do not seem symptomatic with mild anemia (hct 25% - 35%), progressive anemia does stress the heart. As the hematocrit decreases in renal failure patients, left ventricular hypertrophy increases. Prolonged LVH leads to CHF and is a risk factor for coronary artery disease.

We need larger studies which examine the impact of treating mild anemia for CHF. These data add support to the need for such studies.

Frequent readers know that I dislike the dietary supplement industry. The 1994 law which allowed this industry to grow was, in my opinion, a menace to public health. While I have multiple problems with the industry, the hot button issue these days is ephedra. One must view each supplement individually, however one can attack the entire industry. Studies of Dietary Supplements Come Under Growing Scrutiny

When a California judge handed down a $12.5 million false-advertising judgment against the maker of an ephedra-based weight-loss pill late last month, he also issued what amounted to a bill of reproach against the science of dietary supplements.

The company, Cytodyne Technologies, maker of Xenadrine RFA-1, the supplement implicated in the death of a Baltimore Orioles pitcher, had not just exaggerated the findings of clinical trials it commissioned, Superior Court Judge Ronald L. Styn said in ruling on a class-action suit, but had also cajoled some researchers into fudging results in published scientific articles.

The evidence, Judge Styn said, had left him no alternative but to conclude that the researchers had set out to create a study that "justified the money being spent" by Cytodyne and would ensure that they received further work from the company.

The Cytodyne case is part of a swelling tide of litigation that is raising serious questions about the way makers of ephedra and other dietary supplements use — and often misuse — the promise of scientific proof to market their products.

In the last eight months, three leading manufacturers of weight-loss pills have been hit with false-advertising verdicts in the millions of dollars. A fourth has been rebuked by a federal judge for hiding evidence. The Missouri attorney general and a group of district attorneys in California have also brought false-advertising suits against manufacturers, and Congress has demanded Cytodyne's research records.

The dietary supplement industry can endanger the public. The lack of regulation spells danger.

Precisely because the industry is not regulated, though, its research is sometimes less than strictly scientific, experts say.

"There will be 250 to 300 clinical trials on nutraceuticals this year," said Anthony Almada, a consultant and founder of EAS, the biggest sports nutrition company, who advocates scientific research on products but has become a critic of the way supplement makers conduct it. "The rigor applied in these studies on the average is somewhat notably less than that of a drug study."

Often relying on as few as a dozen subjects, these studies are scaled-down versions of the double-blind, placebo-controlled clinical trials required before drugs can be approved. Some are published in abbreviated form at meetings of scientific organizations, or in obscure journals, providing a basis for marketing claims like "clinically proven."

An industry spokesman, Steven Dentali, vice president for science and technical affairs at the American Herbal Products Association, acknowledged that "whenever there's a desired outcome, you've got the potential for bias." At the same time, he argued that supplement science is no worse than that done for pharmaceuticals.

Read the entire article. Stay away from unproven supplements. Do not get duped by fancy glossy ads. This industry needs regulation - for the public health.

Thomas Sowell generally makes one think. He views all problems from the Milton Friedman school. Here is his column on prescription drug benefits - Prescriptions and politics

In the midst of a bipartisan stampede toward "prescription drug benefits for the elderly," someone needs to ask the question: Why should seniors be singled out to be subsidized by the taxpayers, except that their votes are being sought by both parties?

We have all heard the terrible stories about people stricken with diseases requiring costly medications they cannot afford. If we wish to do something to help such people, fine. But let's help them based on the predicament they are in, whether they are 19 or 90.

Health problems are of course more common among the elderly. But if you know it and I know it, so do others ? including insurance companies, who are in the business of selling protection against all sorts of risks. Again, if there are people who cannot afford insurance and we want to help them, then the criterion should be their economic condition, not their age.

Wow! Sowell views this problem from a logical stance, not a political stance. He states that the Medicare drug benefit plan comes more from politics than need. He strikes a nerve here. If we want to help the needy, we should not arbitrarily start that help at age 65.

When politicians talk about bringing down the cost of prescription drugs, they are exploiting a widespread confusion between prices and costs. Prices are not costs. Prices are what pay for costs ? and if you don't pay those costs, you are not going to keep on getting what you want.

The cost of creating a single new medication runs into hundreds of millions of dollars. You can play all the political games you want with prices, but if those hundreds of millions of dollars are not paid for, don't expect people to keep investing that kind of money to develop new drugs to deal with cancer, AIDS, Alzheimer's and all the other afflictions of human beings.

That money comes from pension plans that millions of people pay into, as well as from banks and other investment sources. Politicians can always find ways to chisel these people out of their money in the short run, but the public will pay in the long run.

Fewer new drugs mean needless suffering, disability, hospitalization and premature death. Higher hospitalization rates alone can wipe out savings from lower drug prices. Paying the mounting costs of medical care has turned into a shell game, where everyone tries to get someone else to be stuck with these costs. But these costs are not going away.

Why would Americans, with the highest-quality medical care in the world, and a pharmaceutical industry creating more new major prescriptions drugs than anywhere else in the world, want to jeopardize all that for the lure and the promise of political miracles?

I personally think that he has used hyperbole in this argument. The pharmaceutical industry will not stop research and development unless they are not allowed a reasonable profit. I wonder how one defines reasonable. At times drug companies focus, in my opinion, too much on profit. Their well documented shenanigans do not advance health care.

We need checks and balances on the pharmaceutical industry. As Robert Prather points out frequently, the dissociation between drug prices and individual choice leads to an artificial market.

As we consider the release of OTC Prilosec, we hear complaints because once a drug class goes OTC, insurance will likely no longer cover that class. Thus, having a $1 per pill OTC Prilosec will cost the consumer more than $4 per pill prescription Nexium. We need a better market to influence the industry. Patients do not make informed choices, because they are not individually aware of the trade offs. Until we have a financing system that involves individual decision making, we cannot champion the pharmaceutical industry, nor castigate it (on economic grounds). Drugs like Nexium succeed (in my opinion) because most patients do not explicitly pay the price.

So I give Sowell a gentleman's B. He clearly provides an alternative to the proposed benefit, but may well miss the point on the pharmaceutical industry. I enjoyed this commentary because it did make me think.

F.D.A. Approves Over-Counter Sales of Top Ulcer Drug

Prilosec is expected to sell for less than $1 a pill when it becomes available without a prescription this fall, compared with $4 a pill now. But few consumers who have health insurance will see any savings, because many managed care plans will stop paying for the drug altogether, health care executives said.

"We don't cover over-the-counter drugs," said Deborah Whitehead of Tufts Health Plan, a major insurer in the Boston area.

But older people of limited means who have no health insurance other than Medicare, which does not cover prescription drugs, stand to save hundreds of dollars a year.

Patients who take similar drugs, like Nexium, Prevacid, Protonix and Aciphex, may soon find that their health insurers have made the medications more expensive or harder to obtain, managed care executives said. That would parallel what has happened since Claritin, the widely used allergy drug, was switched to over-the-counter from prescription sales late last year.

Millions more Americans will be affected this time. Prilosec and similar drugs, known as proton-pump inhibitors, had $13 billion in total sales last year, more than any other class of drug and more than twice that of Claritin and similar antihistamines, according to NDCHealth, a health information company. Unlike allergy drugs, whose effects vary somewhat, the proton-pump inhibitors all have nearly identical effects on patients. That may give health plans a freer hand to force patients to use over-the-counter Prilosec rather than the prescription versions.

So paradoxically, a cheaper drug might cost you more! This ruling makes sense for the nation. This ruling makes sense for patients who pay for their own medications. But it will cost some patients money.

From today's Lancet -

Waiting lists: irritation or death sentence?

Julian Gunn

Percutaneous coronary intervention (PCI) is becoming commonplace and routine. My patients expect to have an average of two vessels stented via a 6 French (2 mm) catheter in the femoral artery and, at the end of the procedure, have a collagen sealing device fitted, enabling mobilisation at 2 h. 40% of them go home the same day. With such a routine procedure, the loss of a patient is particularly shocking. A 52-year-old man presented with angina. His treadmill test showed reversible ischaemia and he underwent cardiac catheterisation in May, 2001. This showed good left ventricular function and severe diffuse disease affecting the bifurcation of the left anterior descending artery and its second diagonal branch. The circumflex and dominant right coronary arteries were not significantly stenosed. He was referred to me for PCI. As is common in the UK, he spent 5 months on a waiting list. The procedure was technically difficult. Even passing a coronary guidewire down the two arteries was challenging. I inflated an intra-arterial balloon inflation and deployed a stent. A filling defect appeared in the lumen; often indicative of a thrombus or a mural dissection. I gave him abciximab; a glycoprotein IIbIIIa inhibitor. Flow became sluggish in the whole left coronary artery. I inserted an intra-aortic balloon pump to support the circulation but the blood pressure continued to fall and, ultimately, all blood flow ceased in the coronary artery. My patient drifted into unconsciousness and, despite aggressive efforts at resuscitation, died in front of me. Breaking the news to his wife and 14-year-old daughter, when they returned from a shopping trip, was an experience which left an indelible impression upon me.

Interventional cardiologists will be familiar with the problem of acute vessel closure during PCI, but watching all blood flow slow down and stop was highly unusual. I could not account for it. I suspected extensive intra-coronary thrombosis precipitated by the exposure of a large amount of plaque consequent upon balloon injury. I had to persuade the coroner's officer to open an inquest. Necropsy showed that the whole coronary tree was heavily diseased with atheroma, but also, that the right coronary artery was completely and chronically occluded. This must have occurred (without the patient presenting to hospital) while he had been on the waiting list. If I had re-checked the patency of the right coronary artery at the beginning of the procedure, I would not have undertaken such a complex intervention on his only other coronary artery, and a schoolgirl would still have a father.

As we consider explicitly the trade offs we must make in financing health care, we must consider stories like this one. Few economists or medical leaders will state this concept. Health costs are increasing because we are providing more advanced health care. If we (the American people) want "state of the art" care", we must pay the price. We should not obsess about the percentage of GNP devoted to health care. For the sick person, one can hardly place a price on improved health. Other countries implicitly ration important care. Many studies should statistically that delays generally do not lead to worse outcomes. Tell the cardiologist who bravely wrote this story. Tell the wife. Tell the schoolgirl.

An article in the current issue of the Journal of the American College of Cardiology discusses the prevention of contrast induced renal dysfunction.

Recent studies have highlighted the potential protective effect of oral acetylcysteine (NAC), an antioxidant, in addition to saline hydration in preventing RCIN, although this has not been a universal finding. The successful protocols tested to date require the initiation of therapy on the day before contrast exposure, precluding the treatment of same-day and emergency patients.

The reported study tested a rapid IV protocol which allowed for prophylaxis shortly before a dye study, rather than the day prior. In this study, renal dysfunction decreased from 21% to 5%.

My take home message from this study: always consider the possibility of renal injury from dye studies. N-acetyl cysteine (Mucomyst) does offer some protection, and we are wise to consider using it when patients have significant risk.

Senate Votes to Give Consumers Faster Access to Generic Drugs

The Senate overwhelmingly approved a proposal today to give consumers swifter access to low-cost copies of brand-name prescription drugs.

It also turned back a Democratic effort to limit the premiums that could be charged for new prescription drug benefits under Medicare.

The 94-to-1 vote on generic drugs came just minutes after the 56-to-39 vote on Medicare premiums.

Both proposals were offered as amendments to a sweeping bill that would add drug benefits to Medicare and fundamentally restructure the program, which provides health insurance to 40 million people who are elderly or disabled.

We will have a Medicare drug bill. The political forces that favor this bill are too strong to stop a bill.

Will we have the right bill? Probably not, but one can argue that this imperfect bill will improve patient health. Back to the generic issue:

House Republican leaders have shown little interest in such generic drug legislation. But Mr. Schumer said it would be difficult for them to kill the proposal in the expected conference committee to iron out differences on the overall Medicare bill.

Mr. Schumer said the generic drug proposal could save consumers $60 billion to $70 billion in the next decade and could reduce Medicare costs by $18 billion to $20 billion. The proposal goes beyond new rules issued last week by the Food and Drug Administration, which took its own action to make generic drugs more accessible. In recent years, Mr. Schumer said, brand-name drug companies have used "frivolous patents, lawsuits and legal mumbo-jumbo" to delay the marketing of generic drugs.

The Gregg-Schumer proposal would limit the ability of brand-name drug companies to delay federal approval of competing generic drugs. Brand-name manufacturers would be allowed only a single 30-month stay, while a court tries to resolve patent disputes. Brand-name companies have sometimes blocked competition for much longer, by filing additional patent claims and piling 30-month stays on top of one another.

The measure would also bar collusive agreements under which brand-name drug companies pay generic companies to keep generic drugs off the market.

The existing law provides an incentive for generic drug companies to challenge patents that may be invalid. If they are successful, such companies have the exclusive right to market the generic drug for 180 days, but sometimes the drug never reaches the market. Under the Gregg-Schumer proposal, generic drug companies would have to market the drug in a timely way or lose their 180-day protection.

This bill should fix a system that has meandered from original intent. We want the pharmaceutical industry to have sufficient incentives to produce new drugs. They deserve some patent protection. Where I (and many physicians) object is the legal games that the industry plays to extend patent protection beyond the time the law allows. This drug should close some legal loopholes. Patients will benefit.

Here is the link - no commentary at this time. AMA Sets Ethical Code for "Boutique" Medicine

The latest trend in private practice medicine--"boutique practices"--does not violate medical ethics as long as the contract practices do not promise better medical care, according to the American Medical Association's Council on Ethical and Judicial Affairs (CEJA).

CEJA chair Dr. Leonard Morse said the new practices, which are know by a variety of names including retainer, boutique, and executive medical practices, fit well into the AMA's "pluralistic approach to medical care." But he cautioned that the practices cross the ethical line if they guarantee better diagnosis or care.

Typically these practices charge patients an upfront fee of $1500 or more to "retain" the services of a physician. This retainer gives the patients rapid access to the physician, shorter waiting times for appointments and longer office visits.

In its decision, which was presented on Tuesday at the annual meeting of the AMA's House of Delegates, the CEJA states, "it is important that a retainer contract not be promoted as a promise for more or better diagnostic or therapeutic services."

However, since the boutique practices are marketed in much the same way as luxury cars or first-class plane tickets, it is difficult to imagine that the contracts will meet this ethical litmus test. In fact, Dr. Morse told Reuters Health that CEJA drafted the new policy without ever reviewing a retainer medical practice contract, so the council does not know what level of care is offered by contracts.

Nonetheless, Dr. Morse said there is nothing inherently unethical about entering into a contract relationship with a patient. But medical care, he said, "should have nothing to do with the patient's ability to pay." Simply put: the same level of care should be offered to every patient who needs treatment.

This is the second time the ethics group asked the AMA's policy-making body, its 541-member House of Delegates, to sign-off on an ethics opinion about retainer medical practices. The first time around the ethics group "concentrated too much on the negative aspects of these practices," Dr. Morse said. He noted that the council toned down its concerns and instead highlighted the fact that the contract-type practices might be a way to "for patients to establish trust in a physician."

But even after the ethics group adopted this new laissez-faire attitude toward boutique practices, it ran into opposition in the AMA house. The problem this time was the decision to include a reminder that physicians "have a professional obligation to provide care to those in need, regardless of ability to pay, particularly to those in need of urgent care. Physicians who engage in retainer practices should seek specific opportunities to fulfill this obligation."

Several delegates balked at this language because the ethics group used the word "urgent." Doctors, the critics charged, are only obligated to provide care in emergency, not urgent situations. But support for the new position outweighed concern over word choice.

At a press conference, Dr. Morse said that he does not know any physicians who have shifted to retainer practices, but noted that the movement is growing in a number of areas of the country--the Pacific northwest and the Northeast, especially the greater Boston area, and Florida, being the main areas where boutique medicine is gaining in popularity.

He said, however, that it is unlikely that any area of the country would "go to all retainer medicine, because most people can't afford it."

Why Do We Lie To Our Doctors?

I am the most health-conscious person in the world ? for the two weeks prior to my physical exam. I eat right, I get plenty of exercise, and I think positive thoughts. However, as soon as I leave the doctor's office after the exam, I drive ? not walk ? to the deli down the street and eat whatever I want. It's as if I "study" for my physical, then after I pass the test, I celebrate by undoing all that good stuff. Why do so many of us try to "cheat" on our tests like this? Why do we try to trick our doctors?

One of the most common things that people misrepresent ? not just to doctors but to everyone ? is their weight. When some people weigh themselves at the doctor's office, they don't just disrobe, they also take off their watches.

Sex is another area that people tend to wander away from the absolute truth. Doctors report that patients are reluctant to admit that they have any sexual problems. Depending on one's gender, age, and self-image, people might either exaggerate or minimize how frequently they have sex. We spend our whole lives not being completely honest about sex, so I guess it's not surprising that even though they're adults in a doctor's office, some people are still embarrassed about S-E-X.

If your doctor suggested that you cut back on alcohol a year ago, odds are that you'll report that you are no longer drinking as much at your appointment this year. If you exercise once or twice a week, you'll say you exercise twice a week. If you drink anywhere from two to six cups of coffee per day, you might say that you drink two cups. If you eat three strips of bacon every morning, you're likely to fudge about that. And if you eat fudge every day, well, you get the point.

I think the main reason that we don't always tell our doctors the whole truth and nothing but the truth is because of one of our most basic fears: WE DON'T WANT TO GET IN TROUBLE. We don't want to be yelled at. We don't want that authority figure to shake his or her head and make that disappointed face. So, sometimes when we're with that person in the white coat, we become like children wanting to please their parents.

How do we as physicians help patients tell the truth? The first key is in our attitude (or at least how the patient perceives us). If we appear judgemental, then the patient will more likely lie. When we appear more accepting of the truth, then the patient will more likely tell us the truth.

We need studies on how to deliver advice. How should I get this patient to stop smoking, start exercising, etc? What are the magic words? What tone should I use? What body language induces healthy behavior?

Until we really understand this issue, we will continue our dance. We dance without touching. We each leave convinced that we are making progress. But how often do we make real progress?

I saw this story on TV last night. Apparently, this new drug binds the brain's nicotine receptors but does not give pleasure. Thus, it blocks the pleasant sensation of smoking and blocks withdrawal symptoms. Pfizer unveils anti-smoking drug

In clinical trials involving several hundred smokers, the New York-based company said almost half of smokers given this oral medicine, called Varenicline, were able to quit smoking after only seven weeks.

In the same trial, only 16 percent of people receiving sugar pills managed to stop, while 33 percent of patients who received Zyban, a pill made by GlaxoSmithKline (GSK: Research, Estimates) and also sold as Wellbutrin for depression, were able to quit, the drugmaker told CNN/Money.

"This is a significant improvement over results achieved with Zyban, an antidepressant approved as an aid to smoking cessation," said Joe Feczko, president for worldwide drug development at Pfizer.

Side effects of the Pfizer drug appeared negligible so far, and the drug has "an excellent safety profile," said Betsy Raymond, Pfizer's spokeswoman.

Varenicline is currently in the final phase of widespread human clinical trials, but there's no timeline for when the anti-smoking drug might hit the U.S. market, she added.

I hope that further clinical trials are successful. We need a better pharmacologic aid to smoking cessation.

Obesity costs moeny. That is the conclusion of these business leaders. Employers Plan Obesity Fight, Citing $12 Billion-a-Year Cost.

A group of large employers headed by Ford Motor, Honeywell, General Mills and PepsiCo announced a campaign yesterday to encourage overweight workers to slim down as a way to improve both their personal health and the corporate bottom line.

Dr. Vince Kerr, director of health care management at Ford, said weight-related costs were adding $12 billion a year to costs of employers nationwide, including medical bills, reduced productivity, increased absenteeism and higher health and disability insurance premiums.

"Obesity is becoming as large a factor as tobacco once was," Dr. Kerr said. Weight-related ailments are taking "amazingly large portions" of the $3 billion that Ford spent on health care benefits last year, he said.

Michigan, Ford's industrial base, is among the worst states for obesity and tobacco use, Dr. Kerr said.

He said the company's employees mirrored the general population in the growing incidence of diabetes and other diseases that often overlap with weight problems.

Ford is a founding board member of the Institute on the Costs and Health Effects of Obesity, organized by the Washington Business Group on Health, a group of 175 large employers that provide benefits for 40 million people.

The institute plans to draw on research financed by the federal Centers for Disease Control and Prevention and the Institute of Medicine of the National Academy of Sciences. The centers and the Institute of Medicine have also joined the new obesity institute board.

When business decides that obesity eats into profits (pun intended), then they act. We need to restructure our work places. We need exercise time and space. We need to walk more and ride less.

Our 'lunch rooms' and restaurants need to quick 'supersizing'. We can do much as a society and as businesses to improve this problem.

I applaud this interest from business and look forward to some positive results.

I never know when a rant will create controversy and commentary. Last night I posted on the primary care fiscal crisis - Primary care fiscal problems. By this morning I have 4 comments and a "trackback". I do want to respond to my frequent correspondent - Bernie Simon - because his commentary demands a rant.

I don't mean to sound callous or cruel, but why isn't this a problem that the free market can solve? Presumably doctors are opting for specialties rather than primary care practice because it is more prestigious, the work is easier, and the pay is better. In due course there will be a shortage of primary care physicians and their pay will have to rise and their working conditions improve in order to attract more doctors into the field. Maybe I just don't understand how the system works and compensation is so tightly regulated that market forces don't work any more. But sooner or later something will have to give.

I agree with Bernie and I disagree. Let me try to clarify my thoughts here.

I do believe that the free market is starting to work. Physicians are developing creative payment schemes (e.g., retainer medicine, chargers for phone calls and forms, cash only business, refusing new Medicare patients); primary care physicians are leaving the field (see comment 4); less students and residents are choosing primary care.

This will lead eventually to increased pay for primary care and we will have a better balance. I have ranted about this previously - Physicians less interested in managed care and Medicare

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.

One could argue (and apparently Bernie does) that we should just wait for market forces to correct the current situation. I would argue that we can and should act more proactively to fix problems before the become crises.

We are entering an access crisis in primary care. Too many patients cannot find a primary care physician. Too many locales have insufficient physician numbers.

We can wait for the invisible hand , but at what human cost. I will continue to try (through this blog and through medical societies) to highlight the current crisis.

Since we do not really work in a capitalistic profession (my office rates are controlled), we must use the bully pulpit. I hope that this is a small bully pulpit. If you agree with me, tell another person or two. We just might start a movement (db fades out recalling Alice's Restaurant in a moment of free association).

Early in medical school we learn about the physical exam. Actually in the United States we generally start to learn about physical examination, but rarely become good at this skill. We rely on laboratory tests and imaging, and often underemphasize our physical examination - assuming that our own observations are somehow inferior to "objective data".

Generally, residents from other countries have superior physical examination skills. They are taught the examination more carefully, perhaps because they do not have access to our technology.

This article laments our skills, and discusses the many reasons for doing a good physical examination - Losing the Touch

Like many of my fellow residents, I am little trained in the "art" of medicine. We embarked on our medical careers during an era of dizzying advances in technology. Unlike our more seasoned attending physicians, we grew up in the shadow of modern medicine, where imaging has supplanted clinical skills. An echocardiogram (not the swishing sound we hear through a stethoscope when the heart's valves close) tells us whether a patient has a heart murmur. An MRI (not our neurologic exam) tells us a patient suffered a stroke. Lab tests (not the patient's swollen, warm fingers) tell us that she has rheumatoid arthritis.

I wonder what my role models -- senior clinicians who seem to know what ails patients just by looking at them -- would think of my lost faith in the physical exam. Throughout my training, I have called upon them to discuss patients. These attending physicians take me into the patients' room and kindly show me how to make a diagnosis by homing in on one or two important tests in a physical exam. I want to emulate their clinical acumen, but I worry that I cannot.

Trainees like myself face more paperwork, menial tasks and the need to master a daunting range of medical innovations. We dictate discharge summaries and transport patients to their tests while trying to stay abreast of evidence-based medicine and the most current tests available. Yesterday, cholesterol levels indicated coronary artery disease, but today it is C-reactive protein. It is no surprise that residents struggle to maintain their physical diagnosis skills when they hit the wards.

Time constraints also discourage performing a complete physical during routine office visits. The managed care system pushes doctors to see patients as briefly as possible. In many busy practices, patients are scheduled every seven to 12 minutes, although a complete physical exam alone takes at least seven minutes to perform properly.

The challenge for all physicians is to understand the physical examination as a diagnostic test. We need to teach examination skills and emphasize the sensitivity and specificity of each maneuver.

In the 1970s, researchers started to rigorously study whether there was evidence to support a lot of what was being done in medicine: Studies were conducted to determine whether patients improved with treatment, while others aimed to evaluate the accuracy of diagnostic tests. Evidence-based medicine was born.

Researchers began to view the clinical exam as just another diagnostic test and started to investigate its accuracy. Previously the value of the history and physical was considered self-evident, and these basic tools of medicine were handed down from generation to generation without being subjected to scientific evaluation. More than 250 physical exam maneuvers, like tapping on the liver to determine its size, have been taught for centuries without being validated by research.

Since 1992 JAMA has published 45 review articles as part of a series called the Rational Clinical Examination to separate the wheat from the chaff. "The mission of the series is to sort out what is useful from what is useless," said David Simel, editor of the series and professor of medicine at the Durham Veterans Affairs Medical Center in North Carolina. "Physicians can then focus on the parts of the history and physical that will allow them to make a diagnosis, not exam maneuvers that are unhelpful."

We do try to emphasize these skills in our residency. We refer to the JAMA series. However, we are fighting an uphill battle.

"I am resigned to the idea that the world has changed and that technology is reigning. I don't, however, think the advantages of technology compensate for the loss of the human relationship," said Munden. She fears that the physical exam, an essential part of the doctor-patient relationship, has been sacrificed.

"It bonds you to your doctor," according to Munden. "The physical intimacy that is part of the exam makes you feel close to your doctor. All patients, like myself, want to have a close relationship with their doctor. And, as with all relationships, it is physical contact that makes the relationship close."

With each passing year, Munden has more medical problems. "I try not to worry about my health, but it is difficult to get old," said Munden. "When I have a complete physical exam -- when the doctor listens to my lungs and heart and examines my tummy -- and finds nothing, I feel very relieved. Everything checked out fine. Sometimes when the doctor just listens to me talk about my symptoms, I feel better."

This article is important and reassuring to this medical educator. We still have a lot to teach. I only hope that our students and residents learn.

While I often rant against 'dietary supplements', I know that we cannot ignore them. Just this morning we discussed a patient admitted last night for whom supplements provided an important piece of our differential. We must ask about non-prescribed remedies. Questions the Doctor Never Asked I am skeptical of most 'alternative' therapies, however, I must know what the patient is doing for their own care. This article raises some difficult issues, but we must remember that asking may help us diagnose the patient's complaints.

We have become so fearful of skin cancer that we may not get enought sunlight. A Second Opinion on Sunshine: It Can Be Good Medicine After All

Can sunshine, now shunned by so many who fear skin cancer and wrinkles, save many more lives than it harms? Most definitely, says a leading expert in the field, Dr. Michael F. Holick, a professor of medicine, dermatology, physiology and biophysics at the Boston University School of Medicine.

Dr. Holick, who discovered the active form of vitamin D, has pulled together an impressive body of evidence in support of his advice that no one should be, as he puts it, a "sunphobe" or, for that matter, a sun worshiper.

He has concluded that relatively brief but unfettered exposure to sunshine or its equivalent several times a week can help to ward off a host of debilitating and sometimes deadly diseases, including osteoporosis, hypertension, diabetes, multiple sclerosis, rheumatoid arthritis, depression and cancers of the colon, prostate and breast.

In other words, Dr. Holick says, sunshine is good medicine.

But like all medicines, the right dosage is critical to reaping the rewards that sunlight has to offer without suffering unwanted consequences.

As I spend much time in the sun (playing golf), I find this article refreshing and welcome. Everything in moderation!

Primary-Care Doctors Suffer Fiscal Maladies I am going to quote the entire piece as I suspect the link will not be durable. A colleague sent this to me. The commentary hits the nail on the head!

There is a standing medical school joke.

Question: What do fourth-year medical students who choose to go into primary care get?

Answer: A brain scan to see what is wrong with them.

Does our society want a health-care system without primary-care physicians? It is quite possible that within the next few years, the only doctors able to afford to remain in business will be plastic surgeons.

The ever-increasing cost of running a practice combined with ever-decreasing reimbursements to primary-care doctors (pediatricians, family doctors, internists) has created a situation in which many providers are close to going out of business.

This will result in less access to health care for all of us.

Some primary-care doctors see up to 50 patients a day (not by choice), return the same number of phone calls, review a similar number of charts, fill out useless forms and interact with insurance companies, while trying to keep up to date with the latest medical discoveries.

Medical care is the most regulated profession in the country, and doctors with managed-care contracts cannot change fees to reflect any increase in costs.

Before you tsk-tsk and refuse to have sympathy for "rich doctors," let me assure you that primary-care physicians struggle to pay bills like everyone else. Health insurers are not only slow to reimburse patients, if they do so at all, but they treat doctors in the same manner.

We also live in a society in which patients are much more eager to spend $5,000 on a tummy tuck than to pay a $15 co-payment to the physician who takes care of them when they are ill.

There has always been an unwritten understanding that in choosing to serve society for the greater good, a physician sacrifices a large chunk of his or her own life. Through the years, this means many missed or interrupted Little League or soccer games, school activities, family dinners, holiday celebrations, plays and concerts. In short, a primary-care doctor gives up a large part of his or her own family life to be there for someone else's family.

To make it even more complicated, a doctor is expected to be perfect 100% of the time. No one is just a patient anymore. Each and every one of us is a potential litigant. There are certainly physicians who have no business staying in practice, and the medical establishment doesn't do nearly enough to weed these people out.

However, most primary-care doctors are skilled professionals who do the best they can to provide patients with the best possible care.

Primary-care doctors began their journey knowing full well that they would never be at the top of the medical income pool. They could not have imagined that the many sacrifices they made through the years would lead to the health-care system of today, a system that puts their survival and our access to quality health care at risk.

It is time for us to prioritize what is important to us, for our politicians to stop dawdling and take action, and for insurance companies to rein in their greed. Otherwise, the next time you have the flu, you may have to go to your local family plastic surgeon.

Read it and then reread it. The concepts are not new to medrants readers. They are important. This is society's crisis.

Maine has done it. Maine's Big Health Coverage Step

State lawmakers passed a bill that would provide 180,000 uninsured people access to medical coverage in one of the nation's most comprehensive health insurance plans.

The House tally was 105-38 and the Senate approved the measure 25-8, allowing the state to start organizing the program in 90 days. The plan is expected to go into effect next year.

First-year Democratic Gov. John Baldacci, who campaigned on the promise of universal health care, was expected to sign the bill next week, spokesman Lee Umphrey said.

The plan would create a quasi-public agency to help people secure medical coverage through private insurers. Under the plan, all Maine residents who cannot otherwise afford health care insurance would have access to low cost coverage by 2009.

Participants would be charged subsidized premiums that would vary according to their ability to pay and the amount of coverage purchased.

Funding would come from a patchwork of sources, including a tax on insurance companies and $80 million the state expects to save each year by eliminating unreimbursed medical costs run up by uninsured people.

But critics portrayed the program as untried and doomed to failure.

"This bill is illusion and promise not fulfilled," Assistant House Minority Leader David Bowles, a Republican, said before the final vote. "This bill is not the right thing."

We will watch this effort carefully. What will the program really cost? How will the uninsured respond? Will the state really save $80 million in unreimbursed medical costs?

The NY Times favors the current proposal. They rightly point out many flaws, but call some positive features flawed. This is a balanced editorial in my opinion - The Medicare Momentum

There are great uncertainties about the likely impact of the emerging Medicare legislation. No one knows whether the truly private part of the program — in which preferred-provider organizations are expected to compete for the current system's customers — will enroll enough elderly people to be viable. If not, there will be no chance to assess, in head-to-head competition, whether the private sector or the government program performs better. The new drug coverage could also have the perverse consequence of encouraging private corporations to curtail their own retiree drug plans and dump the burden on Medicare, driving up the cost to taxpayers and leaving some of the elderly with worse coverage than they now have. Congress will need to ensure, through subsidies and by changing a provision that seems to penalize retirees who receive drug coverage from a former employer, that such erosion of corporate benefits is minimal.

Although the new drug coverage would cost a hefty $400 billion over 10 years, that is not enough to provide the kind of coverage elderly Americans had every reason to expect, given the promises made in the last presidential campaign. The benefits, which would not kick in until 2006, are relatively generous for low-income patients but limited for everyone else by various deductibles, copayments, and holes in the coverage. But given the current state of the federal deficit, Congress has picked the right priorities. The bills moving toward votes in both houses of Congress offer the best hope in years of providing a Medicare drug benefit. There will be opportunities later to repair any deficiencies.

One way to limit prescription drug expenses uses drug formularies. Managed care companies generally use them. Many hospitals use them. Now many Medicaid programs have adopted this strategy. 22 States Limiting Doctors' Latitude in Medicaid Drugs

New York State, which spends far more on Medicaid than any other state, is moving toward joining that group, with the Senate and Assembly deep in negotiations over a bill that officials in both houses say could win approval in the week remaining in this year's legislative session. A similar program is under consideration in New Jersey.

Preferred drug lists steer doctors away from some of the most expensive drugs and toward different, less expensive ones that the state deems equally effective, a practice that many private insurance companies and employee health plans have adopted and that is being considered by Congress as part of a government-subsidized drug benefit for 40 million Medicare recipients. Such limits have persuaded pharmaceutical companies to lower the cost to states of some medicines. Doctors who want to deviate from the list must get prior approval, a process whose difficulty varies widely from state to state.

Medicaid officials in Florida say their program is saving more than $200 million a year, Michigan officials say theirs cut costs by $45 million a year, and some legislators in New York predict annual savings for their state as high as $400 million. Such claims are difficult to judge, because states negotiate below-retail prices and rebates with drug makers but keep those figures secret at the manufacturers' insistence.

Health care experts say the potential savings nationally from the use of preferred drug lists, or formularies, could reach into the billions of dollars. It is one of several steps states have taken in recent years to try to control Medicaid costs, including moving recipients into managed care plans. "Containing prescription drug costs is at the top of nearly every state's agenda, and this could be an effective strategy for doing that," said Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured. "But at the rates costs are rising, even if this effort is very successful, it will do no more than slow the rate of growth."

Among the most frequently excluded drugs are widely advertised, high-priced pills like Nexium and Prevacid for acid reflux, and Vioxx and Celebrex for arthritis pain, for which there are no generic versions yet on the market. Several states report that they save more on acid reflux drugs than any other category; Vermont, a state with half as many people as the Bronx, reports saving more than $2 million a year on this class of medicines alone. The states allow easy access to a decade-old class of drugs called histamine 2 receptor antagonists that includes Zantac, Pepcid, Tagamet and several generic and over-the-counter variants. But they are restricting access to most of the newer, more expensive class called proton pump inhibitors.

The trend is playing out in thousands of visits like the one a middle-aged woman, suffering from heartburn and acid reflux, recently paid to Dr. John Matthew at his clinic in Plainfield, in central Vermont. She asked for the pills she had seen advertised the night before on television, Dr. Matthew recalled, and not long ago, he would have written the prescription without a second thought.

Instead, he explained to her that the state of Vermont wanted him to stop prescribing that drug to people on Medicaid and opt for something less expensive. "She understood, and she was fine with it," Dr. Matthew recalled. "And that, somewhat to my surprise, has been the response from almost all our patients."

This strategy has legitimacy. It makes us as physicians better consider the indications for expensive drugs. When they are necessary (for the patient's benefit), we have a process for approval. The formulary system limits unnecessary use of expensive brand name medications.

This study confirms what we already believed. Study backs statin drugs for millions of diabetics

But a five-year study involving nearly 6,000 patients found taking a once-daily statin pill cut that risk by about a third, even in patients with relatively low cholesterol levels.

"What this study indicates quite clearly is that if you have got diabetes, your cholesterol levels are too high for you and that lowering your cholesterol will lower your risk," said Professor Rory Collins of the Clinical Trials Service Unit at Oxford University, lead author of the study.

Doctors should now routinely consider giving statins to people with diabetes as the third leg of a strategy which already includes treatment for blood sugar levels and high blood pressure, Collins believes.

Such an approach could benefit around two-thirds of diabetics and prevent a million heart attacks and strokes worldwide each year.

We need to read the article - MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial - in The Lancet. Quoting from the abstract

The present study provides direct evidence that cholesterol-lowering therapy is beneficial for people with diabetes even if they do not already have manifest coronary disease or high cholesterol concentrations. Allocation to 40 mg simvastatin daily reduced the rate of first major vascular events by about a quarter in a wide range of diabetic patients studied. After making allowance for non-compliance, actual use of this statin regimen would probably reduce these rates by about a third. For example, among the type of diabetic patient studied without occlusive arterial disease, 5 years of treatment would be expected to prevent about 45 people per 1000 from having at least one major vascular event (and, among these 45 people, to prevent about 70 first or subsequent events during this treatment period). Statin therapy should now be considered routinely for all diabetic patients at sufficiently high risk of major vascular events, irrespective of their initial cholesterol concentrations.

These data make sense, given that most adults with diabetes have atherosclerosis prior to our diagnosis. I suspect this article will influence practice. I will spend some time reading this article and subsequent commentaries more carefully.

I have read some excellent relevant pieces on other blogs this week. Here is a sample:

• Market-Oriented Health Care Needed - a piece by Robert Prather on the problems of over-regulation of medical care
• The Medicare Drug Benefit Is A Betrayal And Should Be Stopped In Its Present Form - another Prather piece which complements (I think) my rant on the problems with the Medicare drug benefit.
• W.F.Buckey on Reefer Madness! Why is marijuana illegal? - in which Chris Rangel takes my short rant and provides a useful essay on the problem
• Has the medical profession not done enough to minimize risk? - another example of Rangel expanding on a rant.

As is obvious, I do read Prather and Rangel regularly. So should you. Rangel blogs episodically, but with great thought. He has been brilliant especially over the last month. If you do not read him, click, and read his recent archives.

Prather writes about more than medical care. He and I share a marketbased liberatarian philosophy. I enjoy his wit, and the breadth of his commentary.

This article says it all - Patients prefer doctors who wear white lab coat

Patients prefer their doctor to top off their professional attire with a white lab coat and nametag, according to a new report.

"It appears that the attire of the healthcare provider is important to patients across all lines of population and geography studied to date: young or old, child or parent, eastern or western, northern or southern," according to Dr. Lawrence J. Brandt, who evaluated 31 studies that assessed attitudes on what constitutes appropriate attire for healthcare providers.

In many studies, patients placed a high regard on physicians who sported a white lab coat over professional attire, according to Brandt, who is with Albert Einstein College of Medicine in New York City.

According to Brandt, the research shows that the vast majority of doctors as well as many patients believe that the physical appearance of a healthcare professional strongly influences a patient's opinion of medical care.

Patients and physicians expressed a disdain for surgical scrubs, excessive jewelry, long fingernails, blue jeans, sandals, sneakers and clogs, Brandt notes in a commentary published in the Archives of Internal Medicine.

Even so, a neat clean appearance seems to be more important to patients than the particular clothes a doctor wears, Brandt adds.

The New York physician notes that dressing up in nice clothes is no substitute for "a gentle, concerned physician with an engaging, friendly, empathic demeanor."

I will show this article to the new interns next week.

British physicians must read this blog. Our correspondent, the lovely Razzberry, had a guest piece here about a fat tax. British physicians are serious - British doctors urge 'fat tax'

Hamburgers, soft drinks and cakes could be hit with a "fat-tax" in a bid to combat Britain's growing levels of obesity, doctors said Monday.

The British Medical Association is proposing a 17.5 percent VAT (value added tax) on high-fat foods like cookies and processed meats to solve obesity-related problems, which cost the health care system roughly $825 million a year.

"There is an epidemic of obesity in the UK," said BMA spokesman Dr. Martin Breach. "You are what you eat and if that is the case the British public have a huge problem."

"Charging VAT on saturated foods found in processed meat products like sausages, pies and pastries, butter and cream, may help save some lives."

So we must ask whether the problem is our diet or (as I ranted yesterday) our lack of activity. Perhaps we can blame both. I hope Great Britain passes this tax so that we can see the outcome. Of course, I live in Alabama and we will never pass such a tax.

Bush Announces an Easing of Rules on New Generic Drugs

President Bush announced new rules today that make it easier to introduce lower-cost generic versions of prescription drugs, intensifying his efforts to address health care issues ahead of next year's election.

The president, making good on a proposal he first made last year, said the Food and Drug Administration's action would limit the ability of pharmaceutical companies to delay the introduction of generic versions of prescription medicines. He said the F.D.A. rule would curtail a practice among manufacturers of brand-name drugs of delaying the introduction of generic versions by filing multiple patent-infringement lawsuits against potential competitors.

Under current rules, each patent-infringement suit causes a 30-month delay by the F.D.A. in considering generic versions of a drug for approval. Mr. Bush said drug makers would now be limited to a single 30-month regulatory delay to sort out patent disputes.

Mr. Bush said he was also directing the agency not to block generics because of patent disputes over minor issues like the color of a pill bottle or the use of ingredients not related to the drug's effectiveness. And he said his action would tighten the overall rules on patent applications, making it a criminal offense to make false statements to get a patent.

"By taking these actions, we will bring generic drugs to the market much more quickly ? in some cases, years earlier," Mr. Bush said during an appearance at a hospital here. "And this should save the American consumers about $3.5 billion a year, savings that will go, of course, to the consumers, to our seniors, or to Medicare programs administered by the state or to employer health plans."

The trade association for the big pharmaceutical companies signaled that they opposed the administration's decision and would fight similar legislation pending in the Senate.

Physicians generally favor using generics. Not all patients agree. Just do a search on generic omeprazole and you can read about the many readers who believe that this generic drug does not work.

I certainly favor more access to generics. While drug costs continue to rise even for generics, they do tend to stimulate market forces and lower prices for the class involved.

A reader questioned our inactive lifestyle as a cause of obesity. This article certainly supports that concept - Battling the bulge in the burbs

?We shape our buildings, and afterwards our buildings shape us,? Winston Churchill once said. Today, there?s new meaning to Churchill?s often cited quote: A growing number of public health researchers blame our sprawling suburban landscapes in part for Americans? bulging bellies.

NO DOUBT you?ve seen the statistics on obesity in America. Perhaps you?ve seen them on yourself.

Arlin Wasserman, an anti-sprawl advocate formerly with the Michigan Land Use Institute, says that when he moved from his native Philadelphia, where he biked everywhere, to suburban Traverse City, Mich., he put on 35 pounds.

?The move to Ann Arbor, where I logged 15,000 miles a year driving, gained me 15 pounds, even though I was still biking to work,? says Wasserman. ?But the move to Traverse City gained me another 20.?

Americans are becoming less physically active, not so much out of laziness but because of changes in the ?urban form? that are dictating more sedentary behavior, according to a new line of thinking in public health.

Advocates of anti-sprawl ?smart growth,? like Wasserman, say the theory adds ammunition to the arguments against suburban development, which has been blamed for loss of farmland and open space, as well as increasing traffic congestion.

?It?s not just a matter of our having ?super-sized? our meals or that we don?t exercise enough,? says Thomas Schmid, a public health researcher at the Centers for Disease Control. We?ve also drastically reduced the amount of regular walking, biking or getting around under our own steam as part of our daily activities, says Schmid.

I have tried to add walking to my daily routine. This is often difficult. This concept does make some sense. Can you modify your routine to include more movement?

I have some fear concerning Medicare reform. The Washington Post opines today - Medicare Muddle

At the same time, many of the "reforms" tacked on to the bills seem half-baked at best. Plans to add another, private option for Medicare recipients seem doomed to failure, as Congress wants it regulated in such a way that it's hard to see why any profit-making company would want to get involved. Estimates of how many seniors would opt to use this private option range from 2 percent to 20 percent, an enormous gap. Nor is it clear, even to supporters of the legislation, that private providers would save the government any money. The impact of the Senate's plan to offer fallback drug coverage in areas where private companies fail to offer at least two drug insurance plans is equally hard to predict and could doom seniors to rotate annually from plan to plan. The bill would continue to provide low-income seniors with drugs through Medicaid, possibly encouraging states to cut their Medicaid rolls further; at the same time, the Medicare drug benefit would go to all seniors, even the wealthiest. Private employers, for their part, might well be prompted to drop the drug coverage they currently offer their retirees. Congress and the president seem unlikely to let any of these problems stand in the way of passage and subsequent crowing. But the responsible route would be back to the drawing board.

While I do not agree with the entire editorial, I do agree that the Congress plans to pass something, even a mediocre bill, rather than no bill. We should fear this political reality. This guest author at the National Review has strong opinions also - Daschle Doesn’t Get It: The trouble with Medicare.

Senate Minority Leader Tom Daschle (D., S.D.), recently wrote in a letter to President Bush that he wants the president to "put aside" his proposal to "privatize Medicare."

It would be too expensive, he says, citing a recent study that found that private plans pay 15 percent more than Medicare does for the same medical services.

He doesn't note that Medicare's payments don't come close to covering the full bill or that the average Medicare patient pays roughly $2,000 per year to cover the shortfalls. He doesn't talk about the crisis situations that have erupted in some cities because doctors refuse to take on new Medicare patients.

Yet this problem has reached a breaking point, particularly in Denver and Seattle. In Denver, only a third of the doctors say they will accept new Medicare patients. That's down from 52 percent in 2001, a rate of decrease that Kathy Lindquist-Kliessler, executive director of the Denver Medical Society, calls "alarming." In Seattle, the percentage of doctors who accept new Medicare patients fell from 71 percent to 55 percent in four years, according to the Washington-based Center for Studying Health System Change.

Gaining access to doctors, particularly specialists, has become increasingly difficult for seniors. Another report by the Center for Studying Health System Change indicates seniors are waiting far longer to see doctors for checkups and even for specific illnesses, that the proportion of physicians who accept all new Medicare patients is falling (from 74.6 percent to 71.1 percent in just four years) and that the percentage of surgeons willing to operate on new Medicare patients is falling faster still — from 81.5 percent to 73 percent in the same period.

More to the point, Dr. Lois Copeland, a physician in Hillsdale, N.J., said she has lost two patients recently because surgeons refused to operate on them — one because an overworked doctor said he was too "exhausted" to operate safely. "Bring the over-65 population into the private insurance market," says Copeland. "Rationing is upon us, brought on by the malpractice litigation crisis and aggravated by the price controls of Medicare."

Why? Medicare controls its costs by limiting benefits and setting artificially low fee schedules for the services it does cover. Last year, for example, Medicare unilaterally cut physician payments 5.4 percent. And doctors, who have seen the costs of operating a medical practice increase 60 percent in the last decade, can't and won't take such hits much longer.

The American College of Physicians, the source of the 60 percent figure, had to revise its guidelines recently to accommodate doctors who want to recover some of these rising costs by charging for phone consultations, filling out forms for patients and handling non-emergency matters during their off hours.

While I am not sure that "privatization" would answer all our problems, the author makes a solid argument that our current system is failing. The proposed changes probably make failure more imminent. But then no one is really asking the doctors. These decisions apply to elections not common sense.

Reefer Madness: Our current Prohibition.

The marijuana laws can most directly be compared to the Prohibition-era laws, which didn't work, undermined the law, and were capriciously enforced. Pot consumption varies, but not in correlation with the laws' throw-weight. If you buy an ounce in New York State, that could bring you a fine of $l00; in Louisiana, a jail sentence of 20 years. Ed Rosenthal is quoted by author Schlosser. Will the laws in America dissipate, as they have done in Europe? He doesn't think so. "They've made the laws so brittle, one day they're going to break." The whole edifice of prohibition would come down, he predicted, "like the fall of the Berlin Wall." Schlosser nicely summarized Rosenthal's prediction. "A group of powerful, white, middle-aged men will meet in a room to discuss what to do about marijuana. And they will reach the only logical conclusion: tax it."

Like booze, some will then go on to abuse it, though with consequences less dire.

We (physicians) should have the option of using marijuana for patients. It does have some positive effects. The current laws have negative effects - and the public knows it. When will our government make logical decisions with regards to illegal drugs?

I do not always agree with Robert Goldberg, but I always read him. He makes me think. I agree with much that he says in this piece about the Medicare prescription drug plan. Dangerous drug plan. His main point (one which I have previously made also) is that we do not need a blanket drug plan. We need one for the truly needy. He argues that we should not subsidize the wealthy elderly. His ideas will receive little attention. AARP is a more powerful lobby than common sense. We could save money and spend it more wisely if we did not have political realities.

Reason demands that we do not let this problem become dormant. This editorial from US News and World Report is "spot on". Welcome to Sue City, U.S.A.

The Bush administration is committed to tort reform. It has proposed capping jury "pain and suffering" awards in medical malpractice suits at $250,000, limiting punitive damages and lawyers' contingency fees. Democrats oppose these proposals, on the grounds that no restrictions should be placed on any injured American's right to sue. We can all agree that one injured medical patient is one too many. But one falsely accused doctor is one too many, as well. Somehow, we must restore a sense of responsibility, and of proportion.

To do so, we must create a new system of medical justice. Clearly, we want to distinguish between good care and bad care, but juries have limited appreciation of the scientific issues and are not much helped by expert witnesses endlessly contradicting each other. We could, instead, rely on independent panels answerable to the court. We might also penalize those who bring frivolous lawsuits, have damages set by judges rather than by juries, and make the losing party pay the legal expenses of the winner.

Reforms will not come easily, given that trial lawyers have become the most powerful special interest group in American politics, bankrolling politicians, especially Democrats. But tort litigation is costing us all. The current estimate is $200 billion a year, and rising. As author John Naisbitt said in Megatrends, "Lawyers are like beavers. They get in the mainstream and dam it up."

This is one dam we must dynamite--now.

The entire editorial is well written. I found this link at the Common Good web site about which I ranted last week.

Sometimes the latest and greatest does not surpass old faithful. Why the major papers have not picked up this story is unclear? I guess it did not pass the "sexy" test. This study has great importance. Aspirin May Be Better Than Ticlopidine for Recurrent Stroke Prevention in African Americans

Ticlopidine (Ticlid; Roche) does not appear to be superior to aspirin in preventing recurrent strokes in African-American patients, according to the results of the African American Antiplatelet Stroke Prevention Study (AAASPS), published in the June 11 issue of The Journal of the American Medical Association.

Physicians should not go beyond the data, however, the researchers say. Aspirin should be considered as initial treatment for appropriate patients, but those who have done well on ticlopidine should not necessarily be switched.

"We had anticipated that ticlopidine would be more effective than aspirin in our African-American study participants. However, this was not the case," lead author Philip B. Gorelick, MD, MPH, FACP, Jannotta Presidential Professor of Neurology at Rush Medical College in Chicago, Illinois, told Medscape. "Based on the AAASPS data, we have concluded that aspirin is a better treatment than ticlopidine for aspirin-tolerant, African-American, noncardioembolic ischemic stroke patients.

You can read about this study here (if you do not have a Medscape logon) - Study: Stroke drug no better than aspirin As they describe the results -

The study was halted last year, a year early, when it became apparent that ticlopidine patients were faring no better than the aspirin group.

A total of 133 recurrent strokes, heart attacks or vascular-related deaths occurred in the ticlopidine group, compared with 112 in the aspirin patients. The difference was not statistically significant.

There also were slightly more serious side effects in the ticlopidine group, including one possible case of a potentially deadly blood disease called thrombotic thrombocytopenic purpura. Aspirin patients had slightly more cases of gastrointestinal bleeding, but neither of these results was statistically significant.

Study participants took either 650 milligrams daily of aspirin or 500 milligrams daily of ticlopidine.

Sacco said the findings "help substantiate that cheap and widely accessible agents such as aspirin can make a difference."

So we will stick with an aspirin a day for our stroke patients. While the authors do not encourage us to continue ticlopidine, their reasoning seems flawed. I will stick with the cheaper (and probably more effective) old standby.

Admittedly these are epidemiologic data - but that is all we have. Eating fruits and vegetables will not hurt you, and they probably will help you. Healthy Diet in Midlife Saves on Healthcare Costs Later on

Higher intake of vegetables and fruits in midlife is associated with lower healthcare costs in older age, according to research reported on Monday at the American Heart Association's Second Asia Pacific Scientific Forum in Honolulu.

"Healthy eating previously has been inversely related to mortality for heart disease and total mortality and, in some studies, to cancer," study presenter Dr. Kiang Lui of Northwestern University in Chicago told Reuters Health. "Here for the first time we showed that it is not only related inversely to disease, but also inversely related to healthcare costs in older age."

Dr. Lui and colleagues used data from the Health Care Financing Administration (HCFA) for 1984-2000 to estimate average annual healthcare cost for 1070 Medicare-eligible surviving participants of the Chicago Western Electric Study. At entry in the Western Electric study in 1957, the men were between 40 and 55 years of age and were free of coronary heart disease.

The researchers found that the 237 men with the highest intake of fruits and vegetables (42 cups or more per month) had the lowest total annual Medicare charges ($11,416) and the lowest charges specifically related to heart disease.

In contrast, the 290 men with the lowest intake of fruits and vegetables (less than 14 cups per month) had the highest total annual Medicare charges ($14,655). The 543 men in the middle group for intake (14 to 42 cups per month) had total annual Medicare charges of $12,622.

These findings were independent of confounding cardiovascular risk factors such as age, obesity, cholesterol, BP and smoking.

So keep eating those fruits and vegetables. This study assumes that the fruits and vegetables make the difference. Careful methodologists must ask whether eating fruits and vegetables serves as a marker for another healthy behavior. Nonetheless the evidence that eating more fruits and vegetables probably helps seems reasonable. Pass me that banana please.

Too often we (physicians) do not focus on peripheral arterial disease. This excellent review from the NY Times puts peripheral artierial disease into perspective - Disease of the Peripheral Arteries Can Be a Crucial Warning Signal

Peripheral artery disease is a common progressive disorder that interferes with circulation to the legs, particularly in people over 55. Sufferers have a greatly increased risk of heart attack or stroke, and of dying within a decade.

The disease is an early warning sign that cries out for help. Yet two-thirds of those afflicted do not know they have it because they have no symptoms. Doctors often fail to diagnose it even in those with symptoms, though there is a simple, noninvasive test for it. And even many who know they have it are not receiving potentially lifesaving treatment.

Death rates are high, even for those with no symptoms: 30 percent to 40 percent die within five years, 50 percent within 10 years and up to 75 percent within 15 years. Those with the most severe form face an annual death rate of 25 percent. In the United States, the disease is estimated to cost $151 billion in direct and indirect expenditures.

This makes peripheral artery disease one of the most serious underdiagnosed and undertreated disorders in the Western world. An estimated 27 million people in North America and Europe have the ailment, and the number will probably grow as the population ages.

Of the 10.5 million people with symptoms, many never tell their doctors because they assume leg pains are just part of aging.

Last month, in the journal Archives of Internal Medicine, an international group of experts issued a "call to action" to increase awareness of the problem among doctors and the public and to foster its diagnosis and treatment to head off costly catastrophic illness and death.

For those who have access to the Archives on line - Critical Issues in Peripheral Arterial Disease Detection and Management and
Meeting the Challenge of Peripheral Arterial Disease.

Relying solely on symptoms of intermittent claudication causes 85 percent to 90 percent of cases to be missed, say the call-to-action authors, led by Dr. Jill F. Belch, professor of vascular medicine at the University of Dundee in Scotland. Rather, the group suggests that doctors use a simple 10-minute screening test called A.B.I., for ankle-brachial index, to detect clogged arteries. It involves measuring blood pressure in the ankle using Doppler ultrasound and in the upper arm.

The resulting difference, expressed as a ratio, indicates just how seriously clogged the arteries may be. If blood pressure in the ankle is 70 to 90 percent of that in the arm, mild artery disease is probably present.

Readings from 40 to 70 indicate moderate disease, and readings below 40 percent indicate a severe case. The pain of intermittent claudication usually occurs when the ankle pressure is half that in the arm.

Peripheral artery disease is very important. We know the risk factors - they are the same as coronary artery disease. We know the treatments - diet, exericise, and the same medications we use in attempts to decrease atherosclerosis elsewhere.

The call for action seems reasonable, however, this adds to the time problem. We need to spend more time with our patients, and address more prevention - both primary and secondary. Time is money. So read the next rant.

As I have considered this topic in the past and again since yesterday, I pondered cute titles which incorporated song titles or quotes. Time fascinates almost everyone. Time also frustrates many. Most physicians complain of being trapped by time. In workday race, doctors scramble, but clock often wins

Time is not on his side.

David Ellington, MD, hustles to keep up with the pace of modern medicine, making sure his visits with patients cover the growing recommendations for preventive services, putting to use new diagnostic and treatment methods, plowing through managed care paperwork and juggling enough patients to offset dropping reimbursements.

"There are just so many things you need to address now. The volume of information out there is expanding exponentially. It's tough to keep up," said Dr. Ellington, a family physician in Lexington, Va.

Dr. Ellington struggles to get sufficient time with his patients. Other doctors do, too. A new study of physicians and patients shows complaints of inadequate time have increased since five years ago. And physicians are trying to compensate.

Doctors spent about two more hours a week on patient care in 2001 than in 1997, according to the study, released in May by the Center for Studying Health System Change. And the proportion of time physicians devoted to direct patient care activities grew from 81% to 86% during the same five years.

But it's still not enough, doctors say. In 2001, 34% of physicians reported inadequate time with patients -- up from 28% in 1997, the study said.
Doctors spent about 2 more hours on patient care in 2001 than in 1997.

There are several factors behind the time crunch, the study found: Medical advances translate to more treatment options; people are living longer with chronic illnesses; experts recommend doctors provide more preventive services.

"All this is going to take more face-to-face time with patients," said Sally Trude, PhD, the study's author and a senior health researcher for the center, a Washington, D.C.-based policy research organization.

To repeat a favored mantra, our current reimbursement system financially penalizes physicians for spending more time with patients. We have perverse incentives. These incentives do not align with good medical care.

Read this entire article. It makes the points I keep trying to make with outstanding examples.

Dr. Brad Radu is a senior scientist in our comprehensive cancer center. He writes and speaks extensively on the use of smokeless tobacco as a smoking alternative (he is pro). He writes this commentary in today's Washington Times - News you can't use

Dr. Richard Carmona, the Surgeon General and the Bush administration's primary adviser on the nation's public health, demonstrated that he is sadly ill-informed about the nation's No. 1 health problem, cigarette smoking, during testimony at a House Energy and Commerce subcommittee hearing on June 3.

Dr. Carmona's first blunder was his contention that "there is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes." Dr. Carmona ignored decades of published research and the prestigious British Royal College of Physicians, who reported last year that smokeless tobacco products are "on the order of 10 to 1,000 times less hazardous than smoking."

Surely Dr. Carmona knows that cigarette smoking is a major risk factor for lung and other cancers, heart diseases and emphysema, resulting in 440,000 deaths annually in the United States. But he doesn't seem to appreciate that smokeless tobacco use carries no risk for lung cancer, heart diseases or emphysema.The only consequential risk for long-term smokeless use is mouth cancer. Fifty years of research prove that even this risk is very low (less than half that associated with smoking). In fact, smokeless tobacco use is about as safe as automobile use.That's 98 percent safer than smoking.

Now while not all experts agree with Dr. Radu, he makes a very important point. We must look carefully at the evidence, even if the evidence does not coincide with our preferred world view. He is asking, albeit in a challenging way, the Surgeon General to study prior to speaking out on an issue. In that Radu is correct.

Dr. Carmona's other blunder was his support for banning tobacco products. Asked if he "would support banning or abolishing all tobacco products," Dr. Carmona responded "I would at this point, yes."This marked the first time a Surgeon General has called for outright prohibition, and he sent would-be supporters running from the Hill. Even the Campaign for Tobacco-Free Kids, which has shown little interest in helping inveterate adult smokers, couldn't support Dr. Carmona. Its spokesman commented that "We would all like to see a tobacco-free world...we can't just take away their tobacco."Dr. Carmona's boss can't be happy; Bush administration officials responded quickly. "That is not the policy of the administration," commented White House spokesman Scott McClellan, saying that Dr. Carmona's comments represented only his views as a doctor.

But Dr. Carmona's views as a doctor are just the point. He occupies one of the most trusted positions in American medicine and in American government. The Bush administration should do more than distance itself from these dangerous and irresponsible positions. It should direct Dr. Carmona to read the dozens of scientific research papers on tobacco harm reduction. It should direct him to review the evidence from Sweden that smokers can quit by substituting smokeless tobacco.

Finally, it should require that he tell American smokers the truth about all available options for quitting. After all, the 10 million smokers who will die over the next two decades are, in a very tangible way, his responsibility and his legacy.

We need scientific integrity even in political discussions. We also need common sense in leaders. Calling for a complete ban on tobacco is almost as stupid as alcohol prohibition was and marijuana prohibition is.

Relief From High Drug Costs

Senate committees will take up two bills this week that could help many Americans cope with the ever-rising cost of prescription drugs. With both parties looking toward the 2004 elections, the chances are improving for useful drug legislation to be approved by Congress and signed into law by President Bush.

The most important bill, to be considered by the Senate Finance Committee, would add a prescription drug benefit to the Medicare program for elderly and disabled Americans. This is a badly needed benefit that would drag Medicare into the modern age by including drug coverage alongside the traditional hospital and medical coverage.

Some patients need a prescription drug benefit. We should take into consideration ability to pay. If not, any plan could have major financial implications on Medicare.

Time for another edition of Q&A. Comments are flowing in, especially on the malpractice problem. We have some heated exchanges, which I will touch on. Keep those comments coming!!!

Yes, a lack of activity and a plethora of calories leads to unhealthy weight. This is a simple equation. However, I find that the articles I read on the subject of obesity in North American society consistantly oversimplify the issue. Okay, so teenagers are eating high calorie, low nutrition foods and are less active (as is the rest of the population). Well, why don't we ask the next logical question: "Why?"

With so many socio-economic factors contributing to this "epidemic of obesity," stating that a better diet and "get[ting] off our butts" is not going to make any difference in obesity rates. I acknowledge the importance of taking some personal responsibility for physical health, but when you dig deeper into obesity rates in America, you find a) a very strong link between poverty and obesity; and b) that our culture sends constant messages to consume. We have created an environment that produces obesity, and yet we seem confused when it occurs. Ignoring the social factors of obesity and placing the focus exclusively on a lack of personal responsibility only marginalizes an evergrowing portion of the population, when in fact they are simply a product of the society we've created.

This important comment highlights an important social and political issue. Should we blame society, and then sit back, waiting for society to fix the problem? Or rather should we acknowledge society's role, and offer solutions? I prefer the latter.

When dealing with individuals (which is my main role as a physician), I must focus on individual responsibility. We work to get patients more active and modifying their eating habits.

As a blogger, I have often highlighted efforts to positively impact society. We should support and demand changes to physical education programs in the schools. We should support and demand safe areas for outdoor exercise - running and bike paths for example. We should support programs to introduce more fruits and vegatables to poor areas (especially at reasonable prices).

While we strive to alter society, we still must give advice to individual patients. There we can only stress individual responsibility. If, through this blog, I convince one person to exercise and eat intelligently, then I have a success.

I am not so sure I would give the trial bar such an easy pass on their role in the crisis. They are the most significant force in the tort business, soliciting aggressively and portraying the filing of suits as an easy, cost-free, risk-free and consequence-free enterprise. That, of course, is a deception, and it successfully perverts and corrupts the public into believing there are no consequences to this kind of jackpot-seeking litigation. The fact is we all pay, and not just for medically-related litigation.

If a doctor operates unnecessarily or for inappropriate reasons, there are mechanisms that can stop that doctor: in hospitals, surgery centers, medical associations and state licensing boards. No, these mechanisms are not perfect. They can be resisted (by lawyers!) but they exist. Where is the similar mechanism for lawyers who abuse their professional privileges? When, short of criminal conviction, is it imposed? Our legislatures and much of our national political leadership is populated by attorneys. Is it any surprise the laws are lawyer-friendly?

This comment refers to a long rant from Friday. I focused on the tort laws rather than the lawyers. CHenry challenges me here, and specifically blames the lawyers.

This issue leaves me confused. One can almost make this a chicken and egg question. With proper tort reform, we would stymie the lawyers.

I argued that the lawyers see a way to make big bucks, and take advantage of the opportunity. While I would like to see lawyers consider the great societal good, I have a difficult time arguing that that is their responsibility.

As physicians we focus primarily on our individual patients. If our patient needs something, we are willing to have someone spend whatever it takes (AICD, IVIG, the latest greatest antiretroviral). While our patients advocacy may not aid the nation's health, we feel (appropriately) a moral obligation to advocate for our patient.

Thus, I have critiqued the tort system that allows lawyers to produce the current malpractice crisis. The tort system is the disease (admittedly one that lawyers produced). The individual lawyers see a financial opportunity and take it. They couch their client advocacy in flowery terms, but their goals seem financial. But we should not focus on changing them. They will only sue us if the laws allow. We must change our paradigm and educate everyone about the tort crisis and propose solutions which protect patients and the health care system.

"Most cases that actually go to trial are lost by the defendant" - true, because only the valid cases will ever go to trial. The others are dropped or settled. However, that doesn't mean that the frivolous attempts are cost-free - they aren't. Whether or not a case ever goes to trial, every attempt made at a lawsuit has to be investigated by the physician's insurance carrier. This takes time and money. Enough of these attempts and the physician's insurance premiums will go up, even if the physician is never actually sued.

This is an excellent comment from a fellow physician blogger - Feet First.

This is heartrending. And, unfortunately, not an unusual story by any means. I wish patients and their families could better understand what is meant by "extending their lives" most of the time.

Recently, a patient of mine with Alzheimer's deteriorated to the point that she was no longer eating because she could not remember how to swallow. The food merely sat in her mouth. I had multiple conversations with her granddaughter about placing a feeding tube. I made it clear that I did not recommend this procedure, that it would lengthen her life but that she would continue in the nursing home intensely demented and crippled by a stroke.

The granddaughter, of course, elected to have the tube placed. She's still with us today. Sometimes I think we ought to ask family members: "If YOU were in this situation, would you want your family to do this for you?" I think a sizable number of them would say no.

This is another post from Alice of Feet First. I have included it to highlight a problem, and suggest a solution. Alice's story happens frequently. We see these patients in the hospital and wonder - "what were they thinking".

Personally, as a ward attending, I have a rule about feeding tubes and PEG tubes (a PEG tube is a feeding tube which goes directly through the skin into the stomach). My rule - we should never place a feeding tube which does not have the probability of improving the patient's quality of life. When the patient can no longer participate in the decision making process, I do not feel an obligation to offer a feeding tube to a patient if he/she does not meet the above stated rule.

We are fortunate at our VA hospital to have an outstanding palliative care service. I often involve them in such decision making. Through many discussions, I have learned to only offer this option sparingly. I also resist this option with the argument that we would only prolong suffering (unless the patient meets the rule of the feeding tube improving the quality of life).

We (physicians) should become more paternalistic in these situations. Patient centered decision making works in most circumstances. This circumstance may require a more persuasive paternalistic approach.

At the end of the day all effective medical malpractice reform reduces to three options:

(1) Reduce the amount of compensation paid to the victims.

(2) Transfer the cost of the compensation from doctors to the taxpayer. Or spread the cost among all doctors equally so risky specialties such as obstetrics aren't hit especially hard.

(3) Make the practice of medicine less risky.

Option number three seems the obvious choice. I don't hear chiropracters complaining about their malpractice rates, because their practice has a smaller risk and their premiums are correspondingly less, despite having to face the same "greedy" trial lawyers. Now obviously making the practice of medicine less risky is easier said than done. But I think the real crisis in medicine is not the rising malpractice rates, it's the amount of risk in medical practice.

Bernie (of The Careless Hand) has posted often this week. We obviously see the world differently. He misses the point completely, especially in this post.

The costs of malpractice are spread. That is one of the problems! If I practice excellent medicine, and never get sued, my malpractice rates still skyrocket.

Please explain his third point to anyone (including me). Sick patients come to us hoping to improve. They would like a cure (and sometimes we can provide that). They want us to help them improve their quality of life (and often we can provide that).

As I have ranted often, each action we take to help the patient has a probability of success. It also has a probability of failure. It also has a probability of side effects. And the patient has a probability of getting another problem.

We can minimize risk only if we minimize the chance for benefit. We must work to balance risk and benefit, but ultimately we (the patient and the physician) must accept some risk to get some benefit.

If this makes my profession risky, then I accept that risk. We cannot make medicine less risky and more beneficial. These are the yin and yang of our work. Perhaps we need to do a better job of explaining this dilemma to society and to individual patients.

We get sued often because sometimes the risk materializes and the benefit does not occur. We may help 90 of 100 patients, but 10 patients have a poor outcome. We consider that a success. Lawyers consider that an opportunity. The 10 patients think we have failed. The 90 consider us wonderful.

....

So ends another Q&A. As usual each Sunday I rant on those issues which strike me as controversial or otherwise interesting. I do read every comment, but do not always respond because of time pressures (I have this other job). Thnaks for writing and making the blog more interesting!

Over-the-Counter Rx

ADDRESSING THE HIGH COST of prescription drugs is an important and complicated national problem, but one relatively simple fix could provide a measure of relief: making sure such drugs truly require a doctor's prescription and letting those that don't be sold over the counter. The matter of a drug's status is up to the Food and Drug Administration, but the agency has historically taken a reactive approach, reviewing whether a medicine should be moved from prescription-only to over-the-counter availability only when drug companies asked for a switch and provided the necessary proof. As a practical matter, that has often meant that drug companies waited until patents were about to expire -- exposing them to price competition from generic versions -- and then asked to go over the counter, reaping the dual benefits of brand-name identification and a bigger potential market. But with drug costs escalating, insurers who bear the extra costs for many Americans have begun to press the FDA to act on its own.

The first such switch, launched at the behest of WellPoint Health Networks, a California insurer, occurred in time for the allergy season this spring, with the country's most popular allergy drug, Claritin, being made available over the counter. The maker of Claritin, Schering-Plough, grudgingly acceded to the change in status, and the price of Claritin has dropped from $3 a pill to $1 -- with generics and store brands available for even less. The FDA may soon move for the first time to force a switch for two similar antihistamines, Allegra and Zyrtec. An FDA advisory panel concluded the medications could safely be sold without prescriptions, as they have been in other countries for years, but the industry is resisting, and a legal battle is likely. Possibilities for other switches include the ulcer and heartburn drug Nexium, arthritis and anti-inflammatory drugs such as Celebrex and Vioxx, and perhaps even the morning-after birth control pill. With the advent of more effective home testing and monitoring devices, the possible universe of candidates for over-the-counter status could expand further.

The Washington Post argues in favor of these switches. I have mixed feelings. Some of the drugs mentioned could either hide more serious disease, or cause signficant complications. However, decreasing drug costs is a worthwhile goal. Balancing my fears with the financial realities leaves me generally in favor of allowing more drug classes to go OTC.

This information is important. I want to continue playing without injury. Warm-Up Helps Prevent Golfing Injuries

Most golf injuries are from overuse, according to the results of a retrospective cohort study reported in the May/June issue of the American Journal of Sports Medicine. Warm-up routines lasting more than 10 minutes tended to reduce the risk of injury.

"Although golf is becoming more popular, there is a lack of reliable epidemiologic data on golf injuries and overuse syndromes, especially regarding their severity," write Georg Gosheger, MD, and colleagues from the University of Muenster in Germany.

The authors analyzed injury data from a six-page questionnaire completed by 703 golfers randomly selected over two golfing seasons. Of 637 reported injuries, 526 (82.6%) involved overuse and 111 (17.4%) were single traumatic events.

Severity of reported injuries was minor in 51.5%, moderate in 26.8%, and major in 21.7%. Age, sex, and body mass index did not predict number of injuries.

Professional golfers were injured more often, typically in the back, wrist, and shoulder, whereas amateurs reported many elbow, back, and shoulder injuries. Carrying the golf bag was associated with injury to the low back, shoulder, and ankle. If warm-up routines were at least 10 minutes long, they helped protect against injury.

Study limitations include possible selection bias, subjective reporting, and recall bias.

Two days ago I ranted about Common Good. Over the past 2 days we have had a fairly heated exhange in the comments section. As I have read the comments (and yes I do read every comment), I have considered the various opinions about the malpractice crisis.

Many years ago I read a famous book from the Harvard Negotiation Project - Getting to Yes! This book has guided me in various negotiations over the years. If I recall the principles correctly, one early step towards getting to "yes" is to understand the various interests. This principle parallels Steven Covey's "Seek First to Understand, Then to Be Understood" (the 5th Habit of Highly Effective People).

This rant represents my effort to understand the problem from various sides. I hope this explication works. If it does not, then I expect appropriately pointed commentary!

What do patients want?

Patients want excellent health care. More than knowing that they are receiving excellent health care, they must believe that they are receiving excellent health care. The doctor patient relationship has its own therapeutic value. Patients want to bond with their physicians and trust them. Generally they do.

Patients also want perfect outcomes. Regardless of the illness or injury some patients expect us (the medical profession) to cure them. We have done a great job at improving both the quality and quantity of life for many people. We have, however, raised expectations that we can always cure the patient.

Patients often do not understand or accept the limitations of medical care. They sometimes believe that there is a better doctor elsewhere who could have done a better job. Some patients will not accept a poor outcome.

Let me give explicit examples. A 21 year old man is riding a motorcycle without a helmet. He has an accident and suffers severe head trauma. The patient's only hope is immedicate surgery. Prior to surgery, the probability of survival was 0% without surgery and 20% with surgery. Despite the neurosurgeon's heroic efforts, the patient dies. Some families (not many, but enough) cannot accept that the death came from the accident. They believe that the neurosurgeon could have, and should have saved the patient.

So some patients want great outcomes guaranteed. They do not understand probabilities and the role of chance. They want physicians to communicate clearly and set realistic expectations.

What do physicians want?

We want to practice excellent health care. Society rewards us generously for this work. We get there through an investment of many years and many dollars. We expect a reasonable return on that investment.

Most physicians understand that providing health care is a business. We want to receive a reasonable return on our investment (see above paragraph) and to be able to run our business predictably.

Most physicians (all physicians will admit that like any other profession we have our bad apples) strive to provide the best possible care. We would like to work at a pace which allows us to make carefully thought out decisions. We want excellent outcomes, but understand the role of chance in every therapeutic or diagnostic decision. We have all done the right thing, and had the patient either die or suffer. Our decisions affect our patients.

We want all physicians to do a good job. We would like to police ourselves, however we understand the difficulties of policing the profession.

We want to be rewarded for providing appropriate care. We do not want to be sued when we have done nothing wrong. We do not want our malpractice insurance rates to increase because another doctor got sued.

What do lawyers want?

[insert jokes here] - Seriously, tort lawyers take what the law allows. Their job is to make a good living, and win lawsuits for their patients. While I like to paint them as evil, we should recognize that the problem is the laws and precedents that encourage them to become aggressively litigous. They are only foraging what they can legally forage. We should not label them with evil intent, or even expect them to consider the common good. That is not their job.

What do the insurance companies want?

They want to make a profit for their shareholders.

Where are the solutions?

First, blaming the insurance companies is unlikely to be productive. No one can make them provide insurance coverage to physicians if they cannot make a profit. That is their job, and their only job.

Second, we really cannot blame the lawyers (as much as I would like to blame them). We can only blame the laws. Our tort system is the disease. Any good physician knows that we must treat the disease not the symptoms.

Third, we must educate the public. They should understand the limitations of medicine. We must provide better information about outcomes prior to initiating care. Involving patients in medical decision making should help greatly.

Fourth, we must develop a better method of policing physicians. We need objective standards and peer assessment of physicians. We as physicians have an obligation to provide appropriate medical care. If we no longer provide such care, we should no longer have the privilege of practicing medicine.

I believe that Common Good is on the right path. They understand that attacking lawyers is not the answer. They understand the limiting awards represents a bandaid solution.

What's missing are reliable standards, the essence of what law is supposed to provide. Today, there are no deliberate rulings of who can sue for what, or what is appropriate care. There are no societal judgments of the appropriate levels of compensation, or even a recognition that moneys spent in lawsuits reduce funds for future healthcare. There are no inducements for openness and for improved systems.

I hope that physicians, all health care workers, patients and even lawyers can work together to improve the quality of health care. Our current tort system will lead to decreased health care access (see many rants over the past several months). We all must demand a new creative solution. The current system is broken, we must fix it!!

Congress continues to work on providing a prescription drug benefit. We all want such a benefit, but many worry that we cannot really afford that benefit. As usual Robert Prather has weighed in - There Ain't No Such Thing As A Free Lunch (TANSTAAFL). Now I know that TANSTAAFL comes from a science fiction book, written by Robert Heinlein. It should become a widely used phrase.

Robert Samuelson, who is always refreshingly honest, says flatly that a prescription drug benefit for Medicare is a bad idea. I agree. My solution, as I've said numerous times, is to provide Medical Savings Accounts (MSAs) coupled with catastrophic care insurance for hospitalization. The MSAs could be used to buy drugs, but would also cover doctor's visits, blood tests and the like. Insurance would only be used for emergencies, as it was originally intended.

Social Security has an unfunded liability of $8.7 trillion in 2002 dollars and Medicare has an unfunded liability of $5.9 trillion in 1999 dollars. Together they represent more than our annual GDP. Nothing less than radical reform of both systems is required or the burden placed on future workers will be crippling. Adding a prescription drug benefit will only add to an already tremendous problem.

The Republicans are being dishonest but are trying to add a cheap version of the drug benefit. The Democrats are being even more dishonest in saying they can provide universal care and the drug benefit and pay for it by simply repealing the Bush tax cuts. As Samuelson points out, the real cost of the drug benefit doesn't kick in until 2011 and the projections currently being used only account for two of those years. Nor does it include the inevitable increase in demand for prescription drugs because they will now be "free".

Read his full entry and especially the comments. Prather speaks logically - this means he is unelectable - but I admire his reasoning.

Read this poignant op-ed - False Hope in a Bottle

Susan was treated at a prestigious medical center with access to a wide array of innovative drugs, including a Gliadel wafer, which delivered chemotherapy directly to the site of her tumor. On average, we were told, this treatment extends life by about two months. But Susan suffered a great many problems over the next few horrific months. She was hospitalized five more times and had two more brain surgeries. After a third surgery, she had a stroke that left her almost totally paralyzed and unable to speak or eat ? leaving me with the decision to take her off life support.

But according to the medical profession, the experimental treatment had worked. Susan lived almost three months longer than the average patient with glioblastoma. Somewhere in some computer database, Susan's experimental regimen will be counted a success. She was a "responder." And therein lies the terrible truth behind the approval of "miracle drugs" on the basis of "tumor shrinkage" or "extended days." Susan's life was extended. But at what cost?

During those final months, we incurred expenses for four ambulance trips, two weeks in a critical care center, a full-time home health-care aide, a feeding tube and electronic monitor, home hospital equipment, occupational therapists, social workers and medication. My wife's treatment cost at least $200,000 (most of which, fortunately, was covered by insurance). I had to greatly curtail my work schedule and hire someone to handle the myriad bills.

I still hear the words of my wife's surgeon after her disastrous third surgery: "We have saved your wife's life. . . . We have given you the ability to spend more quality time with your loved one." And the words she scribbled on a notepad two weeks later: "depressed . . . no more . . . please."

Susan's last half hour was peaceful. We gave her morphine. Her eyes fluttered. I held her hand. Finally, her breathing stopped. On the table next to her were hundreds of pills, nutrition bottles, vials, needles. No longer needed.

As I was browsing the Time magazine articles, I came across this link - Common Good. They have a petition calling for a reliable system of medical justice. I was delighted to see that my dean had already signed this petition. I signed the petition today. Please read it, and consider signing it. I do believe this organization has an enlightened approach - and not just a bandaid.

An Urgent Call for a Reliable System of Medical Justice

Current reform proposals to "cap" one category of damages are not nearly ambitious enough. Providing relief to doctors squeezed by insurance premiums is important, but will not heal the deep distrust of justice that skews daily decisions. Nor will it provide incentives to overhaul outdated practices.

America needs an entirely new system of medical justice. Its first goal is to be reliable - reliable to protect patients against bad practices, reliable to protect caregivers who act reasonably, and reliable to interpret standards of care so that all participants know where they stand, and where they must improve.

We call upon Congress immediately to initiate hearings on the broad effects of litigation on healthcare, not just on the immediate litigation insurance crisis, and to consider recommendations on how to create new systems of medical justice that will promote better care, not undermine it. The health of all Americans depends upon it.

I have not had time to read the issue yet, but here is the on line link - The Doctor Won't See You Now. Hopefully some loyal readers and commentators will have time and help us with commentary.

It shouldn't take a number

Some were convinced that the scientists and the doctors were conspiring to pull the rug out from under us again like they did a few years ago when many of us became overweight overnight when the "body mass index" was revised. Why was this happening? How could previously healthy numbers suddenly turn into a warning signal?

Part of the reason is that clinical research evidence accumulates, and ideas about what's risky and what's not change as a result. Claude Lenfant, director of the Institute, says he can remember a time when doctors asked their patients to add 100 to their age to find their "normal" blood pressure. Researchers have completed more than 30 large clinical studies of blood pressure treatment and prevention since the last guidelines were issued in 1997, uncovering some valuable information along the way.

The studies suggest the risk of developing and dying from high blood pressure-related diseases are much greater than previously thought. Both men and women age 55 have a 90 percent risk of developing high blood pressure, and Lenfant says that "the harm starts long before people get treatment."

But there's a larger lesson in the new guidelines that has nothing to do with numbers and everything to do with behavior: High blood pressure is just one part of what clinicians are beginning to call "the lifestyle syndrome" ? an alarming rise in disease caused by obesity, inactivity and other risky health conduct like smoking, drinking to excess or engaging in unsafe sex.

Not surprisingly, people in the new pre-hypertensive category are urged to eat better, lose weight, get more exercise, drink in moderation and forget smoking. Even people who already have high blood pressure can forgo medication and lower their risks with a purely behavioral approach, according to recent research.

"The bottom line is that Americans must change how they think about blood pressure. The sooner they take action, the better," says Dr. Ed Rocella, coordinator of the National Institutes of Health education campaign about the new guidelines. "It's vital that they adopt a heart-healthy lifestyle early, even if their blood pressure is normal."

And in doing so, maybe they'll also change how they think about health.

This commentary puts the new guidelines into perspective. I rant frequently about adopting a healthy lifestyle. I believe (as apparently did my mother) that if I nag enough, someone will pay attention. Thus, the rants will not end, but continue each time an opportunity makes itself available.

If you do not exercise regularly - please start. If you are not watching your diet and striving towards a good body fat percentage - please start. If you smoke - please stop.

As part of our residency program, we sponsor "outpatient morning report". This conference focuses discussion of common outpatient complaints. We hope to bring the same intellectual rigor to outpatient problems that internal medicine programs have traditionally brought to inpatient rounds.

A common chief complaint in that conference is back pain. All generalists see back pain frequently. Today's JAMA has an important article relating to back pain - Radiographs as Good as MRI for Most Patients With Low Back Pain. The authors asked an important question: Are plain X-rays as good as rapid MRI in back pain patients who require an imaging study?

Plain radiographs are as good as magnetic resonance imaging (MRI) for most patients with low back pain, according to the results of a randomized controlled trial published in the June 4 issue of The Journal of the American Medical Association. Although MRI increased the cost by increasing the number of spine operations, the outcomes were the same. The editorialist suggests that people with low back pain may be better off coping on their own rather than choosing to become patients.

"A major impetus for this work was the concern that substituting radiographs with rapid MRI scans would result in worse patient outcomes because incidental abnormalities would foster increased interventions and unnecessary morbidity," write Jeffrey G. Jarvik, MD, MPH, from the University of Washington in Seattle, and colleagues. "Our study suggests that substituting rapid MRI scan for radiographs is likely safe but may in fact result in more specialist consultations and operations. Despite the higher rate of surgery, average outcomes were not better among those in the rapid MRI group."

Between November 1998 and June 2000, the authors recruited 380 patients aged 18 years or older whose primary physicians had ordered x-rays for evaluation of their low back pain. Study sites included a university-based teaching program, a nonuniversity-based teaching program, and two private clinics. Patients were randomized to receive lumbar spine evaluation by rapid MRI or by radiograph. At 12 months, 337 (89%) of the 380 patients were available for assessment of functional disability with the back-related disability modified Roland score. Mean score was 8.75 in the radiograph evaluation group and 9.34 in the rapid MRI evaluation group (mean difference, -0.59; 95% confidence interval [CI], -1.69 to 0.87). Secondary outcomes of pain bothersomeness, pain frequency, subscales of bodily pain and physical functioning did not differ significantly between groups.

Ten patients in the rapid MRI group and four in the radiograph group had lumbar spine operations. Mean cost per patient was $2,380 for the rapid MRI strategy and $2,059 for the radiograph strategy (mean difference, $321; 95% CI, -1,100 to 458).

"Given the current evidence, it is difficult to make strong recommendations regarding the use of rapid MRI for patients with low back pain," the authors write. "We recommend that rapid MRI not become the first imaging test for primary care patients with back pain until its consequences for surgical rates and costs are better defined."

I suspect that we will soon here from the neurosurgery and orthopedic communities criticizing this study. The data speak louder than any anecdotes. I will continue to perform plain film LS spine X-rays when indicated.

One of my colleagues has commented beautfully on a rant from last Thurday. I am quoting his long commentary to highlight his important contribution.

I loved this article. I strongly value a "patient centered" philosophy of health care. I thought it helpful to read a summary of how physicians and patients estimate and comprehend risk differently.

As a physician, I find it most helpful to think of "patient centered care" as a situation where I try to align my professional actions (toward health, the only area where I am credentialed professionally) with the patient's values and life context. Discovering which specific patient values and which elements of their context have the most bearing on a particular decision tends to require a lot of open-ended questions. This may be where the "art" of medicine lies.

I confess, however, that there remains considerable challenge in responding to situations where physician and patient have clearly established with each other that they comprehend and value things in very different ways. We may achieve mutual understanding, but ultimately see things very differently. A problem may turn less on ignorance of each others' values, and more on raw disagreement as to what actions or decisions really are in the service of health.

For example, a patient with a modest but troublingly chronic pain problem, a significant anxiety problem, and a recent history of active substance abuse (perhaps quiescent for a month or a week, perhaps not) may request a prescription for opiate pain medicine (a narcotic) on a long-term continuing basis. As physician, I have been in this situation countless times.

From the patient's viewpoint at the moment of their encounter with me, the patient-centric valued outcome could be a prescription that many physicians may not wish to write. In some jurisdictions, incidentally, that prescription (depending on the care context in which it is written) could leave its writer susceptible to legal prosecution!

For some physicians, I suspect the instinct not to honor this request may not be particularly well thought out. If I try to put words on some otherwise-inchoate negative reactions I have felt, for instance, I might say "I don't want to be scammed," or "I could be feeding an addiction," or "I don't like being used."

All of these notions might hold some grain of valuable truth, maybe. If I hold out such thoughts as justification for any decision I make on behalf of the patient, however, then I could be charged with some sloppy deliberation on the question of what it means to care for patients.

As a justification for how one responds to a patient, fear of "being used" could prove difficult to reconcile with a notion of patient-centered care, ie a notion that care should be aligned with the values held by the patient, and where the clinician's value ultimately lies in service to the patient. We should strive to be "of use" to patients in the context of their lives, should we not? Most clinicians, I submit, would like to say that they are "of service" but would hate to go home feeling "used."

My hunch is that the difference between those two states has a lot more to do with how clinicians value the feeling of control and power in relation to patients, and perhaps less to do with deliberations over the patient's health.

I would like to suggest that the example articulates a larger dilemma that we face in assuring that care is patient-centered. Separate from whether or not one personally stresses over "feeling used," the hypothetical example may amount to a situation where a clinician is torn between 2 conflicting judgments regarding health. One understanding: a professionally formed judgment of what might seem an undesirable health state (perhaps an addicted state?). The other: the patient's valid understanding of what health state he or she desires (free from pain, and perhaps free from worry?).

I find it hard not to conclude that there are instances where a professionally-formed and valued notion of "health" could wind up in conflict with an individual patient's notion of what would be, from his or her perspective, "health." I submit that a conscientious clinician should feel a measure of anxiety when their understanding of health, for a particular patient, falls into conflict with the understanding of health held by that patient.

Clear and detailed exploration of the patient's life and understandings should minimize the number of situations where such conflicts appear. Where they do happen, however, a clinician should be able to provide a rational account of what specific values seemed to be in conflict, how they chose a course of action, and what measures they took to continue to care for the patient.

Beautifully stated and well worth reading carefully.

I love linking to commentaries written by friends. I have known Milt Weinstein for 20 years. He has greatly influenced our understanding of medical decision making and cost effectiveness at a policy level. Milton Weinstein is the Henry J. Kaiser Professor of Health Policy and Management at the Harvard School of Public Health. He wrote this piece for Sunday's Washington Post - We Ration Health Care. Better to Do It Rationally

Fact: There is no way for everyone to get every medical service that might do some good. It would cost billions more than employers and insurance companies and our economy could afford. So medical services have to be "rationed" -- parceled out to some and not others. It may come as an unpleasant surprise, but rationing has become a part of our health care system. The problem is, it is happening haphazardly rather than purposefully, which means that we're not getting as much for our health care dollars as we could if we confronted the problem of rationing directly rather than pretending that it doesn't exist. Despite all the talk in Congress and on the campaign trail about rising medical costs, nobody is willing to acknowledge the steps that need to be taken to maximize the value of what we spend on health care.

One form of rationing that we tolerate is to allow 15 percent of Americans to go without health insurance. The rest of us get a bigger piece of the medical care pie because the uninsured get only the barest emergency care. But even the insured experience rationing: There are many medical services that insurers limit or choose not to cover. Among these uncovered services are preventive screening procedures and treatments that most of us don't worry about in the short term, but that could make us healthier in the long run. Escalating prices for co-payments and deductibles further discourage us from seeking some medical treatments, and force us to make choices about health care even though we may not know which treatments we can most afford to do without.

There is a better way to ration health services. It relies on an evidence-based analysis of the value we get from a specific medical treatment or service. We can use established scientific methods to measure how much health benefit each service could give to every patient, in terms of longer life and improved quality of life. We can value longer life in terms of added months or years of life expectancy, and we can value improved quality of life according to people's preferences -- how much weight they place on various health improvements. By combining these two measurements, we can quantify health value in units known as "quality-adjusted life years," or QALYs. Finally, we can calculate how much each service costs and how much of the cost will be offset by future savings through prevention.

With such information, we can then rank various services according to how much benefit they offer per dollar spent -- value for money. Within a health plan, services would be provided starting from the top of the list, down to the point where the insurance company's or Medicare's money runs out. The services that offer the most health value would get the highest priority for coverage, and physicians would be entrusted with judging that value based on the scientific evidence and their patients' preferences. It's still rationing, and some people don't like the very idea of it. But it's better than the arbitrary system we have. Doing it this way will improve health care, and the affordability of health care, for more people. This is rational rationing.

To make this real, consider some widely recommended cancer screening tests. Annual mammograms probably do save lives, but according to studies in leading medical journals, the added value compared with doing mammograms every two years is probably fewer than 10 QALYs for every $1 million spent on screening women over 50. Contrast this with screening every woman over 50 for colon cancer every 5 to 10 years, which would yield about 50 QALYs for the same $1 million. In other words, we could save more quality-adjusted years of life -- 5 times as many in this example -- if mammograms were done every two years and the money saved was spent instead on giving every woman a colonoscopy every 5 to 10 years. But at the present time, more women get annual mammograms than ever get screened for colon cancer.

Here's another example. Pap smears every few years to prevent cervical cancer are a health care bargain, at more than 100 QALYs gained for every $1 million. But the costs and benefits of an annual Pap screening are quite different. According to estimates from many independent studies, yearly Pap tests add just a few hours to quality-adjusted life expectancy of the average woman, above and beyond the gains from less frequent testing. But the expense of more frequent testing (and the abnormal results that some of them produce, requiring still more follow-up tests) are huge, adding up to as much as $20 billion nationally. This amount would produce far more health benefit if it were spent on screening these women for colon cancer, or treating their high blood pressure, or reducing their risk of osteoporosis.

Read the entire article; think about his approach. Milt challenges us to develop a rational, not a political, method for rationing health care. He makes the point that we can not avoid rationing, thus we should proceed logically rather than emotionally. I wish we could adopt his model. I doubt that it would withstand the lobbying efforts.

I rant incessantly about unintended consequences. Apparently, I am not the only one.

I started back as ward attending this Saturday. As we made rounds, I quickly learned that I would have to remember patient rooms, as most rooms no longer had the patient's name outside the room. While this is an annoyance for me, it has greater ramifications - A Privacy Law's Unintended Results

A woman lay unconscious and dying at Suburban Hospital in Bethesda, Md. But the hospital would not tell her friends and relatives what room she was in.

Janlori Goldman, a cousin who had power of attorney for the woman's health care, said the operator told people that the hospital could not release any information about the woman or even say whether she was a patient there.

The day was April 17, three days after major new medical privacy rules went into effect nationwide.

"Relatives were calling me on the cellphone completely livid," said Ms. Goldman, director of the Health Privacy Project, an advocacy group in Washington. "And I, in the middle of having a relative in the process of dying, had to call the head of hospital administration and say, `I'm going to explain this law to you,' " Ms. Goldman recalled.

The rules, incorporated in the Health Insurance Portability and Accountability Act of 1996, are the first federal privacy standards to limit how health care providers ? hospitals, physicians, pharmacists and health insurers ? can use and release medical information.

The rules were initially conceived to protect the privacy of electronically transmitted information, but they were expanded to cover broader areas.

Though hailed as important legislation by many consumer groups, the rules have had unintended consequences.

Under the rules, hospitals have to allow patients to opt out of the hospital directory to preserve their privacy. Suburban Hospital, though, presumes that patients want to be kept out of its directory unless they opt in. That may seem like little more than semantics. But if someone is unconscious or otherwise unable to choose, the patient will not be in the directory, and relatives and friends may have trouble finding them.

Ms. Goldman sees the policy as overcautious and as a misapplication of the law.

All too often our legislators make laws without working through the consequences of those laws. This law stems from an understandable concern, but I believe it has created more harm than good. But then I am not surprised. The road to hell is paved with good intentions. Good intentions are just not good enough.

A colleague forwarded this link. The title bothers me - so does the article. Busy Harvard doctors balk at teaching

Harvard Medical School is struggling to persuade its physicians to teach its students, as doctors seeing more patients to stay afloat financially have less time to educate the next generation of doctors at one of the country's most prestigious medical colleges.

The medical school dean, Dr. Joseph B. Martin, who was hired in 1997, appointed a task force to study the issue as part of a far broader curriculum overhaul, the first major rethinking of the school's curriculum in 20 years.

Earlier this year at a faculty meeting, Martin, who is generally soft-spoken, let faculty know he was upset about the teaching situation. ''Martin expressed deep and serious frustration at not being able to convince more faculty that teaching responsibilities are the core of a faculty appointment and that faculty have an obligation to carry out their teaching responsibilities,'' according to the faculty report of the meeting in February. ''He said efforts to convey this have been largely unsuccessful.''

Members of the Task Force on Faculty Teaching Responsibility said course directors are finding it increasingly difficult to recruit faculty to teach -- despite the school having 9,000 physicians and researchers at its affiliated hospitals and institutions and a requirement that they teach 50 hours a year if asked. More faculty are saying no to requests, many physicians in the hospitals will agree to teach students at patients' bedsides for only two weeks rather than a full month, and, in rare cases, course directors are hiring non-Harvard faculty to tutor small groups and oversee labs.

Some doctors, particularly those in busy primary care practices, said productivity demands will force them to cut back on teaching this year -- particularly since teaching pays very little, if at all. Other medical schools face similar problems, a sign, physicians said, that the economic pressures in the health care system are seeping into the protected world of academia.

We academics know this problem. I stayed in academic medicine precisely so that I could teach. Teaching medicine is fundamental to being a physician. We must teach the next generation. We must find the wherewithal to teach or we can no longer be a great profession.

The current issue of the Journal of the American College of Cardiology has 2 articles on the management of atrial fibrillation and an editorial comment. These articles add to a growing body of literature which has addressed the question of rhythm versus rate control in atrial fibrillation patients.

Several years ago, a colleague and I debated this issue at Grand Rounds. I argued that as long as rate control provided symptom control, the potential adverse effects of the antiarrythmics outweighed the benefits of sinus rhythm. He argued that sinus rhythm would decrease thromboembolic complications and probably improve the quality of life.

It appears that in most patients my arguments now receive clinical trial support! Several trials have taught us that in the absence of symptoms, rate control works at least as well, and probably better than attempts at rhythm control. Factors which influence these findings include:

• A low percentage of patients actually remain in sinus rhythm, even with antiarrythmics
• Patients in sinus rhythm too often have their anticoagulants stopped. These patients then revert to atrial fibrillation and without anticoagulation have a significant risk for thromboembolic events.
• Most patients have a very good quality of life with rate control, thus rhythm control cannot improve their quality of life.

If the patient has symptoms due to atrial fibrillation, then we should consider the possibility of rhythm control. If the patient has a decreased ejection fraction and symptoms, then one should consider nodal ablation and pacing. This treatment combination does seem to help symptomatic patients.

Yesterday I provided a link to Broder's commentary on the health insurance crisis. I am pleased that Robert Prather has commented eloquently on this issue. Health Care Costs Yet Again

In an earlier post I said the test of a good health care reform proposal is one that doesn't divorce the consumers of health care from the cost of the services they receive. I'm still not hearing any good proposals by that standard, but this David Broder column contains some interesting numbers in it, allowing me to look at some scenarios where a combination of MSAs and catastrophic care insurance is used to provide insurance for employees.

The story says Cinergy pays $10,000 per year, per employee for health care coverage. That's a hell of a lot of money and, possibly, offers opportunities for massive savings. If Cinergy were to offer each employee a Medical Savings Account (MSA) of $3000 per year -- any unused portion rolls over to the next year -- for all out of hospital costs such as drugs and doctor's visits along with a catastrophic coverage policy to cover hospitalization which would cost, according to this About.com story, about $4000 for a husband and wife, that would cut Cinergy's outlay to $7000 for a married couple with no kids. Of course, the company will have a mix of employees, some single, some married and no kids and some that are married with kids. There will also be people whose spouse's insurance covers him. How all of this shakes out is impossible for me to tell. This is just a simple look at the numbers.

Go read Prather's full commentary - then read his links. He champions Medical Savings Accounts for routine medical care. When one has such an account, medical expenditures become more tangible to patients. The patients will begin to notice cost, and perhaps make some decisions based on those costs. Prather is on to an important concept.

I am a bit late getting to this important article - 'No Matter What the Data Say' . Sydney Smith (Medpundit's pseudonym) minimizes the effect of diet and blames our increasing obesity on lack of exercise.

A recent study of teenagers' habits over the past twenty years supports this observation. Nutritionist Lisa Sutherland of the University of North Carolina at Chapel Hill looked at data from the CDC's National Health and Nutrition Examination Survey and Youth Risk Behavior Surveillance System, and the Department of Agriculture's Nationwide Food Consumption Survey, all of which have been following our national weight trends, activity trends, and food consumption trends for several years. She found that over the past twenty years, teenagers have, on average, increased their caloric intake by one percent. During that same time period, the percentage of teenagers who said they engaged in some sort of physical activity for thirty minutes a day dropped from 42 percent to 29 percent. Not surprisingly, teenage obesity over the twenty year period increased by 10 percent. The logical conclusion is that it isn't junk food that's making teenagers fat - it's their lack of activity.

This isn't the first study that has suggested the importance of exercise in the obesity equation. Consider the Pima Indians. The Pima Indians of Arizona have one of the highest rates of obesity in the world, while the Pima Indians of Mexico have very low rates - even though they eat on average the same number of calories a day. The difference? The Mexican Pimas spend twice as much time engaging in physical activity as American Pimas. Or consider the study of British twins which showed less body fat in twins who exercised compared to their less active siblings. And then there are the weight loss success stories. Study after study shows that those who lose weight and keep it off are those who exercise regularly.

Medpundit makes a reasonable argument here. I have often argued that weight control requires attention to increasing caloric expenditure (more exercise) and decreasing caloric intake (careful diet). I am skeptical of dietary data. We generally rely on surveys for these data - and I am skeptical of surveys in general.

While I believe that too many teenagers and adults take in excessive calories, Medpundit makes an important point. If we get off our butts and move we can handle more calories.

Time for some excellent questions and comments.

What study is your use of metoprolol in heart failure based upon and where did you get your information that Coreg 12.5 mg and metoprolol 25 mg are equivalent doses and where do you get a 25 mg tablet of metoprolol?

These are good questions, and I can only answer one for certain. The MERIT-HF study supported metoprolol for CHF - Fagerberg B, et al. Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet June 12, 1999;353:2001-7.. I got the equivalent dose information from the COMET study - specifically this quote from theheart.org describing the COMET study -

They were randomized to carvedilol (target dose 25 mg twice daily) or metoprolol tartrate (target dose 50 mg twice daily). These doses were chosen because it was believed that they would give a comparable degree of beta blockade in both groups.

This comment comes from an earlier post, which is superceded by - COMET results previewed

The medical community has been working under market conditions that have applied to only a few other industries. There is of course the possibility of raising prices, but the buyers, in most cases insurers of patients and the government, have dictated reimbursement and effectively fixed prices, either by contract or by law. Only a few patients, very few, actually pay the charges at listed price. So there is not truly a free market in medical care. What there is is a sort of demand economy, where a few very large buyers, largely leveraged by the federal government and the reimbursement schedules paid by Medicare, fix the market prices, and where other payors usually follow suit. Of course, doctors are free to exclude insurers that pay poorly, the reason why so many refuse to accept Medicaid and Medicaid-like plans, lowball HMOs and plans that practice mendacious claims denials and downcoding.

It is a business of compromises. See enough patients that have plans that pay enough quickly enough so you can meet your bills and make a living for yourself that adequately compensates for your time, training and risks. Nothing is really different from other small businesses that way. As for patients, very few people have ever paid their full bill for their medical services as they might for other commerce where there is no third-party payor. This has been the case in the U.S. for more than a generation. Copayments, when they are due, are largely token payments and represent only a small proportion of the costs or the full payment expected. So patients usually are not rational participants in decisions about consuming medical care. There isn't exactly market transparency and those receiving care aren't the ones who pay the full bill and so don't feel the need to contain costs.

This is wisdom from CHenry. This echoes much that I have written over the past few months. Medical practice functions under a perverse system of fixed charges and increasing overhead. As Robert Prather argues, we need a true free market for medicine.

well...don't we all live in a society where we buy name brand items...from cars to clothes to the restaurants we eat....MD's sure are picky and I am sure their loved ones get the best medicine...the ones that are promoted

I beg to differ with this comment. Many physicians prefer generic drugs for their families, especially those who eschew free samples. I personally see no reason to spend more for an advertised trade name drug - when a generic will work just as well.

As a resident who has felt the changes of adapting to an 80 hour work week first-hand, I also have dealt with the difficulty of balancing the responsibilty of getting my interns out of the hospital on time with teaching them the importance of their responsiblity in appropriate patient transfer and care. I feel that this bill threatens at some level our clinical judgement by pressuring an already stressed out team to neatly wrap things up, often dumping a tremendous work load on either a busy on-call team or a day-float.

Even if they are allowed to leave, I want my intern's to at least intellectually.. want to stay. I want them to
learn to build relationships with their patients that makes the work not a burden or a time-clock slot but an opportunity to spend more time with someone who is suffering and in need of their help. Unfortunately relationships don't always come in a pre-packaged 12 hour time slots, they take time. If I can teach them that, then it doesn't matter how much time they spend at the hospital, they will have learned what it is to care for a patient, and that's all I want in my doctor.

First, I want to thank my former student for this insightful comment. It is exciting to receive comments from people I know!

Read this comment carefully. The resident makes some very important points. Rules (like the ACGME guidelines) can be dangerous. We really do not want physicians in training to develop a "punch the clock" mentality. We want them to care for their patients. Some days, weeks and months may require longer hours; some days, weeks and months may allow shorter hours. Arbitrary rules can negatively impact patient care and professionalism.

The ACGME has a laudable goal. I fear the unintended consequences of using rigid rules to legislate common sense. This July looms as an uncontrolled experiment in housestaff education and patient care. I will be there on the front lines with the new interns. I will report on our new system.

I have been diagnosed with eosinophilic fasciitis. Symptoms began in JANUARY. Swollen hands; carpal tunnel followed. By MARCH, Pale pink rash on knees and back of thighs, which became very painful, burning. Finally diagnosed 5/6/03 from biopsy of rash back of knee, which by then ws leathery. Now lungs are involved. Am on 40 mg. of prednisone (since 5/6/03) and 200 mg.of doxyciline. Wondering when I will get well. Please rant!

I wish I could answer questions like this one. We (physicians) often do not know when patients will improve. Often we try therapies, and then observe the response. This happens more often with less common diseases (like the one mentioned in this comment).

I wish I could give perfect medical advice to everyone who writes. Unfortunately, medicine remains part science, and part art. Sometimes, we do have to try therapies without out knowing how the patient will respond. In doing so, we try to balance risks and benefits.

I apologize for the long winded response. I cannot answer your question - and my frustration is minimal compared to the frustration that you must have concerning this problem.

...

So this ends another Q&A. I hope everyone has had a great weekend. And remember that Father's Day is only 2 weeks away!!!
 

Q&A later today sometime (off to make rounds soon). High Cost Of Inaction On Health Care

These firms are all members of the National Coalition on Health Care, a bipartisan organization whose honorary co-chairmen are former presidents Jimmy Carter and Gerald Ford.

The organization has not endorsed a specific plan, but its message is clear: Unless the approach is comprehensive, it is unlikely to head off this looming catastrophe. Its principles call for universal health insurance as a first step toward controlling expenses and ending the cost-shifting that burdens policyholders and their employers for the uncompensated costs of those who show up at hospitals and emergency rooms without insurance.

A comprehensive reform would also aim at improved quality, by emphasizing preventive medicine and carefully measuring the value of various treatments, and would simplify the overly complex system of financing and administration we know today.

Is such a system feasible? The answer, all these hardheaded businessmen say, is yes. It is not only possible but necessary. Otherwise, according to the coalition's best estimates, the average annual premium for employer-sponsored family health coverage may reach $14,545 in 2006, more than double the average premium in 2001, and the number of uninsured Americans will grow by 10 million to more than 51 million.

That's why this is much more than a Democratic nomination-fight issue.