Congratulations to Steve Hoffman, who writes Tales of Hoffman. He has moved his blog - I have changed my blogroll to direct you to the new address.

He works for Medscape - my single favorite site for article summaries in internal medicine. He has pushed for a medical panel at "Bloggercon". He is right.

Hospitals Pressured by Soaring Demand for Obesity Surgery

Dozens of hospitals are adding special operating suites for the procedure, called bariatric surgery, which attracted wide notice after public figures like Al Roker of "Today" on NBC, Sharon Osbourne of "The Osbournes" on MTV and Representative Jerrold Nadler, a Manhattan Democrat, had it done. Some bariatric surgeons are fully scheduled 12 months in advance, and hundreds of doctors have jumped into the field recently and started to advertise their availability.

Bariatric procedures - meant for obese people who are at extremely high risk of severe health problems, as defined by a National Institutes of Health consensus - surged more than 40 percent last year, to 80,000. This year, the number is expected to climb to 120,000, according to Frost & Sullivan, a consulting firm. Spending on bariatrics is approaching $3 billion a year, at an average cost of $25,000 for each procedure.

With the number of people eligible for the procedures growing by an estimated 10 to 12 percent a year, bariatric surgery can be profitable for hospitals ? and even more so for surgeons. But the costs are a major concern for insurance companies and employer health plans. Surgeons say that some insurers routinely delay approvals.

"The companies throw up roadblocks," said Dr. James Rosser, a surgeon at Beth Israel Medical Center in Manhattan. "They keep requesting more information. Patients are left to really hound the insurance companies to get the approvals."

Doctors and patients, meanwhile, are putting pressure on insurers to lower the body-size threshold for paying for the operation for people who have advanced problems with diabetes and other weight-related diseases. That could triple the number of people potentially eligible for the operation to more than 30 million, a panel of medical advisers to the national Blue Cross and Blue Shield association was told recently.

One group having trouble winning access to treatment is the poor, among whom obesity is an especially acute concern. Doctors say that Medicaid programs in many states have been reluctant to pay for the procedures. At the University of California at Davis, for example, Medi-Cal patients face a 12-year wait for bariatric surgery, said Dr. Bruce M. Wolfe, a bariatric surgeon and professor of surgery. Medi-Cal reimburses Davis for the procedure at less than a third of the hospital's cost.

This story makes one think. Clearly the surgery - which I must note carries small but major risk (including mortality) - helps many patients. I have seen patients whose lives have greatly benefitted. We (physicians) probably all have.

However, I do find it sad that we have to resort to this extreme therapy for obesity. That severe obesity is epidemic (and perhaps endemic) saddens most observers. We should develop better prevention for this problem. Exercise and a healthy diet work. How can we reconfigure our society to encourage exercise and smarter eating?

No snide comments allowed. Constipation does cause significant morbidity. Generalists often have difficulty helping patients suffering from chronic constipation. This article might help - Constipation and its management

For people with mild longstanding constipation investigations are not required, and dietary management is usually sufficient to relieve symptoms. When chronic constipation is more severe, detailed consideration of likely causes and other treatments is warranted.

Many patients with mild constipation can be managed with simple bulking agents or laxatives. After thousands of years of empirical use of such agents, prescribing can now be based on evidence from controlled trials. In elderly patients with resistant constipation, a stimulant such as senna, possibly combined with a bulking agent, is more effective and cheaper than lactulose. Polyethylene glycol based laxatives have recently been shown to provide long term benefit in patients with idiopathic constipation and faecal impaction.

For many patients, however, laxatives do not provide sustained relief of symptoms. In addition increasing dietary fibre has been shown to worsen symptoms in many patients by causing increased bloating without an improvement in bowel function.

Let me translate a few concepts here. First, diet is the first line. Many patients will have constipation decrease by changing their diet to include more fiber. Second, senna (e.g., Ex-Lax, Sennokot) plus a bulking agent (like Metamucil) will help many patients. Some patients with severe constipation will need chronic therapy with electrolyte solutions such as GoLytely (polyethylene glycol). Fiber can make some patients worse.

For those who do not benefit from simple bulking agents, laxatives, or behavioural treatments, new pharmacological approaches may offer help. The neurochemical basis for peristalsis is now better appreciated and known to involve 5-hydroxytryptamine4 (serotonin type 4) receptors. In contrast to laxatives, which work via a luminal mechanism, the newly developed 5-hydroxytryptamine4 agonists are absorbed in the small intestine and induce peristalsis through a systemic mechanism. Tegaserod and prucalopride are two such drugs; the former is licensed in the United States but not in the United Kingdom or most of Europe. The latter is still under development.

This article is very helpful for outlining a rational approach to chronic constipation. I plan to use it in the future for selected patients.

Back in June, the NEJM had a review of the malpractice crisis - The New Medical Malpractice Crisis (subscribers only). This article does explore the issues from all sides. I particularly like the final paragraph.

An important shortcoming of traditional tort reform is that it does little to improve the widely recognized deficiencies of the tort system in preventing injuries due to medical errors. Expert committees from the Institute of Medicine and elsewhere are calling for experimentation with more radical reforms, including alternatives to adversarial litigation. For now, however, most expect the malpractice crisis to deepen and spread even in the face of aggressive tort-reform efforts at the state and federal levels.

Today's NEJM has two letters concerning this article. The New Medical Malpractice Crisis Let me provide the text for non-subscribers.

Mello et al. do an excellent job of summarizing the current medical malpractice crisis but overlook one of the simplest solutions. Physicians, unlike those in virtually any other business or industry, are unable to pass on costs. If, with every hike in malpractice premiums, we could increase our charges (and actually collect them), then the burden of malpractice premiums would fall on society as a whole. These increased charges would be no different from the increased prices we pay for most products when the industry producing them is hit with new taxes, wage hikes, increased costs of insurance, and so forth. At that point, society could decide how much it wished to spend on medical malpractice. I suspect the answer would be "not much," and the crisis would be rapidly resolved.

This writer is (as the English say) spot on!! This echos many comments that I have made over the past year. Restricting the reimbursement for providing care, while allowing overhead (and malpractice is overhead) to increase becomes untenable! The current system hides the cost of malpractice from patients. This hiding prevents economics from working.

Despite a more socialized health system, Australia has medical malpractice problems that are almost identical to those in the United States. The largest medical insurer collapsed, necessitating a government bailout, and there has been talk of tort reforms and capitation limits on blue-sky claims. This will serve only as a Band-Aid, and a few years down the track the same problems will surface.

Most writers on this issue and many legislators are lawyers, and as a result, the perceived right to sue has become a sacred cow. Until this notional right is overcome, there will be only marginal change. The pity of it is that excellent schemes such as the New Zealand accident-compensation scheme and other no-fault models in Scandinavia could serve as a template to address these issues. Most damage suits could not have been foreseen and rarely result from incompetence, malfeasance, or criminal behavior. If these circumstances exist, there are much more appropriate ways of dealing with them than hungry plaintiff lawyers' clamoring for a jury award. A no-fault scheme provides appropriate compensation, ongoing care, and professional protection.

While I am not familiar with the New Zealand and Scandinavian models, they sound intriguing. If any readers can provide information I and many readers will owe you a debt of gratitude.

Interesting piece - A Killer Top 10 List

My mindless survival puts me in no position to lecture. But a recent glance at a list of the top 10 killers of people between ages 18 and 43 -- in other words, between high school graduation and 25-year reunion -- gave me pause: I've sure dodged a lot of bullets.

A closer look at that list, compiled from National Center for Health Statistics (NCHS) figures, suggests that with some planning, you (or a young person you know) might up your odds of dodging a few yourself. Here's the top 10 list, annotated with comments from two experts -- Michele Allen, who practices family medicine at UCLA, and Edward Creagan, an oncologist at the Mayo Clinic in Rochester, Minn., and the author of "How Not to Be My Patient: A Physician's Secrets for Staying Healthy And Surviving Any Diagnosis" (HCI, Oct. 2003). And, okay, I've added a few comments of my own.

You should peruse this very interesting list. Then think about how to stay off the list.

Creagan has a list of his own, "Ten Commandments to Go the Distance" with soul-nurturing recommendations such as: Get enough sleep (six to eight hours a night, please), maintain a sense of spirituality, make sure your life includes challenges ("gently pushing the envelope"), develop an ability to absorb -- not be tortured by -- criticism, "acknowledge the value of animals in our lives," and -- in the tenth spot, "Log onto Google and look under 'predictions that never came true.' Don't ever, EVER let somebody tell you your idea is stupid and won't work." Allowing yourself to get emotionally beaten up wreaks havoc on the immune system, he says, which opens the door to all kinds of maladies.

Creagan adds a few extra tips: Start planning your financial future now so you don't end up outliving your money; cultivate a relationship with a primary care physician right away ("the Yellow Pages is nowhere to go when you're sick," he says) and most of all, take a proactive role in maintaining your health. "It's how we live, not the gene pool we inherit," that most determines how healthy we are, he says.

So who is Creagan? He is a Mayo oncologist and author - Introduction to 'How Not to Be my Patient

Insurers balk at obesity surgery costsMany who undergo the surgery have seemingly miraculous recoveries from chronic health conditions - at least in the short term - and report dramatic improvement in energy levels and quality of life.

However, many insurance companies in the Northwest, where the Burcks live, including Health Net, Regence BlueCross BlueShield of Oregon and PacificSource, do not cover the procedure, or cover it only at an employer?s request. The companies cite a harsh economic climate and lack of long-term studies.

"Of all the reasonable candidates, most haven't gotten approval through their insurance companies," said Dr. Bart Duell, associate professor at the Oregon Health & Science University School of Medicine and director of the institute's metabolic disorders clinic.

Bariatric surgery has great risks (as I have written previously). Morbid obesity may have greater risks.

The insurance companies are (in my opinion) showing no common sense here. They will likely save money from these operations (due to decreased medical costs in the future).

I lament the need for these operations, however, they are often efficacious.

Comparing Prescription Drugs

The befuddled consumer can be forgiven for not knowing whether one prescription drug is better than another for any given illness. Most of the time medical experts do not know either. That is because the drugs used in this country are seldom tested against one another in head-to-head combat. Instead, each is tested separately against a placebo and then, if shown to be safe and effective, is approved for marketing. Whether a new drug is better or worse than other drugs used for the same condition is seldom determined.

That leaves patients and doctors to rely mostly on intuition, trial and error, or the salesmanship of the drug makers. Pharmaceutical companies typically promote their newest and most expensive drugs heavily, even if there is scant evidence that they are any better than older and cheaper rivals.

Well said!

I have ranted about housestaff training often. Most internal medicine educators know that some prestigious programs have worked their residents harder than the standard program. Hopkins just got caught (analogous to Yale's surgery program problems last year). Hopkins Accused of Overworking New Physicians

Hopkins was cited for scheduling physicians to be on call every other night for at least part of the time they served in the intensive care unit. The new rules say that in a 30-day period, residents can't be on call more than the equivalent of every third night.

Although the Hopkins schedule complied with that rule -- the ICU residents were given a run of free nights between the intense periods -- it turns out that medicine residency programs accredited by the council had prohibited such averaging for many years. Hopkins had not been cited in the past, and the hospital believed that it was in compliance with both the old and new rules, Nichols said.

The council also said the hospital needs to make changes that relieve physicians of such time-consuming tasks as drawing blood and retrieving X-rays at night so they can devote their attention to patient care.

The ACGME will enforce the rules. All programs should take heed. Hopkins will change their system (while grumbling I suspect).

Thanks to all the comments about highlighting. My summary was that highlighting was generally favored, but several readers felt it was too bold. I have tried to make it more subtle. What do you think?

While I write Medrants primarily for myself, I do want to provide an interesting site for you, the readers. I recently read a criticism of my formatting, and want feedback.

Several months ago, I adopted a technique that I had seen on other blogs - highlighting. Here is an example: highlighted text in contrast with regular text. I like it personally, however, my question stems from the criticism. Does highlighting make you more or less likely to read a passage? Should I emphasize ideas with bolding or italics instead? Should I not bother to emphasize?

While I am asking opinions let me ask two other questions? Please critique my quoting style (i.e. the dashed boxes that identify quoted material. Also, I would appreciate any feedback on what types of content you find most useful and interesting.

I offer this disclaimer. This blog is not a democracy, rather I am a benevolent despot. However, even despots need good advisors!!!

Thanks for reading and thanks in advance for your comments.

I write about palliative care periodically. Here is another good story about this important field. To read more - just search my archives. Finally (or Not), Relief: Palliative Care Aims to Soothe the Sickest, Even When Hope Remains Alive

Palliative care shares the same goals as hospice care: providing patients relief from pain and other unpleasant symptoms and offering them and their families a wide range of support services. But unlike hospice programs, which are targeted to dying patients, palliative medicine may be used to help those who are pursuing curative treatment and who may go on to live for many years.

Studies of the effectiveness of palliative care programs show that they significantly reduce patients' pain levels and control symptoms such as fatigue, anxiety and nausea. Palliative care also reduces hospital stays and pharmaceutical costs and increases patient satisfaction and quality of life, according to the New York-based Center to Advance Palliative Care (CAPC). Palliative care services are covered by Medicare and most insurance companies.

Six years ago, palliative care programs were virtually unknown in the United States. But according to the American Hospital Association, more than 17 percent of community hospitals and 26 percent of university hospitals now have such programs.

The VA where I attend on the wards has a very active palliative care program. That program has improved the quality of life for the patients and the physicians. We no longer throw our hands up in dispair, but rather have an approach to help the patient. We better understand (thanks to our palliative care colleagues) that controlling symptoms in sick patients is often the appropriate goal.

Rising Obesity in Children Prompts Call to Action

In a report this month that points up this discrepancy, the American Academy of Pediatrics has called on members to make obesity screening and counseling routine parts of children's checkups, like testing reflexes or measles immunizations.

The report offers pediatricians procedures to identify and intervene with patients before weight problems start, rather than waiting until children are too heavy. After children have gained too much weight, the report suggests, it can be very hard for them to lose it and keep it off.

Dr. Nancy Krebs, a pediatrician at the University of Colorado and a lead author of the report, said, "In the last five years, with both adults and pediatrics, there's certainly been a trend toward saying, `Treatment success is so bleak, we've got to stop it because we can't treat it once it occurs.' "

The authors of the report acknowledge that proven strategies for children are extremely limited. But they add that the scope of the epidemic makes it urgent for pediatricians to start acting.

I admit it - I love red wine and olive oil. These are good things to love. Mediterranean diet 'extends life'

Drinking red wine and cooking with olive oil may help us to live longer, say scientists.

They have found that key ingredients in both substances can significantly increase the lifespan of yeast.

Since yeast and humans share many genes, scientists have speculated they may have the same effect in people.

The findings provide more evidence to suggest that the Mediterranean diet may be the secret to living a long and healthy life.

This story is very interesting - Scientists Gain Insight From Man's Vision

When the doctors unwrapped the bandages, Michael May was stunned: He could see shadows and shapes, and, after scanning the fuzzy images around him, make out his wife's blue eyes and blond hair for the first time.

May, who had been blinded by a chemical explosion at age 3, had undergone an experimental procedure the day before in the hopes of restoring his vision. But after more than 40 sightless years, he had expected it would take weeks to find out whether he would be able to see the world again.

Political Debate Looms Over Obesity

Even fat is the stuff of politics in Washington. And with obesity a growing health problem, lawmakers, lawyers and activists are lining up the way they do for most issues: on two sides.

The left's view is that the food industry and advertisers are big bullies that practically force-feed people with gimmicks and high-calorie treats. They say Ronald McDonald is the cousin of Joe Camel.

The right's argument has been dubbed: You're fat, your fault. They say people can make their own choices about food and exercise.

``I don't think people want to go back,'' says Tomas Philipson, a University of Chicago economist. ``They'd rather be fatter and richer.''

The debate has spilled over into public policy, with proposals for a junk-food tax, limits on food advertising, demands for more details on labeling and lawsuits against food manufacturers. Several states are considering limits on sweets sold in schools; Some are debating whether to force chain restaurants to list nutrition information on menus.

Sen. Mitch McConnell, R-Ky., recently introduced a bill that would prevent people from suing restaurants and food manufacturers for making them fat. Similar legislation has been introduced in the House.

The stakes are high. Some 300,000 Americans die prematurely each year from being overweight. It's the leading lifestyle-related cause of disease and death in the United States after smoking.

Apparently, the obesity lawsuits captured political attention. As a libertarian, I believe that each individual must take responsibility for his/her own actions. Thus, I cannot support suing over obesity. The article seems balanced and presents both sides.

Back from my beach hiatus, I browse the NY Times quickly and find! Congress Weighs Drug Comparisons

Over fierce resistance from the drug industry, Congress is moving to authorize research that systematically compares the effectiveness and cost of top-selling prescription drugs.

Proponents say that if Medicare is to spend $400 billion on new drug benefits over the next 10 years, it should have objective, reliable information about which medicines are most effective.

"Often there are a number of competing drugs to treat the same condition," said Senator Hillary Rodham Clinton, Democrat of New York, a leader of bipartisan efforts on the issue. "But which is more effective? Oftentimes we just do not know."

The House voted last month to provide $12 million to the Public Health Service to conduct "research on the comparative effectiveness" of prescription drugs. The money was in an appropriations bill for the fiscal year that will begin on Oct. 1.

Drug companies say they fear that such studies will be used to restrict patients' access to medicines perceived as too expensive. But supporters of the research say it will improve the quality of care. Doctors, patients and insurers need help in making informed choices, said Representative Doug Bereuter, Republican of Nebraska.

Representative Nancy L. Johnson, Republican of Connecticut, said the proposal was "absolutely key to reducing the cost of drugs."

"There are many expensive products on the market that are no better than aspirin," said Mrs. Johnson, the chairwoman of the Ways and Means Subcommittee on Health. "We need to be able to demonstrate that and provide senior citizens and all Americans with that information so they can choose the most cost-effective, medically effective pharmaceutical for their particular needs."

Researchers said they might address questions like these: How does Lipitor stack up against Zocor for lowering cholesterol? How does Prilosec compare with Protonix for ulcers and heartburn? How do the long-term effects of Vioxx and Celebrex compare with those of older drugs for arthritis, like Motrin and Naprosyn?

Mrs. Clinton and Representatives Tom Allen, Democrat of Maine, and Jo Ann Emerson, Republican of Missouri, have proposed spending $75 million on comparative studies by the National Institutes of Health and the federal Agency for Healthcare Research and Quality. The studies would focus on drugs widely used by Medicare and Medicaid beneficiaries.

Mr. Allen said, "Our proposal would ensure that doctors and patients have credible, unbiased information, as an antidote to the claims made in so many pharmaceutical TV commercials."

As expected, the pharmaceutical companies oppose this plan. Their rationale is incomprehensible.

With studies comparing various drugs, federal officials could make "simplistic, one-size-fits-all decisions about which patients should have access to new medicines," the industry said.

The Pharmaceutical Research and Manufacturers of America also made these arguments:

¶The federal studies would almost surely influence private insurers. "As a result, the government's cost-based decisions about medical access would be imposed on many patients in both public and private health plans."

¶Cost-effectiveness studies show which drug works best, on average, for large numbers of patients, but the studies often overlook the value of specific medicines for individuals or subgroups, like racial minorities. "Different people need different medicines" because they respond differently.

¶Federal studies could stymie "incremental innovation." The government often does not appreciate the value of the incremental benefits of a new drug over existing treatments, but a series of modest gains can produce a major improvement ? a much safer, more effective medicine.

Sometimes an idea makes great sense. This idea fits that category.

The New England Journal of Medicine has several interesting articles today about the US and Canadian health systems. The NY Times is running this brief Reuters article: Health Costs Compared

A comparison of health care costs has found that 31 cents of every dollar spent on health care in the United States pays administrative costs, nearly double the rate in Canada.

Researchers who prepared the comparison said today that the United States wasted more money on health bureaucracy than it would cost to provide health care to the tens of millions of the uninsured. Americans spend $752 more per person per year than Canadians in administrative costs, investigators from Harvard and the Canadian Institute for Health Information found.

That is the entire NY Times piece. The editor did not do his/her homework and omitted important parts of the article. Bureaucracy dogs health care: study

But in an editorial in the journal, Henry Aaron of the Brookings Institution in Washington, said the administrative costs in the United States may be 24 percent lower than the Woolhandler estimate.

He said the excess spending on health care administration in 1999 was probably closer to $159 billion, not $209 billion cited in the study.

Aaron said it also doesn?t prove the United States would save a lot of money if it converted to the Canadian system.

While Aaron characterized the U.S. health care system as ?an administrative monstrosity,? he said the latest comparisons ?clearly exaggerate? the differences between the North American neighbors.

Better yet they and you should read the entire editorial which finishes:

More fundamentally, the administrative structure of any nation's health care system, and certainly those of Canada and the United States, evolves out of its political history and institutions. The U.S. health care administration, weird though it may be, exists for fundamental reasons, including a pervasive popular distrust of centralized authority, a federalist governmental structure, insistence on individual choice (even when, as it appears to me, choice sometimes yields no demonstrable benefit), the continuing and unabated power of large economic interests, and the virtual impossibility (during normal times in a democracy whose Constitution potentiates the power of dissenting minorities) of radically restructuring the nation's largest industry ? an industry as big as the entire economy of France. For these reasons, careful scrutiny of how the United States administers its health care system, with an eye to how it can be improved within the limits imposed by history, politics, and economics, is useful. But analytically flawed comparisons with other nations, whose systems differ greatly from our own and that we are most unlikely to emulate, may titillate policymakers and others but provide them with little useful guidance.

For those who get the NEJM, read the editorial here: The Costs of Health Care Administration in the United States and Canada ? Questionable Answers to a Questionable Question

Medicare to Pay for Major Lung Operation

Medicare said yesterday that it would cover the operation for two groups of patients: those who have severe emphysema in the upper lobes of their lungs, and those who have both severe disease elsewhere in the lungs and a poor ability to exercise. In addition, such patients would need certain other test results to make sure they were not at high risk of dying from the surgery itself.

Medicare will also require that patients be given an extensive exercise and education program to improve lung function both before and after the surgery.

The operation will be covered only at certain hospitals accredited by the Centers for Medicare and Medicaid Services; the hospitals have not yet been named.

Two million Americans have emphysema, but only a small fraction ? perhaps as few as 10,000, researchers say ? would qualify for the surgery. The disease, which destroys the air sacs in the lungs, makes it increasingly harder to breathe. It is nearly always caused by smoking. Emphysema is incurable and often fatal, and it causes or contributes to 100,000 deaths a year in the United States. Caring for people with the disease costs more than $2.5 billion a year.

The decision to begin covering the lung reduction surgery is based on the findings of a government-sponsored study published in May in The New England Journal of Medicine. That study, called NETT, for National Emphysema Treatment Trial, found that in about 25 percent of participants, the operation improved both quality of life and length of survival. In others, it did not prolong life but did improve exercise capacity or overall quality of life. In an additional 30 percent, the operation was either too risky or simply did not help.

Simple advice - avoid getting emphysema. Do not smoke!!!!

For those who are not jiggy with the lingo, PPI stands for proton pump inhibitor. This drug class includes Prilosec, Prevacid, Aciphex and Nexium (apologies to foreign readers - these are the US trade names). Since their introduction in the 80s they have made large amounts of money for their respective drug companies. That will probably change very soon. Heartburn Drug Battle Likely

Cracks appeared yesterday in a pillar of drug industry profits with twin announcements that users of a huge-selling heartburn drug will soon have alternatives that will be cheaper and easier to buy. As a result, the biggest fight ever seen between managed-care companies and drug makers could soon begin.

In the first announcement, Novartis said it would soon start selling omeprazole, the generic version of Prilosec, even though a court has yet to approve the sale. The aggressive move could open Novartis to huge damages if a judge eventually ruled that its generic version infringed patents owned by AstraZeneca, which sells Prilosec. But it also means that consumers will soon save a bundle on the medicine. Prilosec currently sells for $116 for a month's supply on Drugstore.com. A lone generic version introduced in December sells for $100; with more generic entries, analysts said the price could drop to $11.

Then Procter & Gamble said yesterday that it would begin selling an over-the-counter version of Prilosec on Sept. 15, priced about 70 cents a pill, or $22 or so for a month's supply.

The two announcements would not be so important if Americans collectively did not eat so much late-night pizza. But the obesity epidemic and the eating habits that have contributed to it have led to an explosion in heartburn in the United States.

Prilosec and its cousins Nexium, Prevacid, Protonix and Aciphex ? collectively known as proton-pump inhibitors, or P.P.I.'s ? are now the biggest-selling drugs in the world, with $13 billion in United States sales last year, according to NDC Health, a health information company. Prilosec's $4.6 billion in sales last year brought at least twice the profit generated by every McDonald's, Wendy's, KFC, Taco Bell and Pizza Hut combined.

But every P.P.I. works almost identically, and there is little evidence that one is any better than another. So when prices of both generic and over-the-counter versions of Prilosec plunge, managed-care companies will try to persuade patients taking other pills to switch. Some will probably stop paying for other brands altogether.

For all P.P.I's, the average monthly out-of-pocket payment for people with insurance is already more than $30 ? which exceeds the expected price of a month's supply of over-the-counter Prilosec. And that average payment will probably increase.

Drug makers, on the other hand, will use their considerable marketing muscle to persuade doctors and patients that they should remain loyal to brand-name prescription pills no matter the price. In similar previous battles, drug makers have generally come out on top.

Several key points here. First, the drugs are not very expensive to make - otherwise the OTC price would be much higher. Second, we will see a marketing battle over PPIs, not an efficacy battle. The NY Times article correctly states that the drugs all work the same. One does need to adjust the dose to achieve equivalence, but omeprazole (Prilosec) works very well.

I expect this rant will receive many testimonials both pro and con. To understand the passion this subject develops check out this December 2002 rant and examine the number of comments - Generic omeprazole . The NY Times predicts that physicians will go generic in this situation.

"A P.P.I. is a P.P.I.; they're interchangeable," he said. Dr. Seidman predicted that generic and over-the-counter versions of Prilosec would greatly reduce the money his patients spend on other P.P.I. brands.

Dr. Mark A. Fendrick, editor of The American Journal of Managed Care, said other companies would follow WellPoint's lead. "This is going to be a real test of how well managed-care companies can fight against the marketing power of the branded pharmaceutical industry," Dr. Fendrick said.

I like these announcements. OTC Prilosec and generic omeprazole (with competition) will save patients and insurance companies money. The pharmaceutical companies deserve an appropriate return on their investment. They have received excessive return thus far and hopefully these announcements will bring those returns back in line for this drug class.

Common wisdom has stated that many patients with coronary artery disease have no known risk factors. The advocates of that position then argue against aggressive cardiac prevention. I do not know from where this "wisdom" comes, but data in today's JAMA suggest that wisdom incorrect. Most Heart Disease Attributable to Common Risk Factors

Contrary to conventional wisdom, traditional cardiac risk factors are present in the majority of patients with coronary heart disease (CHD), according to the findings of two studies in the Journal of the American Medical Association for August 20th.

It is commonly believed that more than half of CHD patients lack any of the four major conventional risk factors--cigarette smoking, diabetes, hyperlipidemia and hypertension. This belief is "pretty wide-spread," co-investigator Dr. Alan R. Dyer told Reuters Health.

"What it's led to is a constant effort to find risk factors that explain CHD risk," he added. "We found that most people are exposed to major risk factors, suggesting that perhaps we should spend more time trying to control those rather than search for novel risk factors."

In one study, Dr. Eric J. Topol, of the Cleveland Clinic Foundation in Ohio, and colleagues analyzed data from 14 international randomized clinical trials of CHD. Included in the trials were more than 122,000 patients with ST-elevation myocardial infarction, unstable angina/non-ST-elevation myocardial infarction, and subjects who underwent percutaneous coronary interventions.

Between 85% and 90% of patients with premature CHD had at least one conventional risk factor. Only when age was above 75 years in women or 65 years in men did more than 20% of subjects lack any of the four major risk factors. When family history of CHD and obesity were factored in, only 8.5% of women and 10.7% of men had no risk factors.

Men 50 years or older and women 55 years or older "who have any of these risk factors are within the zone where the 10-year risk is clearly greater than 10%," Dr. Topol told Reuters Health. He recommends that when patients present with any of these risk factors, clinicians should consider a thorough evaluation, including exercise-stress testing and checking serum levels of C-reactive protein.

In another study, a team led by Dr. Philip Greenland, at the Feinberg School of Medicine in Chicago, examined three prospective cohort studies for which follow-up lasted 21 to 30 years.

For the nearly 21,000 patients with fatal CHD, exposure to at least one clinically elevated major risk factor ranged from 87% to 100%. When cut-offs were established for higher-than-favorable levels (cholesterol at least 200 mg/dL, blood pressure > 120/80), 96% to 100% of all age-sex groups with fatal CHD had prior exposure to a risk factor. These findings were consistent across cohorts and range of baseline ages under 60.

Even among subjects with treated hypertension or treated hyperlipidemia, prevalence of fatal CHD was elevated, Dr. Dyer, of the Feinberg Medical School and co-author of Dr. Greenland's study, told Reuters Health. "Even if blood pressure or cholesterol levels are reduced to typical cut-points, the reduction in risk is less than you might expect."

Dr. Topol agreed, adding, "Treatment of hypertension or hypercholesterolemia is only a palliative modulating force, it doesn't negate the intrinsic problem."

According to Drs. John G. Canto and Ami E. Iskandrian from the University of Alabama at Birmingham, these reports "may have enormous public health implications for targeting a large segment of the population at risk of developing CHD," especially since rates of exposure were probably underestimated. In an editorial, they recommend that aspirin, statins, and ACE-inhibitors be considered for all patients with atherosclerosis and diabetes.

JAMA 2003;290:891-904, 947-949.

These articles are very important. I agree with my UAB colleagues (disclaimer - I do research with Dr. Canto and we are co-authors on several papers - we also are working currently on a major grant which addresses risk factor reduction in post-MI patients).

We would like to diagnose adult onset diabetes before it becomes symptomatic. Experts have argued that we should screen patients at risk to find early diabetes. It can work! Diabetes Screening Guidelines Could Catch All New Cases of the Disease: Study

Consumers Take Charge: Defined-Contribution Health Plans

Complaints about America?s health-care system are legion and familiar to employees and employers alike. After twenty rocky years, more and more people ? employers, physicians, patients, politicians ? are showing their frustration with the managed care system. Medical costs and insurance premiums keep rising. The doctor-patient relationship seems to have become as impersonal as an ATM transaction. And no one seems to have solutions.

Well we have solutions - this ranter and my loyal commenters. We understand the problems - if they would only ask us.

Despite its slow pace, change in the healthcare and insurance services system has been building for several years. The paradigm shift is especially evident in a new kind of health plan, which seeks to address rising costs and service quality shortcomings by giving consumers better information to make decisions and giving them greater control over how they spend their health-care dollars.

The new plan has different names, known variously as defined-contribution, consumer-directed, self-directed, or consumer-driven but it?s a singular idea ? power to the consumer ? whose time has arrived. Indeed, 2003 may be the year that defined-contribution plans begin to make their mark as the most influential new form of health insurance coverage since managed care, according to health-care researchers at the University of Pennsylvania?s Wharton School and consultants at Booz Allen Hamilton. ?By the end of 2003, we believe consumer-directed plans will come to be seen as an inevitable paradigm shift in health care. Defined-contribution plans won?t be the final form of American health care, but they will be the next dominant form,? says Gary Ahlquist, a Booz Allen senior vice president, based in Chicago.

I hope this prediction comes true. With defined contribution plans, patients will have a greater connection to health care costs. As I have ranted in the past, and Robert Prather rants often meaningful changes in expectation will only occur when patients have a stake in the financing of their health care.

A typical consumer-driven plan works this way: An employer places a certain amount of money each year (a defined contribution of, say, $2000) into an employee account that can be used to pay medical expenses. So-called Health Reimbursement Accounts (HRAs) are often the foundation of defined-contribution plans. The contribution is funded directly by the employer on a pretax basis rather than through salary reductions; employees are reimbursed up to the limit when expenses are incurred. These plans also include an employer-funded catastrophic insurance policy with a high annual deductible, perhaps $3,500 for a family and $1,500 for individuals.

If the employee uses all of the $2,000 for medical expenses, he or she would then be responsible for the additional $1,500 in expenses to meet a $3,500 deductible. Afterwards, the catastrophic insurance takes effect. The percentage of expenses the insurance covers is often 80%, with employees paying 20%. But that could vary, depending on whether or not the employee?s physician for that problem participates in a managed-care network. Any of the $2,000 that remains in the account at the end of the year can be carried over to the following year and added to the new employer contribution of $2,000.

Issues, such as the amount of the company?s annual contribution, the deductible, the catastrophic insurance premium, and whether accumulated savings can be rolled over to another company if an employee leaves, vary from employer to employer. Employers also differ on the maximum amount they will allow an employee to accumulate in a medical account. Most companies place limits on the total amount of money that is allowed to accumulate in an employee?s account as funds are rolled over from year to year.

This long article goes on to discuss the pros and cons of such plans. It also addresses the problems of managed care and many other issues. I highly recommend reading the entire piece.

I rant on this subject frequently. Let me give the short version. Health care costs as a percentage of GNP keep rising. We can look at this in several ways. We could assume that costs are artificially inflated each year - so that the medical establishment can make more money. We could understand that the overhead of doing business is increasing - due to malpractice costs, the costs of federal regulations and the cost of labor. We could understand that some costs come from new technologies. All three possibilities probably have an effect, however, today we will read about possibility 3. New Therapies Pose Quandary for Medicare

But health economists and medical experts say the treatment, however alluring, is part of an unsettling trend: new and ever pricier treatments for common medical conditions that are part and parcel of aging ? procedures that could potentially benefit tens of thousands of patients, at a total cost that would far exceed the kind of prescription drug benefit now being considered by Congress.

The questions, these experts say, are how much Medicare can or should pay, and whether cost-effectiveness should enter into the decisions.

This describes the quandry in a nutshell. Can we look solely at effectiveness or should we consider costs? We obviously must consider costs, we would only disagree on how much we would willingly pay.

Dr. Tunis, of the Medicare services center, says he understood that the costs of new technologies can be staggering. But he adds that cost has traditionally not been a consideration in deciding what to cover.

"If the technology was effective, we would find a way to pay for it," he said. "There is no dollar value per life per year at which Medicare would decline to pay."

But costs are mounting.

As a general internist I am personally insulted. Medicare clearly does not value my services. They do limit our fees, yet they claim that cost is no object. Physicians are dropping Medicare patients, yet they (CMS) does not react - and yet they seemingly willingly pay for expensive new therapies.

Medical Establishment Hopes to Thwart Residents' Lawsuit

The nation's medical establishment has grown increasingly anxious about an antitrust suit contending that residents are forced to participate in a system that ensures they work long hours and receive low pay.

Medical schools and teaching hospitals, the principal defendants, are so worried that in recent weeks they have asked their allies in the Senate to enact legislation that would derail the suit, inoculating them from damages that might otherwise run into the hundreds of millions of dollars.

The defendants maintain that the suit, filed by several young doctors, has no merit, and express confidence that they would prevail in court. But they are clearly troubled by the possibility the suit could upend the decades-old system of medical residents' selection and deployment around the country.

The defendants have also hired lobbyists with previous connections to two senators who have been most directly involved in the effort to introduce such legislation: Hillary Rodham Clinton of New York and Edward M. Kennedy of Massachusetts, both Democrats.

At issue is the National Resident Matching Program, known in medical circles as the Match. Every March, a computer determines where new graduates of medical schools will spend the next several years as residents, gaining experience and honing their skills.

More than 80 percent of first-year residency positions are offered exclusively through the program, which is based on rankings submitted both by hospitals, which list the graduates they want, and the 15,000 or so graduates, who list the hospitals they prefer. Both sides agree in advance to accept the pairing.

The suit contends that the Match keeps salaries artificially low ? the annual pay for residents is about $40,000 and varies only marginally regardless of region or speciality ? and crushes any competition that might force teaching hospitals to offer better conditions like shorter working hours. The industry's defense of that system has long been that a residency is not a job per se but instead a continuation of medical education in which the resident ought to be entirely immersed.

And residency is training. This suit really does not make sense. Without residency training, one cannot practice. One can restate residency as post-graduate training. The residency system prepares physicians for their future practice. While some programs might pay more for residents, I doubt that salaries would change dramatically.

Sherman Marek, a Chicago lawyer representing the plaintiffs, said he conceived of the suit when he was representing some young doctors in an unrelated matter and learned of their long hours and low pay.

"It's no secret to residents that they were being mistreated," Mr. Marek said. "Sometimes it takes a lawyer to educate people about a legal right."

Surprise, surprise, this challenge springs from a lawyer. He uses interesting language about educating people about a legal right. What he really wants to do is receive a large judgement (and the fees associated with that judgement).

The match does work. Because of the match, we (the programs) get those students who want to train at our programs. Without the match, we would return to hard sells, arm twisting, and deceit. We would have to make deals to get students; they would have to decide on their residency slot prior to visiting a wide variety of programs.

This suit would hurt future students more than programs. I doubt that it would change work hours or pay at good programs. But it would disminish the process of finding the best residency.

As Yogi Berra reportedly said, it's deja vu all over again. Medicare Fees for Physicians in Line for Cuts

Physicians want to keep treating Medicare patients, but there comes a point where it is just not economically reasonable," Dr. Donald J. Palmisano, president of the American Medical Association, said.

Maureen K. Maxwell, a spokeswoman for the American Academy of Family Physicians, said that more than one-fifth of family doctors were not accepting new Medicare patients.

Marilyn Moon, a health economist, said: "This needs a lot of vigilance. As yet, it's not a crisis. But it could quickly turn into one."

Doctors repeatedly express concern that Medicare payments are not keeping up with their costs.

Medicare has different formulas to pay doctors, hospitals, nursing homes and other providers of care. The program reduces payments to doctors whenever Medicare spending for their services exceeds a goal, the "sustainable growth rate," linked to the nation's economic growth.

Medicare officials said the proposed cut for 2004 resulted from the fact that estimates of economic growth had declined below earlier projections, while the use of health care services by Medicare beneficiaries had grown more than expected.

The cut can be attributed to "slow growth in the economy and to a significant growth in physician outlays," the Department of Health and Human Services stated.

An independent federal panel, the Medicare Payment Advisory Commission, said last year that Congress should repeal the existing formula and replace it with a system that more accurately reflects doctors' costs.

I really have nothing new to say about this issue. I disagree with the economist. This does represent a crisis. The crisis expands as each physician stops taking new Medicare patients.

Patients want the best possible health care, but they do not pay. Patients expect health care and generally have insurance to pay. Health insurance dissociates the costs of care from the receiver of care.

The best medical care costs money, and that cost is increasing. Politicians try to convince us that the costs of medical care are out of control. Everyone wants the best possible care; they want the latest technology; they want the newest medication; and they expect costs to hold steady or decrease. The economics do not make sense.

And the economics of decreasing physician payments while passing laws which increase practice costs make even less sense. Most physicians have enough patients without accepting new Medicare patients. So the losers here are the patients.

This is interesting. In my previous post (see below) I slammed the herbal and supplement industry. Now I am ready to lean towards supporting a supplement - creatine. Creatine 'boosts brain power'

Creatine is a natural compound found in muscle tissue, and has been popular with athletes looking for ways to increase fitness.

However, experts say that it has a role in maintaining energy levels to the brain, and have the theory that taking more creatine might actually improve mental performance.

Researchers from the University of Sydney and Macquarie University, both in Australia, tested this by giving creatine supplements to 45 young adult volunteers.

Vegetarians were used for the tests, mainly because meat in the diet is in itself a source of creatine, and it would be difficult to gauge exactly how much an individual had consumed.

The volunteers were split up and given either creatine or a "dummy" pill for periods of six weeks.

Their ability to repeat back from memory long sequences of numbers was tested, and a general IQ test also given to the volunteers.

The researchers, led by Dr Caroline Rae, found that the creatine supplements - at least in the short term - seemed to have a positive effect.

She said: "Both of these tests require fast brain power and the IQ test was conducted under time pressure.

"The results were clear with both our experimental groups and in both test scenarios.

"Creatine supplementation gave a significant measurable boost to brain power."

Creatine, unlike most supplements, has undergone very careful study. Scientists have used this supplement in randomized controlled trials. We have long follow-up studies looking for side effects. It helps many athletes gain muscle strength.

While I am not ready to declare creatine a great advance, these data have captured my interest. I will try to follow this story carefully. We need more studies, but these findings do show promise.

I have to give the herbal and supplement industry kudos. They market well, and they develop plausible story lines. Unfortunately, when science checks them out, they usually get a failing grade. So it is for another herbal - Guggulipid Ineffective for Lowering Cholesterol

Guggulipid was of no benefit for lowering cholesterol, according to the results of a randomized, double-blind, placebo-controlled trial published in the August 13 issue of The Journal of the American Medical Association. This herbal extract from the resin of the mukul myrrh tree, used for treating high cholesterol, did not improve cholesterol levels over the short term, and it may in fact have raised levels of low-density lipoprotein cholesterol (LDL-C).

"These results do not support the use of dietary supplements containing guggulipid for reduction of LDL-C levels by the general population," write Philippe O. Szapary, MD, from the University of Pennsylvania School of Medicine in Philadelphia, and colleagues. "While guggulipid was generally well tolerated, six participants treated with guggulipid developed a hypersensitivity rash compared with none in the placebo group."

Another failure for herbal (or 'natural') treatment.

I am not surprised by this finding. In fact, I expect herbals to fail. If they showed promise, the pharmaceutical industry would jump on the possibility, modify the compounds and have winners.

Given the scientific basis for modern medical advances, we should all avoid the charlatans. Save your money. Avoid these unproven treatments.

This result is better than nothing, but not really great. Fla. Lawmakers Approve Medical Malpractice Capsl

The measure limits an individual doctor's liability for non-economic damages in most medical malpractice cases to $500,000. A medical facility's liability would be limited to $750,000 in most cases.

Multiple victims -- such as a victim, a spouse and their children -- could file multiple lawsuits against the doctor and the facility, but no group of victims could receive more than $2.5 million.

Economic damages, such as for lost wages or medical care, would not be capped.

"I know this legislation will serve its intended purpose and bring relief to physicians, keep insurance companies writing policies in our state and protect victims of medical malpractice," Senate President James E. King said.

But people on both sides of the debate have criticized the measure.

Doctors whom the bill was intended to help have said they do not support it, and insurance companies say it likely will not lower rates.

Sandra Mortham, chief executive of the Florida Medical Association, said doctors wanted a $250,000 hard cap with no variations.

Malpractice victims say limits on damage payouts make it less likely lawyers will take cases, meaning access to justice could be denied.

This looks like a typical compromise - no one is happy. These caps do not really solve the malpractice crisis. They are a bandaid. Hopefully, in the near future we will see politicians attacking the real problems (see my recent posts on malpractice).

Going on a wonderful, short vacation - a wedding of the son of great friends. Should have much fun. I will try to do a smidgen of blogging now and each day - but you never know!!

First, I am not Al Franken, but like him, my columns are not really funny. I hope FoxNews does not have to sue me (although apparently it would increase readership).

Last week, I ranted about Canadian IV safe injection sites - Canada providing safe sites of IV drug users . A Washington Post stimulated that rant. It also stimulated this opposing viewpoint in the Washington Times - 'Safe drugs'

I must say it seems doubly reprehensible for medical professionals to allow and encourage people to continue suffering. "It's the most ethical work I've ever done as a nurse and a human being," says Ms. Zettel. "We as a society have reinforced their [addicts´] marginalization. They have a poor sense of self-esteem and value. We have reinforced that. That to me is criminal."

So much for nonjudgmentalism. Meanwhile, how it is that injection sites ? which would seem to promise only to keep addicts addicted ? can possibly undo anyone's "marginalization" is a mystery. As for self-esteem ? self-respect would be a healthier aim ? it's hard to see how shooting up, however safely, can ever help.

This finishes the op-ed piece. I present the link here as a balance to my ranting. Of course, since this is my blog, I will counter.

I find this issue troubling but solvable. While I am not in favor of addiction (of any kind) and especially of IV drug use, I do recognize that it occurs. My disapproval, either implicit or explicit, has (in my opinion) almost no effect on the users. The personality traits and social situations that addicts spring from do not generally produce a willingness to listen to the establishment, even the medical establishment.

The road to recovery (ending addiction) is always there, however, only the addict can take the first step on that road. I can point out the road; I can give directions to the road; but I cannot take a step for the addict.

While using IV drugs, the addict puts him/herself at great risk of communicable diseases, e.g., HIV, hepatitis B and C, bacterial infections (most seriously endocarditis). Until the user takes that first step, we as a society have two choices: we can show disdain for the addict and leave them to their own devices (showing no regard for their associated health issues) or we can treat them like any other patient, providing them with the best preventive care possible.

I see these Canadian safe injection sites as preventive medicine. Many addicts do find the path away from addiction. We hope that they are free of disease at that time. Infected addicts infect others, even innocents. If we decrease the infection rate from IV drugs, are we not contributing to the public health.

The image of an addict "shooting up" is deplorable. The images of AIDS, cirrhosis, hepatocellular carcinoma, bacterial endocarditis are more deplorable. Especially when they are potentially preventable.

As I ranted previously, you feeling about this debate depends on how you view IV drug use. If you find it a disease, you may see the safe injection sites as a way to minimize complications. If you view this as simply a moral issue, then you can ignore the complications of IV drug use. One could argue (at least in ones mind) that the users who get AIDS (or hepatitis C or endocarditis) 'deserve' the infection because of their immorality. But how can one argue spreading an epidemic which does infect the innocent is moral?

I believe this argument is really a risk benefit analysis. We should refrain from moral judgements, but first and foremost try to stem these epidemics.

Perhaps when we gain the addict's trust, we might hasten the day when they take the first step on the path to recovery. And even if we do not, when they take that step, they have a better chance for a healthy life in the future.

I have almost a full year of caution documented in the smallpox debate. I worried from the first about the risks of the vaccine. My early rants on the subject: Not excited by widespread smallpox vaccination , More on smallpox , Some teaching hospitals say no to smallpox vaccine . Today the Institute of Medicine provides this caution: Panel Urges Caution on Smallpox Vaccine

Despite worry about the possibility of a terrorist attack using smallpox, a panel of scientists is recommending that members of the general public not get vaccinated against the disease unless they are part of a carefully monitored research study.

The Institute of Medicine committee cited potential risks from the vaccine, for those receiving it as well as people with whom they have close contact. The committee was sending its recommendation to the Centers for Disease Control and Prevention on Tuesday.

Currently the Bush administration is requiring smallpox vaccination for about 500,000 military personnel and is conducting a voluntary program seeking to immunize several million medical and emergency personnel who would be in immediate danger in a biological attack. The civilian program has been lagging, however, with just 38,004 people vaccinated as of July 25. Many healthcare workers have resisted getting the shots out of concern over side effects.

As part of the preparation for a bioterror attack, the committee said, CDC should help create registries of health care workers and others who have been vaccinated, including former members of the military and reservists. Those people could help organize a prompt response to bioterror attack, said the panel.

Annual Physical Checkup May Be an Empty Ritual

Yet in a series of reports that began in 1989 and is still continuing, an expert committee sponsored by the federal Agency for Healthcare Research and Quality, an arm of the Department of Health and Human Services, found little support for many of the tests commonly included in a typical physical exam for symptomless people.

It found no evidence, for example, that routine pelvic, rectal and testicular exams made any difference in overall survival rates for those with no symptoms of illness.

It warned that such tests can lead to false alarms, necessitating a round of expensive and sometimes risky follow-up tests. And even many tests that are useful, like cholesterol and blood pressure checks, need not be done every year, it said in reports to doctors, policy makers and the public.

But if the annual physical is largely obsolete, hardly anyone has gotten the message. While the federal Medicare program does not pay for routine checkups ? by law, it is limited to treating illness ? many insurance companies do, saying their customers continue to demand them. Many doctors say they perform them out of habit or out of a conviction that patients expect them and that they help establish trust.

Even doctors who know all about the evidence-based guidelines for preventive medicine say they often compromise in the interest of keeping patients happy. Dr. John K. Min, an internist in Burlington, N.C., tells the story of a 72-year-old patient who came to him for her annual physical, knowing exactly what tests she wanted.

She wanted a Pap test, but it would have been useless, Dr. Min said, because she had had a hysterectomy. She wanted a chest X-ray, an electrocardiogram. Not necessary, he told her, because it was unlikely that they would reveal a problem that needed treating before symptoms emerged. She left with just a few tests, including blood pressure and cholesterol.

For many years, I have found routine physicals unrewarding. As I read the data, I find little evidence that examining a seemingly healthy patient makes a difference. Of course, everything changes once the patient has symptoms.

There are things we should do for prevention, but they rarely include routine examination.

Many doctors do a careful physical exam on a patient's first visit, to serve as a baseline, but on subsequent visits, groups like the Agency for Healthcare Research and Quality say, patients would be better off if doctors spent their time counseling them on such things as stopping smoking, eating a healthy diet and drinking moderately, using seat belts and having working smoke alarms in their houses.

"When we're spending time doing things that don't potentially benefit people and skipping things that may be of benefit, that's a sign not only of waste but of misplaced priorities," said Dr. Russell Harris, an associate professor of medicine at the University of North Carolina and co-director of the prevention program there.

In an effort to get the message out, the federal health care research agency recently printed pamphlets for men and women, telling them what tests they need, and when.

But doctors say they have yet to see a patient come in waving the guidelines and asking for fewer tests. And many doctors say that although they are well aware of what evidence-based medicine recommends, they often do much more, out of habit and tradition and out of a fear that if they pulled back they would get the sort of reaction Dr. Min did.

This subject is not easy to discuss with patients or even most physicians. The data are clear, the emotions are not.

A reader writes:

I just wanted to write and say thanks for your great blog. I'm considering a career in medicine, but I seriously wonder if it is worth the effort. Your info and rants on the medical business these days is very helpful to me.

What would you do if you were in my shoes, if you were twenty-two years old, with the whole world basically wide open to you? Knowing what you know now, would you think it's worth it to sacrifice so much to be a physician?

Yes! Yes! Yes!

I do rant often about business issues in medicine ranging from the malpractice crisis to the imbalance between fees (holding steady) and overhead (increasing). I find the business of medicine disturbing in 2003.

Yet, I love being a physician. Each day when I look in the mirror, I know that my goal is to help patients, either directly or by teaching students and residents - hopefully making them better physicians. While I have a very reasonable income, I rarely think about the money in relation to the job.

Most physicians could make more money if they choose a different field. Few physicians really consider that possibility. Being a physician defines ones persona. I cannot imagine being anything else!

Medicine satisfies my quest for knowledge. Each week we learn more which we strive to use to help patients.

Patients are often like mysteries. They come to us with problems which we have to decipher. We collect clues - history, physical and appropriate diagnostic testing. Using those clues we strive to develop a management strategy which takes into consideration the patient's desires and our best knowledge of the evidence.

But the doctor patient interaction adds a very important texture to our collective persona. When I introduce myself to a patient (as Dr. Centor), I almost always sense the patient trusting me and wanting to work with me towards the common goal of helping the patient. The doctor side of the doctor patient relationship provides me (and most physicians with whom I have discussed this feeling) a very special validation. We are fortunate that generally patients assume that we care and want to help.

Being a physician is wonderful. We have business concerns today which I believe will lessen over time. The challenge of patient care and the non-monetary rewards will continue to make medicine a wonderful field.

Finally, as I look back at my medical training I cannot really call it a sacrifice. I was generally happy during my training (well at times the 1st two years of medical school made me miserable). Even working every 3rd night as an intern, I found time for socializing, playing basketball and enjoying life.

So I recommend to everyone who asks to pursue medicine, unless their goal is to make money. One should not choose medicine for money, rather for the joy you can bring to yourself and patients.

As an internist focusing primarily on VA hospital patients, I find this issue somewhat peripheral, yet very interesting. This past weekend I was debating this issue with several interested parties. This article provides more information and provides fodder for both sides of the debate - Safety of longer intervals between Pap tests debated

This story will not go away. Las Vegas physician appeals award in lawsuit over waiting time

Pain management specialist Ty Weller, MD, has added a new sign to his waiting room and a couple of new sentences to his patient forms: We try to see everyone in a timely manner. But if we're taking too long, please let us reschedule you.

The new verbiage comes after a patient, upset over waiting three hours, sued him in small claims court and won.

Dr. Weller said he was trying to do Aristotelis Belavilas a favor by getting him into the office for a pain injection that day. The Las Vegas doctor's schedule already was full, but since Belavilas planned to leave for vacation in Greece the next day, Dr. Weller said he would try to fit him in.

Dr. Weller's day, however, got off to a bumpy start. His morning surgery went far longer than expected, and he just couldn't get caught up.

It was about three hours after Belavilas' scheduled appointment by the time Dr. Weller got to him.

"I felt terrible, but like any physician, I could only work as fast as I was comfortable. I had my staff updating him," said Dr. Weller, noting that he had to drive 25 minutes to get across town to the surgery center where Belavilas was waiting. Dr. Weller said he doesn't usually work out of that center, but Belavilas' insurance company would only pay if the procedure was done there.

Belavilas was upset at the wait time and that the doctor couldn't be reached when he asked for pain medication while waiting.

Always remember the old adage, attributed to Claire Booth Luce - 'No good deed goes unpunished'.

Doctors ask hospitals to help pay soaring insurance costs

Experts say hospitals are increasingly stepping in to help independent physicians pay soaring liability insurance premiums. Concerned there won't be enough local physicians offering some medical services, hospitals are writing checks, creating special trust funds and changing business relationships to subsidize insurance costs. And though the arrangements can raise legal issues, experts say more and more hospitals are taking action to keep physicians in their communities.

For Baptist Memorial Health Care Corp., a Memphis-based hospital system, helping Dr. Creekmore's group was a no-brainer. "If we did not get them help, there was going to be a major part of the community that didn't get medical care," said Jim Ainsworth, a vice president for the company.

The hospital system considered several options before developing a program to subsidize insurance premiums for about 30 physicians in Mississippi, one of 19 states the AMA defines as being in a liability crisis.

Legal counsel helped tailor the program so that it fit within guidelines set by the Office of the Inspector General and didn't run afoul of Stark or anti-kickback laws as they apply to relationships between hospitals and physicians. Once they had the program blueprint, hospital system officials set out to find the roughly $650,000 needed to pay for it this year. The program likely will only last a couple of years.

I hate this story. I hate that the malpractice business establishment threatens health care delivery. This article discusses band-aids on a system that needs extensive surgery.

"The pros are that they are able to hopefully retain or recruit physicians for their hospital and continue to offer the services that are necessary for the community. The flip side is that they have to pay for it and it's expensive and it doesn't really provide a solution for the big picture," Rooney said.

Donald J. Palmisano, MD, president of the American Medical Association, said communities must work together to help physicians continue to serve their patients, and help from hospitals with insurance costs is one way to assist.

"They're trying to figure out a way. But we must understand these are temporary measures. We must fix the root cause of this problem -- the broken medical liability system," said Dr. Palmisano.

Many non-physicians believe all physicians rich. I received comments implying this 'fact'. These comments most often come during malpractice debates or any general ranting about overhead costs. All physicians are not rich. Devalued Doctors

My husband and I are both physicians. I am in private practice in internal medicine and he is an ophthalmologist. Our training consisted of four years of college, four years of medical school and four years of residency. Each. Our collective student loan debt is more than a quarter of a million dollars. Each month I pay Nelnet $1,003, Sallie Mae $300 and SunTrust $881, just as an example. Nelnet is a graduated payment. This is the lowest it will be as I pay it off over the next 15 years. When I am 47, I hope to be out of debt and to begin saving for retirement. It is not clear yet when we will be able to afford to have children.

Our mortgage is less than half as much as the loan payments: We save hugely by not living in the city. Some of my husband's loans are fortunately still in deferment, but they are collecting interest all the same. He has another year of residency before joining a practice. His colleagues inform him that the average starting salary for an ophthalmologist, a highly specialized surgeon trained to perform Lasik and extract cataracts, is less than $90,000 in the D.C. area. We have done the math at our dining room table many a Sunday night. His paycheck will not come close to covering his loan payments once his grace period ends.

Something is wrong with our nation's outlook on health care these days. I have come to name this phenomenon the "Devaluation of the Doctor." As I hear grumbling about Congress's making more Medicare cuts and my patients' complaints about $10 co-payments while they dig $300 cell phones out of their Gucci bags, I am getting just the slightest bit bitter. Somewhere along the way, as we sat back and let insurance companies turn caring for the sick into an industry, we lost sight of the importance of medical care and those individuals who sacrifice their entire twenties to learn how to save lives and keep us healthy. HMOs have bred a population more interested in paying for a cellular phone plan than a physical. It saddens me to meet a new patient who is "transferring his care" to me (after sticking loyally to the same doctor for 40 years) just because "Doc So-and-So stopped taking Mamsi."

It's a rainy day, and the neighborhood kids aren't playing basketball as usual. If they were, I'd be tempted to open the front door and holler to them, "You go, boys! Forget about algebra and focus on your three-pointer." After all, what have my hard-earned straight A's and Honor Society tassels gotten me but a fear of foreclosure?

My ranting leads to many readers finding this blog through googling! I received a very nice email from - Louise B. Andrew MD JD FACEP, President, CCEMT.org. Of course I had to check out their web site - Coalition and Center for Ethical Medical Testimony . This organization is fighting against hired guns (slang for physicians who often and consistently testify for money). This organization finds such behavior a major contributor to the malpractice crisis.

The New York Times is the first large media outlet to reveal to the general public the existence of the unethical medical expert witness. Heretofore, the problem of dishonest medical expert testimony has an embarrassing little secret of our profession. Dazzled by hourly fees which far exceed what the average clinician can earn, perhaps unaware of the prevailing standard of care in smaller communities and institutions, and sometimes swayed by incomplete or inaccurate information provided by the hiring attorneys, some physicians are regularly perjuring themselves on both sides of the bar. They are doing this because they are solicited by the attorney advocating for one party to serve as an expert, and are almost wholly dependent upon the materials that attorney provides to make an assessment of the case. They are also doing it, because being an expert witness is far more lucrative and far less stressful than practicing medicine for many physicians today; and because there has previously been no reason for them to believe that their testimony will ever be seen or even heard about by their colleagues, except possibly the experts representing the other side, and peer review has not extended into the courtroom until very recently, as the Times article reveals.

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Two physicians who are particularly passionate about the unethical medical expert witness, Drs. Bernard Ackerman and Dr. Louise Andrew, have begun a nonprofit membership association, the Coalition and Center for Ethical Medical Testimony CCEMT.org, to educate and empower physicians and attorneys on effective ways to deal with dishonest or unethical experts. This grass roots organization encourages and empowers members to use their associations, state medical boards, and any other available avenues for peer review, to inject real time accountability into the business of being an expert witness. Living by its motto, "Nothing but the Truth", CCEMT.org is equally concerned about unethical testimony by witnesses for plaintiffs OR defendants in medical malpractice cases. CCEMT.org was introduced at the AMA meeting in June, and its membership is growing daily. CCEMT.org is providing a way for physicians to turn their anger at unethical experts into useful concerted action designed to "Make Hired Guns History".

So I provide this link as a public service. I have not yet joined the organization, but I do admire their goals and ethical stance.

Walter Olson provided this link. Uncapped Medical Malpractice Awards Adversely Affect Doctor Availability, Health Care Cost and Health Insurance Premiums Here is the description of the organization responsible for the report:

The Employment Policy Foundation (EPF) is a nonprofit, nonpartisan public policy research and educational foundation based in Washington, D.C. focused on workplace trends and policies. Its mission: to shape the direction and development of U.S. employment policies by providing policymakers, the media and the public with timely, high quality economic analysis and commentary. Federal and state executive branch officials and legislators, corporations, think tanks, universities, media and the public use EPF as a primary source of unbiased, reliable data, research and knowledge on employment and labor issues.

I feel certain that the trial lawyers and Democrats will challenge the objectivity of this organization. In contrast, I am happy to accept their analysis.

Rising Verdicts and Increasing Cost of Discovery Forces Rate Increases

Doctors, nurses and hospitals have been faced with skyrocketing malpractice insurance premiums in response to increasing claims. The rising litigation costs are reflected in malpractice insurance underwriting losses, which doubled from $4.1 billion in 1991 to $8.6 billion in 2001. This total includes amounts paid to plaintiffs and their attorneys, expenditures for processing and investigating claims, including the majority that are subsequently dropped or dismissed and expenditures to defend litigated claims. The study found that as the number of claims increased, so too have jury awards. Between 1995 and 2001, median jury awards in medical malpractice cases doubled from $500,000 to $1,000,000 for the typical case with the maximum annual claim award reported nationwide increasing from $5.3 to $20.7 million over the same period.

Malpractice insurers paid out $1.53 in claims settlements and claims adjustment and defense expenses for every dollar that they collected in premiums. In 2001, the gap between premiums collected and underwriting losses amounted to $4,033 per physician, assuming that all 744,000 full-time physicians in the U.S. were covered.

Most Litigation Costs Do Not Benefit Injured Patients

EPF's analysis found that the malpractice litigation system is a highly inefficient method for identifying and correcting medical errors. Plaintiffs eventually receive only 38 percent of the total dollars that flow through the malpractice litigation system. The majority - 62 percent - compensates the plaintiff?s lawyers and expert witnesses and the insurer?s claims adjustment, cost of investigating claims and defending claims made against insured physicians and hospitals.

These data speak loudly. While trial lawyers work hard to obfuscate this issue (remember that they are trained to obfuscate) by blaming the insurance industry, these data suggest otherwise.

Caps on Non-Economic Damage Awards Are Effective

The study found that significant cost differences do exist between states with non-economic damage award caps and those states without limits. Between 1976 and 2000, malpractice insurance premiums nationwide increased 505 percent - equivalent to 7.8 percent annual premium growth compounded over 24 years. In California - which caps non-economic damage awards - malpractice premiums increased 167 percent?equivalent to a 4.2 percent annual growth rate. The resulting impact on premiums is very real. In 2001, the premium range for obstetricians was $143,000 to $203,000 per physician in Florida compared to $23,000 to $72,000 in California. The pattern was similar for surgeons - $63,000 to $159,000 in Florida compared to $14,000 to $42,000 in California.

Indirect Costs Result from ?Defensive? Medicine

Faced with the prospect of litigation, the study found many doctors and hospitals practiced "defensive" medicine. This practice artificially inflates health care expenditures with additional, medically unnecessary tests and diagnostic procedures. EPF's analysis found that controlling excesses in the malpractice litigation system could reduce current health care costs by 5 to 9 percent without sacraficing quality of care. The dollar impact on annual medical expenditures is large - up to $68.8 billion.

This report documents many arguments that I and other bloggers have made over the past year. We have a very serious malpractice crisis. Politics should not prevent rational solutions. But politics do prevent rational solutions!

The study concluded that the medical malpractice litigation system is a costly and ineffective approach that ultimately fails to protect patients. Its primary impact is to increase costs that employers and employees pay for health insurance, to reduce the number of employees and their families covered by affordable employer sponsored health plans and to reduce access to health care in communities impacted by physician flight from liability risks.

Biting The Hand That Fed Me

I, of course, consider myself immune to these blatant attempts at persuasion. Am I? I think so. I read serious medical journals and unbiased reviews of medications. I always try to prescribe based on hard evidence. I use effective generics. I want the best for my patients.

I also know that someday I'll have a patient with irritable-bowel syndrome tell me she's tried everything. I'll ask her if she's tried the drug-that-paid-for-my-dinner. If she says no, I'll consider saying something like, "There's this new drug. It's pretty expensive, and I know that your insurance doesn't cover it, but it might be worth a try."

Ka-ching!

So it's probably time for Doctor E to take the pledge once more. To swear that he won't take any more of these gifts. To promise to get his information about drugs only from objective, unbiased sources. "I'm sorry," I'll say to the next drug rep, "but I can't accept your invitation. I'm doing my part to keep drug costs down."

That's what I'll say -- but do you realize how much ahi carpaccio costs when you have to pay for it out of your own pocket?

Read the entire self confessional. Dr. E lays out the physician pharmaceutical industry relationship concisely. What about db? db will eat the lunch at noon conference. He will occasionally pick up a pen or a pad of paper. db has a $10 rule.

I have at least one drug rep who avoids me entirely. He represents Nexium. I explained to him why I thought his company was acting unethically. I refuse to sign for Nexium free samples in our resident's clinic. He does not bother me anymore.

A reader writes:

I have had extreme chest painw for years, was diagnosed with Gerd. In the past I took prilosec but it didn't help. Maybe I should have been given 20mg. instead of 10. When Astra switched to Nexium I started taking it because it was several dollars less than the Priloc. I've been very lucky as it seems to have kept my chest pain under control. Hoewever I am always hoarse. I wonder if anyone else experiences hoarsness from taking their meds? I was told that it was a common occurence with patients who have GERDS. Like to hear from someone with similar circumstances.

This reader raises some interesting questions. I will address dosing of PPIs and symptoms of reflux esophagitis.

Proton pump inhibitors work by preventing the production of stomach acid. As I read the studies, there should be any major differences among the various PPIs. What does matter is the dose of the particular PPI. When one compares PPIs, one should compare equivalent dosing. As the writer surmises, she probably was taking an inadequate dose of Prilosec (omeprazole). Interestingly, the OTC version reportedly will have a dose of 20mg omeprazole.

The second half of the question relates to the symptoms of reflux esophagitis. The classic symptom is heartburn. For unknown reasons, not everyone with significant reflux gets chest pain. Hoarseness is a fairly common associated symptom. This makes sense when one understands that the problem is acid 'splashing' up into the esophagus. Sometimes the acid goes all the way up the esophagus and reaches the upper airways. Patients can get hoarseness, cough and even asthma symptoms.

I hope this answers the question and helps to clarify reflux esophagitis for some readers.

IS THERE ANY ACE-INHIBITOR WHICH WILL NOT CAUSE A COUGH AS A SIDE-EFFECT. HAVE USED ACCUPRIL AND LOTENSION, BOTH WITH THIS SIDE-EFFECT TO THE EXTENT COULD NOT TAKE THE MEDICINE.

I received this comment today. ACE inhibitor induced cough is a 'class' effect. If one ACE inhibitor causes a cough, likely all will. If one cannot tolerate the cough, often one can take an angiotension receptor blocker as an alternate drug, as ARBs do not cause cough. The ARBs are Losartan (Cozaar), Irbesartan (Avapro), Candesartan (Atacand), Eprosartan (Teveten), Telmisartan (Micardis), and Valsartan (Diovan). Posted by at 03:34 PM | Comments (0) | TrackBack (0)

Over the past 2 days I have monitored a heated exchange in my comments section. The rant in question is - More on the Nevada tort crisis . The exchange started when a reader left this comment:

To reduce risk, doctors perform redundant and unnecessary diagnostic tests and offer only middle-of-the-road medical advice and procedures, even when they know that other treatments would be more beneficial. Not only does this escalate expenses and pad the doctor's wallet, but it also wastes a tremendous amount of time in hopes that the cattle will die and the risk dissipates. Doctors are not performing procedures and tests to resolve medical issues, but instead dance around issues to cover or avert errors and reduce risk. Accordingly, as long as the doctors "do something," regardless of the outcome, then they have done their job, according to the powers-that-be.

It's a trade off. Sub-standard care is politically acceptable to limit risk, which in turn raises risk because of sub-standard care. To avoid the resulting risk, the political system relieves the medical community of accountability. This downward spiral only demonstrates that the politicians are aware of the situation, but are not seeking any resolution. Now, the brunt of the risk is absorbed by the patient in that they're paying for care that they're not obtaining, especially once the doctor errs and is unwilling to accept responsibility. When you buy a car, the dealer is willing to provide support and repairs, even when they err. As naďve as this may sound, I would assume that human life is more precious than an automobile, which makes me wonder why the standards of quality are higher for car maintenance than they are for human care.

Not to mention the fact that this malpractice crisis and tort reform has created a breeding ground for additional deceit and a mechanism to raise the status of the inept in the medical community.

I have read the commenters web site. He is clearly angry at physicians about the care his wife received. I will not argue with his depiction of the care (click on his name in the comments section to read his rant), but try to bring the heat engendered by this comment under control

I do understand that not all medical care works. Physicians generally do their best, and try hard to make decisions which will help patients. Regardless of intention, bad outcomes do happen.

I also understand that some physicians do not meet the standards that I would want for the care of my family. However, I believe that determining the less adequate physicians is much more complex than one might guess. We need a verifiable system of identification. The system must have objective measurable standards.

The author castigates all physicians and especially all physicians in the state of Nevada. This hyperbole creates negative reactions. I assume that the commenter follows his inference and thinks we would be better without physicians.

The crux of the malpractice crisis is how to protect patients and improve overall care. I have argued that we need a better system - most recently - Rethinking Malpractice. We do need a system that protects patients. We do need a system that is fair and predictable to physicians. Our current system does neither.

I have thought about how to address this issue for the past 2 days. Fortunately, Medpundit did a great job and I can focus on another 'sticky wicket'. Medpundit (go to Friday, August 8th - bloggers link function is acting funny again!!).

The Medical Letter, an excellent, unbiased source of drug information, reviewed the subject last month and found the evidence wanting. According to The Letter, the FDC Reports cited a study that found among 1,134 children, ?emotional lability? occurred in 3.2% of users compared to 1.5% of nonusers. ?Emotional lability? was defined as ?crying, mood fluctuations, thoughts of suicide and attempted suicide.? There were no completed suicides in the group. That's an important distinction. It isn't uncommon for depressed people, especially teenagers, to make a consciously feeble attempt at suicide - such as taking a drug they think is harmless, like Tylenol. Their goal isn't to kill themselves, but to gain attention.

On the face of it, the current recommendation to avoid these drugs seems overly cautious. For one thing, compared to older anti-depressants, they are more effective and they are safer. In the old days, before SSRI?s, doctors always excercised caution with anti-depressants because the drugs themselves could be instruments of suicide. Patients would only be given a small amount of the drugs at a time, say a week or two, to avoid intentional overdoses. With the SSRI?s, that?s not a problem.

To read the NY Times article that stimulates this discussion - Debate Resumes on the Safety of Depression's Wonder Drugs. I agree with Medpundit on this issue. I have seen dramatically positive results in many patients. The side effect profile seems much milder than the older antidepressants. She also makes a wonderful point about the NY Times arrogance concerning primary care physicians. Just another reason to show disdain for that paper.

We all now understand the cardiac dangers of hormone replacement therapy. Here is another article on that subject - First Year of Hormone Treatment Is Found to Raise Risk of Heart Attack

The researchers found that a woman's risk of a heart attack rises by 81 percent in the first year of hormone therapy. It levels off, so that after 5.6 years - the length of the study - the increased risk is 24 percent.

Still, Dr. Manson and other physicians not connected to the study noted that the increase in risk may be worth taking for many women whose baseline risk of heart disease is low and who suffer severe hot flashes or night sweats during menopause.

So my position remains - hormone replacement only for those women whose quality of life has deteriorated secondary to menopausal symptoms. And I would even argue against that use in a woman a moderate or higher risk of coronary artery disease.

Keeping up with the medical literature takes time ... and money. Medical journals are very expensive. As an author of many publications, I can assure you that authors receive no money for their articles. In fact, you are encouraged to spend money on reprints.

I do favor capitalism, however, I wish that the medical literature was more accessible. So does the Dr. Harold Varmus. Open Access to Scientific Research

A number of influential scientists have begun to argue that the cost of research publications has grown so large that it impedes the distribution of knowledge. Some subscriptions cost thousands of dollars per year, and those journals are usually available online only to subscribers. This looks less like dissemination than restriction, especially if it is measured against the potential access offered by the Internet. That is why a coalition led by Dr. Harold Varmus, the former director of the National Institutes of Health, is creating a new model, called the Public Library of Science.

Several years ago Dr. Varmus's group issued an open letter, signed by some 30,000 colleagues, calling on the publishers of scientific journals to make their archived research articles freely available online. Most journals declined, so they would not undercut the profitable business of selling expensive subscriptions to libraries. But there is a basic inequity when much of the research has been financed by public money.

The Public Library of Science plans to confront that inequity by establishing a new series of peer-reviewed journals that will be freely available on the Internet. The first ones, published this October, will be PLoS Biology and PLoS Medicine. The aim is to create a freer flow of data about research and results. The journals will pay for themselves by charging a small fee to the organizations and institutions that support the research.

Most of us, admittedly, will not have much use for free access to new discoveries in, say, particle physics. But it is a different matter when it comes to medical research. Popular nostrums abound on the Web, but it can be very hard, if not impossible, to find the results of properly vetted, taxpayer-financed science ? and in some cases it can be hard for your doctor to find them, too. The Public Library of Science could help change all that, creating open access to research. The publishers of scientific journals are naturally skeptical, but the real test will come in the marketplace of ideas. What will matter this fall, when the new journals make their debut, is how many scientists choose to publish in them rather than in the journals traditionally deemed the most prestigious in their disciplines.

"A man may well bring a horse to the water,
But he cannot make him drinke without he will." (from Bartelby.com)

And so it goes for pharmaceuticals. We (physicians, medical researchers) often know how to improve quality of life and how to extend high quality life, however, our knowledge does not always translate to results. Our prescriptions mean nothing if the patient does not take the medication. Reinventing the medicine wheel

Lost in the highly charged debate over Medicare prescription-drug benefits is a significant story that has been largely ignored to date: the fact that tens of thousands of senior citizens will never benefit from the drugs they receive because they can't, won't or just don't take them properly.

There is nothing government can do about this. There are more than 40 million seniors in the United States ? and an additional 77 million baby-boomers right behind them. While Washington can create a new prescription drug entitlement, it can't make a bad-tasting medicine taste good or provide round-the-clock reminders that it's time to take your pills.

What we need are more user-friendly medicines that will enable or encourage the elderly ? who even without a Medicare drug benefit account for approximately 42 percent of the more than $175 billion in annual prescription-drug sales ? to take their medications. Only the pharmaceutical industry can solve this problem, and we need to take on the challenge with the same enthusiasm as our search for the next blockbuster drug.

The problem of prescription "noncompliance," as it is called, cuts across age groups and demographics. As the authoritative "Merck Manual of Diagnosis and Therapy" notes, children are even "less likely than adults to follow a treatment plan." A study of children prescribed 10-day courses of penicillin for streptococcal infections, for example, showed that 56 percent had stopped taking the drug by the third day, 71 percent by the sixth day and 82 percent by the ninth day. "Compliance is worse with chronic diseases requiring complex, long-term treatment," the Merck manual noted.

There are many reasons. Some patients won't take their medicines because they taste bad, or dosage instructions are too complicated. One pill three times a day for 10 days doesn't seem like rocket science. But to a senior citizen already taking medication for arthritis, thyroid problems and high blood pressure, one more prescription can induce drug-instruction overload.

The author makes an important point. We need more once daily drugs (adherence climbs with once daily as opposed to 3 or more times a day). We probably need more combination drugs available. Patients with heart disease will benefit from multiple drugs. We would like to provide those benefits in a single formulation. My ideal solution would be a wide variety of combinations for ACE inhibitor, statin, beta blocker and aspirin. First, we would titrate each class, then we would have a combo pill to fit our titration.

I do not know whether one could formulate such combo pills. They certainly would help patients. This is a good goal for the pharmaceutical industry.

All physicians understand this article. It is not news. Yet, it is important - Doctors waste time on 'menial' jobs. While this article comes from Great Britain, it pertains to the US - and not just hospital work. Listen closely to physicians, and we often complain about the amount of "non-physician" work that we do. We have received extensive education and training. Why does anyone expect us to spend time on work that requires no such education? What is the opportunity cost?

Dr Simon Eccles, who co-authored the research, said that a third of doctors' time was being spent "inappropriately".

"These results don't come as any surprise to us," he said.

"Time is being wasted on these tasks which could have been spent doing what doctors are trained to do - treating patients.

"If you spend 10 minutes chasing up an x-ray, that's 10 minute less to spend with the patient.

"We're not suggesting that we just dump this work on someone else - but we need to create teams of people to relieve this burden during the night."

He said that he would like to see the introduction of US-style "physicians' assistants" who help doctors by completing much of their administrative work.

The body which represents NHS managers agreed that the survey results were shocking.

I beg to differ with Dr. Eccles. We do not have such assistants - especially for our trainees. The point is an important one. Having physicians do non-physician work makes no economic sense.

Rather than trying to tackle this subject anew, I recommend reading Medpundit's commentary - Public Health. This commentary refers to the National Academy of Science position paper - Panel Urges U.S. to Broaden Role in Vaccinations. Medpundit nails it. My comments would add nothing.

This editorial from Nevada - EDITORIAL: Insurers aren't to blame

In Clark County, by contrast, the premium base rate for obstetricians increased from $95,000 per year to $142,000. Since then, the Legislature attempted to implement malpractice reform, but portions of that legislation were designed as a sop to Democrats and their trial lawyer allies. For instance, the $350,000 "cap" on noneconomic damages enacted last year is riddled with loopholes, and there are no limits on joint and several liability, meaning a doctor found to be 1 percent responsible for a mistake could end up liable for 100 percent of the damages.

While the ever-cautious GAO was true to form in one sense -- rather than recommending specific legislation, it suggested that insurance commissioners might want to gather more information -- the report's findings clearly indicated that moves to rein in excessive jury awards and to limit joint and several liability should significantly slow the rise in malpractice insurance premiums.

Whether state or federal lawmakers are courageous enough to take on the powerful plaintiff's bar and make the necessary changes that would moderate those rates is another matter altogether.

No comment is necessary here.

Chips for some, tofu for others

A coalition of academic and community researchers compared grocery store selections in South Los Angeles, Inglewood and North Long Beach with those in the more affluent West Los Angeles. Researchers found that stores in the lower-income neighborhoods were far less likely to carry meats, fresh fruits and vegetables, nonfat milk and low-fat snacks.

"We live with this all the time in our communities," said Lark Galloway-Gilliam, executive director of Community Health Councils Inc., a health promotion organization in the Crenshaw district that helped organize the study. "Now we have data we can point to, evidence of our frustrations and concerns."

Researchers at USC, UCLA and the health councils group trained about 90 students and members of community organizations to survey more than 400 local food markets for their cleanliness, quality of service and foods. South L.A., Inglewood and North Long Beach ? areas chosen for their racial makeup ? were more likely to have convenience stores or small neighborhood markets than supermarkets and chain stores more common in West L.A. They were also dirtier and about 30% less likely to have good service, the researchers found.

But even more surprising, said David Sloane, associate professor of policy, planning and development at USC and one of the study's investigators, was the marked difference in food selections among the stores. Stores in the study's low-income areas carried about half the variety of fruits and vegetables as stores in West L.A. Also, produce items such as apples, grapes, strawberries and lettuce were more likely to be damaged or dirty. All stores surveyed in West L.A. carried whole milk and most carried skim milk. But among stores in the other study neighborhoods, some didn't carry milk at all, and a minority carried skim or reduced-fat milks.

The study also showed that it's hard to find more healthful food items such as soy milk, tofu, whole-grain pasta, low-fat mayonnaise, low-fat potato chips and sugar-free cookies in South L.A., Inglewood and North Long Beach. The stores in those neighborhoods were also much less likely to have sections specializing in products for people on low-salt diets or those with diabetes.

One cannot sort out causation from such a survey study. Perhaps the store in poorer neighborhoods only carry those food which their customers will buy. These data are interesting, and will require further study. Perhaps this could be a role for public health intervention.

Readers know that I favor drug legalization (even the 'dangerous' ones). This libertarian philosophy has practical underpinnings. I calculate (although I must admit this a very soft calculation, because I have no data on which to base the calculations) that the harm from our current prohibition exceeds the harm that would occur from legalization.

This Canadian program makes sense to me - Canadian drug policy seeks a fix

Throughout the country, officials are considering radical changes in Canada?s approach to drugs, rejecting the tendency in the United States to push for law enforcement solutions. In so doing, officials are taking up the stance of several other countries, including Germany, the Netherlands, Switzerland and Australia, where there are various programs for decriminalization, clean needles and free methadone clinics.

The Vancouver-based Harm Reduction Action Society, which advocates changes in drug laws, reported that drug overdoses in Frankfurt, Germany, decreased from 147 in 1991 to 26 in 1997 with the creation of safe injection sites. In Switzerland, the organization said, drug overdoses also decreased, and there was a marked increase in the number of people registering for methadone and other treatment programs.

U.S. officials have angrily criticized the Canadian policy of harm reduction.

"The very name is a lie," John Walters, the White House drug policy director, said in a telephone interview. "There are no safe injection sites." Walter said the United States would continue to treat drug abuse as a "deadly disease that shortens lives."

"It can't be made safe," Walters said. "We believe the only moral responsibility is to treat drug users. It is reprehensible to allow people and encourage people to continue suffering. That is why we don't make this choice and we don't believe we ever will."

Canada also faced criticism from the United States in May when it proposed decriminalizing possession of small amounts of marijuana.

Canadian officials said their approach is intended to combat HIV - rampant among drug users-and to decrease overdoses. Officials in Canada?s largest cities, Toronto, Montreal and Vancouver, are also debating whether supplying heroin to addicts will save lives and combat criminal behavior.

So why is Canada approaching this problem so differently from the United States? I believe the problem is perspective. We (the United States) have elected a government which sees drug use as a moral problem. Thus, we easily condemn this immorality and stop all discussion. Canada has started to look at the overal implications of drug abuse. They are willing to weigh the pros and cons of any program (decriminalizing marijuana, providing a safe place of IV drug abusers to inject their drugs). As they dispassionately evaluate drug abuse, they conclude that the laws impede overall health, respect for the law, and encourage other criminal behavior.

"?Somebody said, "Why are we helping addicts?" " said Viviana Zanocco, a spokeswoman for the Vancouver Coastal Health Authority. "The question is: Why shouldn't we? Are we only supposed to help heart patients?"

The program also makes good economic sense, Zanocco said. "When we get somebody with HIV, it costs $150,000 Canadian [about $107,000] to treat over a lifetime. Some people say you are enabling addicts, but you can point also to the health care system. If we can prevent 10 people from contracting HIV, the safe injection site pays for itself."

We need this logical approach. The political hysteria over drug abuse in this country has too many adverse consequences. While these are unintended consequences, they are consequences nonetheless. We need politicians and leaders with the courage to look at drug abuse as a societal problem which needs societal answers. We should neither demonize the abusers nor the drugs. We should put the pushers out of business the old fashioned way, using capitalism. We should provide legal safe drugs - even those which we know will harm the users. As we sell the drugs, we can then invest money (the money which we are saving on law enforcement and HIV care) on user education and drug treatment programs.

We already sell drugs that we know harm people - cigarettes and alcohol. While I lecture every patient why they should stop smoking, I would not try to make cigarettes illegal. Most people who drink have no problems - and the data even suggest that moderate drinking is good for one's health! I suspect that we would find the same with many illegal drugs (especially marijuana).

I can only hope that we will approach this problem logically in the future. Perhaps Canada will teach us important lessons. But do we have receptors for such knowledge?

I have previously ranted about medical articles being overhyped. Respectable newspapers will use sensationalized headlines. Findings sometimes receive an overenthusiastic response. This writer explains why - Health, Hope and Hype: Why the Media Oversells Medical 'Breakthroughs'

Forgive me if I sound cynical. It's just that, as a journalist, I'm a recently reformed hope pusher myself. The medical stories I used to write always had a strong element of hope, and the same goes for the majority of the articles produced by my colleagues around the country, who collectively serve as a kind of pep squad for biomedical research and medicine.

Here are just a few headlines from an Internet search that turned up 939 stories containing the words "breakthrough" and "medicine" from the month of June alone: "Saving Lives with Living Machines," from Technology Review; "Beat the Clock: Local Scientists May Be on the Verge of a Cancer Breakthrough," in Washingtonian; "Life Saver; There's a Revolutionary Blood Test That Can Predict the Future," in the London Mirror. With all those breakthroughs, you'd think nobody would have to die of cancer any more and we should all be running marathons into our eighties.

But we aren't running marathons in our eighties and we are still dying of cancer and heart disease and you name it. Do you think maybe that's because a lot of what passes as medical journalism contains a bit of hype?

This issue came into sharp relief for me in 1998 during the flap that ensued after the New York Times printed a story about the potential for new compounds known as "anti-angiogenic factors" to treat cancer. The story appeared on a Sunday, on the front page, above the fold, and it quoted Jim Watson, co-discoverer of the structure of DNA, saying, cancer would be cured "in two years." This was a patently ridiculous prediction, and any reporter who has ever interviewed Watson is well aware that he -- how shall I put this? -- has been know to shoot from the hip. But lots of readers and editors didn't know that. Later the New York Times would say it was shocked, shocked, when headlines around the world blared "Cancer Cure," stock prices of half a dozen biotech companies with patents on the compounds hit the stratosphere, and cancer patients clogged the phone lines of every oncologist and cancer center in the country, begging for a shot at the new miracle drugs.

In reality, the compounds hadn't yet been tested on a single human being, and they existed in such tiny quantities that there was scarcely enough to treat a few cancer-ridden mice. That meant that dozens of medical writers around the country, including me, would spend the week pulling together stories to set the record straight and disabuse readers of the notion that anti-angiogenic factors were going to cure anybody's cancer any time soon.

And yet, when the time came to decide how to package the magazine story that a colleague and I had written, somebody hit on the bright idea of running a photo of the breed of mouse that was used in the experiments, under the words, "Meet the Mouse That Beat Cancer." When we writers objected that this headline would further fuel the hype, the editors added "A Cure?" With that, the cover was printed with a wink and nod to what we all knew: Hope sells magazines.

So after reading the entire piece, I am not sure whether the problem lies with the writers or with the editors. The medical blog world - growing and hopefully becoming more important - tries to put these articles into perspective.

The longer one practices, the more careful one becomes when interpreting new studies. The perspective of time provides one with many examples over overhyped findings, diagnostic tests and drugs. This long view makes one look a bit more carefully at the data. We tend to ask more critical questions (although we are trying to teach this healthy skepticism to our trainees).

Perhaps the medical blog community should provide a consortium to place these stories into perspective. Perhaps we already do.

This week I have started listening to Jack Johnson. If you have not heard of him, he is a former Hawaiian surfer turned songwriter/singer. Try to imagine influences like Bob Marley, Jimmy Buffet, John Mayer and Duncan Sheik. The music comes laid back with acoustic guitar, bass and drums only. He has two albums - 'Brushfire Fairytales' and 'On and On'. Here are the lyrics to one song from his newer CD - 'On and On'. It says a great deal about personal responsibility, something which we need to increase in our society.

Cookie Jar (12)
i would turn on the tv, but its so embarrassing
to see all the other people, i dont know what they mean
it was magic at first, when they spoke without sound
but now this world is gonna hurt, you better turn that thing down
turn it around

it wasnt me, says the boy with the gun
sure i pulled the trigger, but it needed to be done
because lifes been killing me ever since it begun
you cant blame me because im too young

you cant blame me, sure the killer was my son
but i didnt teach him to pull the trigger of the gun
its the killing on his tv screen
you cant blame me, its those images he seen

you cant blame me, says the media man
i wasnt the one who came up with the plan
i just point my camera at what the people want to see
its a two way mirror and you cant blame me

you cant blame me, says the singer of the song
or the maker of the movie which he based his life on
its only entertainment, as anyone can see
its smoke machines and makeup, you cant fool me

it was you, it was me, it was every man
weve all got the blood on our hands
we only receive what we demand
and if we want hell then hells what well have

i would turn on the tv, but its so embarrassing
to see all the other people, dont know what they mean
it was magic at first, but let everyone down
and now this world is gonna hurt, you better turn it around
turn it around

The doctor's doctor .

The trial lawyers (and by extension the Democrats) blame the malpractice crisis on the insurance companies and their stock investments. This disingenuous claim makes no sense when one reads about situations like this - Medical insurer to quit Nevada, raising malpractice crisis fears

A medical liability insurance company is quitting Nevada, fueling fears of another state health care crisis.

Medical Insurance Exchange of California cited company losses and the failure of the Nevada Legislature to change state medical malpractice laws as it began notifying doctors this week that it will withdraw coverage in February.

"The absence of very meaningful tort reform in Nevada ... doesn't give us much hope for a future for us in the state," said Ron Neupauer, vice president of underwriting for the physician-owned company based in Oakland, Calif. "We've lost over $19 million in Nevada since we began offering coverage in 1977."

The company will continue to provide coverage in California, Idaho, Alaska and Hawaii, Neupauer said.

I believe this a simple exercise in logic and finances. The insurance company expects to make a profit. If they feel that they cannot make a profit, they should not do business in that state. So this insurance company is walking. This has nothing to do with stock market losses (or they would leave the other states). One can explain this defection from a fear of downside risk. They have run the actuarial estimations and decided the potential for gain is not there. I hope that I never get sick in Nevada.

I saw this story on TV. I had thought about writing about it, but got busy doing other things. Fortunately RangelMD has two good posts - Don't like your doctor? Then sue! and More on suing the "late" doctor

I have little to add to these excellent posts. But you know me, I have to rant just a bit!!

I do understand the patient's problem When I was seeing outpatients, I would personally apologize to those in the waiting room when I was running late. I hated keeping patients waiting.

On the other hand, sometimes you do fall behind. Patients arrive sicker than the office can handle. They require semi-intensive care.

Or early patients come late, thus the later patients have a longer wait. Or you try to squeeze in a few patients as a favor - next thing you know your schedule has gone to hell.

The physician could have probably avoided this suit by simply acknowledging the inconvenience (although I have never had a patient apologize for missing an appointment or arriving late). Regardless, I am shocked that the patient won the suit. If we see further such suits we will have to greatly change how we schedule patients. Rangel comments on these and more issues. If you have not already clicked on the links - get outa here - get over to RangelMD!!!

DIY Drug Development?

Well, there's nothing there that 30 whole hours of free consulting can't fix, I'm sure. And all the universities have to do, it seems, is raise the money for the really expensive stuff. Quite a deal. I wish these folks the best, but I can't help but think that they're going to be climbing a steep learning curve with ropes and pitons. DB's hopeful comment is "If this works, the straw man argument about investing in research may move towards moot." Well, as someone who's been getting beaten up for years by said straw man, let me add some comments of my own: If you know some chemistry, some biochemistry, some molecular biology or medicine, then the business of drug development looks pretty hard. Then when you try it out, you find that it's a lot harder than it looks.

Well you cannot really blame me for hoping. I do believe some companies work very hard at research. One can ask about what kinds of research, how much, and what change would one project if reimportation works. This question (and any answer) has too many hypotheticals to allow good decision making.

So I do understand the difficulty of drug development. However, I am not certain if our current economic situation is sustainable. Moving towards a free market (as the Cato authors suggest) may or may not change research investment.

I have blogged about this issue back in May. ACOG has joined the American Cancer Society by endorsing less frequent PAP smears for some women. Fewer Women to Need Annual Cervical Testing

-Women should undergo annual Pap tests up to age 30.

-Those 30 and older have two options. They can start getting checked every two to three years after having three consecutive, normal Pap tests. Or they undergo a combination of a Pap exam and testing for the human papillomavirus, or HPV, that causes most cervical cancer. Passing both those tests means they need rechecking no more than every three years.

These new recommendations make sense. The data support the change.