Please read this case. It tells an important story. Paying Heed to Problems of the Heart

Though doctors are now more aware of cardiac symptoms in women, even today women with heart disease receive one-third as many bypass operations, angioplasties, stents and implantable defibrillators, as their male counterparts, according to the National Coalition of Women With Heart Disease. In addition, women with cardiac symptoms are hospitalized less often and undergo fewer diagnostic tests. Moreover, women account for only one-quarter of those studied in heart-related research.

So it is no surprise that cardiovascular disease is our nation's No. 1 killer of women, claiming a half-million lives each year, six times as many as breast cancer.

While it is essential that doctors correct a striking imbalance in care, women must also shed attitudes based on myth. We continue to declare our symptoms pedestrian, we consign cardiovascular disease to men, we fixate on breast cancer and we ignore matters of the heart.

Well said and important!

Addiction: A Brain Ailment, Not a Moral Lapse

A better understanding of the pull and tug of addiction can help those who are hooked and those who want the monkey off their backs for good.

The savings in life-years, quality of life and lost income can be huge, not to mention the costs of drug-instigated crime and medical care.

According to the National Institute on Drug Abuse, $133 billion a year is spent just on treating the short-term and long-term medical complications of addiction. Among the many health consequences of addictions are sudden cardiac arrest, irreversible kidney and liver damage, AIDS, fetal harm and many cancers, including cancers of the lung, bladder, breast, pancreas, larynx, liver and oral cavity.

That it is possible to become free of addictions and remain so is unquestioned.

This article does a very nice job of summarizing our knowledge and lack of knowledge related to addictions. Interestingly, almost all addictions have the same final pathway.

The nature of addiction is the same no matter whether the drug is cocaine, heroin, alcohol, marijuana, amphetamines or nicotine. Yes, whether they know it or not, chronic cigarette smokers and users of chewing tobacco are addicts.

Every addictive substance, according to a report this month in The New England Journal of Medicine, induces pleasant states or relieves distress.

Furthermore, the authors of the report, Dr. Jordi Cami and Dr. Magi Farré of Barcelona wrote, "Continued use induces adaptive changes in the central nervous system that lead to tolerance, physical dependence, sensitization, craving and relapse."

In other words, addiction is a brain disease, not a moral failing or behavior problem. People do not deliberately set out to become addicts. Rather, for any number of reasons ? like wanting to be part of the crowd or seeking relief from intense emotional or physical pain ? people may start using a substance and soon find themselves unable to stop.

...

According to the Institute of Medicine of the National Academy of Science, 32 percent of people who try tobacco become dependent, as do 23 percent of those who try heroin, 17 percent who try cocaine, 15 percent who try alcohol and 9 percent who try marijuana.

Interesting statistics! Hopefully, continued research will allow us to better help addicts through their physiologic withdrawal.

Mr. Vastag explained that all drugs of abuse activated a pleasure pathway in the brain, the "dopamine reward circuit," which is connected to areas that control memory, emotion and motivation. Any activity that activates those pathways reinforces the pleasurable behavior.

"Eventually," he wrote, "the dopamine circuit becomes blunted; with tolerance, a drug simply pushes the circuit back to normal, boosting the user out of depression but no longer propelling him or her toward euphoria."

By repeatedly supplying the body with the substance, a new state of "normal" is created, causing the person to continue using the substance to feel normal.

The changes in the brain, though not permanent, can be long lasting. Dr. Volkow found that the dopamine system of cocaine users remained impaired for up to three months after their last snort.

Read this interesting article and you will better understand the challenge these patients face.

The weight of obesity: Linking large people to care

Like most physicians struggling with an ever-fatter patient population, Dr. Griffin is walking a fine line between two extremes.

On one side are the lawyers. Earlier this year, an internist in Ohio lost a wrongful death lawsuit involving an obese smoker who died of a heart attack. The jury awarded the family $3.5 million in part because they felt the physician did not do enough to help the man lose weight. The case is being appealed.

Similar cases are pending elsewhere in the United States. And public interest lawyers who are going after fast-food companies for possibly playing a role in the obesity epidemic have said physicians, too, may become targets if they don't do enough to help their patients slim down.

On the other side are members of the fat acceptance movement. These are people who fight to be accepted at the size they are, even if that size is defined medically as a serious health risk.

"If a doctor could show me a weight-loss method that had greater than a 5% to 10% success rate in the long run, perhaps I'd be interested to hear what they have to say," said Mara Nesbitt-Aldrich, a fat activist in Portland, Ore.

Organizations such as the National Assn. to Advance Fat Acceptance and the International Size Acceptance Assn. fight against discrimination on the basis of size in all walks of life, including the exam room.

"There's a lot of anger and mistrust of the medical community within [this] community," said Allen Steadham, director of ISAA. "The weight in and of itself is not a dangerous medical condition. We don't see obesity as a disease."

NAAFA goes so far as to issue guidelines for physicians and other health care professionals on how fat patients should be treated. The organization does not want patients to be automatically weighed. If they do step on the scales, it should be in private.

If obesity is not a disease, then we can at least agree that it represents a major risk factor for (amongst other diseases): obstructive sleep apnea, type II diabetes mellitus, hyperlipidemia, osteoarthritis (especially of the knees). Smoking is not a disease, yet we try (and should try) to get patients to stop smoking.

Right or wrong, I view morbid obesity as a lifestyle issue. Like other risky lifestyle issues, I keep trying to convince patients to modify their lifestyle to reduce the risk of complications resulting from that lifestyle. And if I do not, then I not honest to my professional ideal.

Most physicians dislike direct to consumer (DTC) advertising. Apparently we are in the minority. F.D.A. Reviews Ads for Drugs

An ad for the prescription drug Zoloft asks: "Feeling sad? Anxious? Tired?" Zoloft is sold by Pfizer as a treatment for depression and other disorders. It is but one of many print and broadcast advertisements that pitch prescription drugs directly to consumers - a category of ads scrutinized last week at a hearing held by the Food and Drug Administration.

The two-day hearing, in Washington, was part of the agency's review of the rules governing prescription-drug advertising. Because many of the 29 studies presented at the hearing reported positive public results - like increased communication between patients and doctors - the prevailing prediction among supporters of the ads was that the drug agency would allow the ads to continue in much the same form as today.

"It's rare that you get such validation from a meeting like this," said Dick O'Brien, executive vice president and director for government affairs at the American Association of Advertising Agencies, a longtime advocate for the ads. "This is one where you feel all of a sudden like you're on the side of angels."

"My hope is that these two days were so positive that they may help to put this controversy to bed once and for all."

Balderdash! I agree more with the following quote.

But some critics showed no sign of backing off.

"This is a really unlevel playing field for consumers," said Larry D. Sasich, a research analyst at the health research group of Public Citizen, a consumer advocacy group. "You have an industry that maintains that a 30-second or 60-second television spot empowers consumers to make an informed decision about their drug therapy."

Instead, Mr. Sasich said, the spots play up the promise of the products, leaving consumers on their own to ferret out potential side effects or adverse reactions.

The Washington meeting did not adequately address such issues, said Barbara Mintzes, a post-doctoral fellow at the Center for Health Services and Policy Research at the University of British Columbia in Vancouver.

"The question is: Who was talking?" Ms. Mintzes said. "There were a few people presenting who were independent, but the large majority were either people from the industry or financed by them."

Anyone was welcome to present original research at the meeting, but an open door does nothing to ensure that all the relevent research is included, Ms. Mintzes said.

I remain skeptical of these ads. However, it does appear that they will remain for the near future.

Rosh Hashanah

And I wish one and all a happy, healthy and sweet New Year!

Wow! This article comes out today almost as if I had planned it. Fat equals lazy, say doctors

Doctors are guilty of wrongly believing that obese people are simply lazy, research suggests.

Researchers at Yale University said the findings highlight the difficulty in tackling the stigma around obesity.

Many obese people complain that others believe they are overweight simply because they eat too much or fail to exercise.

This is despite the fact that obesity can be caused by a variety of other factors, such as genes and environment.

Dr Marlene Schwartz and colleagues carried out psychological tests on 389 professionals who treat and study obese people.

They found that younger professionals, in particular, were most likely to have unfavourable stereotypes of obese people.

Workers who did not deal directly with obese patients were also inclined to see them in an unfavourable light.

"On both implicit and explicit measures, health professionals associated the stereotypes lazy, stupid and worthless with obese people," said Dr Schwartz.

"The stigma of obesity is so strong that even those most knowledgeable about the condition infer that obese people have blameworthy behavioural characteristics that contribute to their problem, i.e. being lazy," she said.

"Furthermore, these biases extend to core characteristics of intelligence and personal worth."

Well, certainly there are genetic factors which we do not yet understand. I hope ongoing research will make those factors more clear. However, genetic factors do not explain the growing epidemic of overweight and obesity. Environment does matter. Blaming all overweight and obesity on genetic factors, and avoiding all personal responsibility seems disingenuous. We all see patients and friends who decide that they no longer want to be obese. They can successfully increase their exercise and control their portion sizes. They can lost weight. I know, because I did! And I have maintained my weight loss for more than 3 years (size 38 pants before, size 35 pants now).

Perhaps we can find a happy medium here. We need to learn more about the causes of obesity. Some patients probably have overwhelming genetic factors leading to obesity. But many patients just combine poor dietary habits and minimal activity to achieve their weight. We should not throw our hands into the air and blame genetics. We should continue to try. For sometimes we succeed!

How can I explain the pleasure and the angst of medicine? No simple essay can encompass the variety one experiences in medicine. We celebrate successes with our patients; we watch them go through their terminal illnesses. Many things that we do are rewarding, while others can frustrate. Breaking bad news may be the most difficult and important part of our profession.

I remember being in medical school. I discussed this issue with my father, who is a retired psychologist. He gave me advice that helped me for the past 30 years. I try to pass that advice on to my students, interns, and residents.

First, make sure you are in a comfortable room, which is quiet and where you will not be interrupted. Next (and this is most important in the hospital), sit down. I always try to relax mentally. My words and expressions are important here. When possible I make light physical contact. Then I start.

I generally start by asking the patient his or her fears. What do they think is the problem? If they fear the diagnosis that we will discuss, then I proceed by confirming their fears. If the diagnosis comes without insight, then I try to go slowly and explain the diagnosis as completely as possible.

When I can give hope of treatment I do. When I cannot, I always make certain that the patient knows that we will not abandon him/her. We often cannot cure lung cancer (for example) but we can promise great attention to quality of life until death. I make that promise. In the inpatient setting we generally spend a bit more time with terminal patients. I always try to sit down and explore their needs. Caring for them requires caring for their family members. It requires patience and answering many questions repeatedly.

When I cared for outpatients, I would have the patient make frequent office visits (every few weeks or at longest once a month). We would mostly discuss symptom control, or just socialize a bit. I would end each session telling the patient how I looked forward to the next visit.

This article discusses the pain of giving bad news. Bearer of Bad News. The article discusses the new quick HIV test. The story discusses the difficulty involved in telling patients they are HIV positive.

While breaking bad news provides one of our greatest challenges, it also gives us an opportunity to make an important difference. Our professsional lives give us the exposure to patients from all walks of life, yet in these crucial moments, we are all alike. How we break bad news matters? Those interactions are painful for the patient and the physician, yet when done properly, with dignity, empathy and respect, they can help the patient start on their path to addressing another hurdle. We matter, and we should.

Each time I break bad news on rounds, I have the students, interns, and residents in the room with me. We always spend some time "decompressing" after the converstaion. I ask them to reflect on what we just did, and what the observed. I challenge them to take my method, and then modify it to fit their personality (for there is no one right way to break bad news). Hopefully, I will help some of these learners as they break bad news to their patients.

This is a request for commenters. Please avoid ad hominem attacks. I just received one -

I based my comments on DB's own admission of constant failure with a particular class of patients, whom he or she vilifies rather than investigating further. There are two comments in this thread alone that point to alternative aetiologies and treatments. I maintain that DB is incompetent. Prejudice has no place in medicine.

The commenter is out of bounds. Without investigating my practice (which is primarily inpatient at this time), and knowing how I care for patients, one should not attack me (nor any other physician).

I confessed to prejudice. Almost all human beings have prejudices. In medicine, I believe that I can have a knowledge of my own prejudices (which I cannot avoid), and yet provide excellent compassionate care. One should judge how I care for patients, rather than how I feel.

I know of few physicians who have success with the excessively obese (morbid obesity +++). To admit that and receive an ad hominem attack for admitting my frustrations as a physician does not seem reasonable.

The purpose of a blog is to make me and my readers think. Such commentary does not advance those purposes. I apparently have incited much thought with that rant. Please respond with the same considerations.

db steps off his soapbox, shakes his head, and moves on.

A cardiologist writes:

Once again, how do you suggest that we treat the anemia? Transfusions? Or are you suggesting that the off label use of recombinant erythropoetin injections be expanded prior to the results of prospective studies? Physicians are not ignoring anemia. However up until recently there has not been any useful approach to bone marrow failure from chronic disease other than repeated blood transfusions. Physicians other than nephrologists, hematologists, and oncologists are generally not familiar with the use of Epogen and Procrit. More studies, not more accusations, are needed.

First, I apologize if my comments were misconstrued. I am not accusing cardiologists or internists of ignoring anemia. Rather, my posts mean to suggest where the field may move. I suspect that we will have an indication for using erythropoeitin in selected CHF patients within the next few years. Currently, our hands are tied.

I am supporting further research on the benefits of erythropoeitin therapy for anemic CHF patients. We need to understand the magnitude of benefit, and the associated costs. Only then will we know whether such therapy may help patients.

The anemia hypothesis does fascinate me, and should fascinate all physicians who care for CHF patients.

I have written about anemia recently. The impact of anemia on congestive heart failure is a growing issue. The heart.org (links are not available - you need to scroll down to this article - Anemia linked to poor outcomes in CHF - dated 9/24/03.

Researchers are reporting that low hemoglobin levels in the setting of heart failure are associated with increased mortality and morbidity. Several studies presented here at the 2003 Heart Failure Society of America Scientific Sessions add to a growing body of evidence suggesting that treatment of anemia may be a novel target for improving outcomes in heart failure.

"Anemia is receiving greater and greater attention, because it's been detected by many groups that anemia is a risk factor for poor survival and an increased number of hospitalizations and increased morbidity and decreased exercise performance in heart failure patients," Dr Stefan Anker (National Heart and Lung Institute, London, Virchow-Klinikum, Berlin) told heartwire. Attention is being focused on the issue now, he said, "because we probably can do something about anemia in the near future."

"This is a relatively new idea," adds Dr Kirkwood F Adams (University of North Carolina, Chapel Hill). While it has been known for some time that hemoglobin is reduced in heart failure, he said, the reductions are relatively modest and were not considered physiologically significant.

"But all the data now, at least from the association data, suggest that these reductions in hemoglobin are important," Adams said. "They're associated with an increased risk of death and increased risk of hospitalization, so we're building the observational story. There obviously have to be clinical trials to show cause and effect, but the observational data are quite strong."

So what levels of anemia are we considering? The report from one study -

"After making adjustments for other comorbidities and other factors, we find that the rates of mortality are higher in the patients who have a lower hemoglobin," Dr John Kim (Amgen) told heartwire.

A 1.0-g/dL increase in hemoglobin reduced mortality odds by a factor of 0.92 (p<0.001), they note. By comparison, a one-year increase in age corresponded to an increase in mortality odds of 1.04 (p<0.001).

In this study they refer to hemoglobins of less than 12 as anemia. I suspect that more prospective studies will help us understand the benefits of treating the anemia.

Well, that sure grabbed everyone's attention. I fear that I did not make myself totally clear. It would help if I define terms. I feel like I work successfully with the overweight and the obese. The small group of morbidly obese (unfortunately an increasingly common problem) present a particular challenge.

It may help to give some weights and heights. If one assumes a goal BMI of 22, overweight BMI of 27, obese BMI of 32, and morbidly obese BMI of at least 40, then we can look at 2 heights - 5 feet 6 inches and 6 feet. For a patient 5 feet 6 inches the respective BMIs come from the following weights - 136, 167, 198, and 247. Thus, a 5 feet 6 inch person who weighs more that 247 is morbidly obese. At 6 feet the weights are - 162, 199, 235 and 294.

In fact I probably do well at a BMI of 40. The patients who exceed even that BMI by 50-100 pounds represent the small subgroup with which I have difficulty.

One commenter suggested that she hoped that I tried to find them a good doctor. I generally try to consider a surgical approach in these patients, as I believe that the probability of weight loss success in these patients is otherwise incredibly low.

I admit that I have a problem with morbid obesity. This article pertains to me. For Medicine, a Growing Problem

No room for the obese -- to a lot of heavy Americans, that seems to be a slogan for the entire American health care system. And this is no minor issue: According to the National Institutes of Health, nearly two-thirds of the population is overweight or obese.

About 9 million Americans are "extremely obese," with a body mass index, or BMI, over 40; they have a substantially increased risk for illness and premature death.

These are people who should be going to the doctor more often than others, but in many cases they are not. Studies suggest this is because they believe the health system doesn't want to deal with them, or is out to humiliate them.

Here is what they experience: gowns that are too small; waiting room chairs they cannot squeeze into; scales placed in public view; exam tables that tip over; procedures (such as pelvic exams) that turn embarrassing when extra staff is required to lift the patient's middle.

And always there is The Lecture: being told, repeatedly, that "all you need to do is lose weight, and only then can we get a handle on your other health issues."

Hally Mahler, a public health expert specializing in HIV and AIDS, remembers getting The Lecture for the first time when she was 8. "He would say to me, 'You're getting too fat, you have to lose weight, it's now or never.' It was embarrassing. It became embarrassing going to the doctor."

Today Mahler is 35 and still big. But that childhood memory lingers. "As a child it was terrible, I resisted it, I did not want to go to the doctor, ever," she says.

Even as an adult, she has found medical personnel not only unsympathetic, but sometimes manifestly hostile. During one recent visit to the doctor's office, she recalls, "I walked in, and the nurse looked me up and down, saying, 'You're too heavy for this table. How much do you weigh?' And she looked me up and down again, in a really nasty way, and she just stormed off."

As a physician I admit to emotional prioritization. I have greater empathy for patients who have no obvious responsibility for their illness. I empathize with pulmonary interstitial fibrosis patients more than COPD patients (especially if they continue to smoke). Morbid obesity bothers me.

There, I have written it. I am revealed. I cannot view all patients the same. I find these patients too frustrating.

Perhaps morbid obesity patients are just too challenging. I know that their problems stem from their weight. When they complain that their knees hurt, what should I say? I know that I am thinking - if my knees had to carry 400 pounds of blubber I guess they would hurt also.

I am not alone. I suspect that I have just been more honest than many physicians. But I will assert that as a physician I understand that I can only point the way to health. With the exception of acute hospitalization, I cannot control what the patient eats, drinks or smokes. I cannot make the patient take his or her medications.

When it comes to guiding patients, I have become emotionally detached. I try to give the best possible advice. I want the patient to succeed an improve their health. But I can only recommend.

When you make repeated recommendations, in various styles, and you get no success, then you become hardened. I have successfully convinced patients to stop smoking, stop drinking and become more adherent to medical therapy. I have never succeed with the morbid obese.

I have many successes with the overweight, and a few successes with the obese, but no successes with the morbidly obese. So I am hardened. And I am prejudiced.

"I see these people marching into terrible dependency," says Barzel. "They are not going to be able to take care of themselves. The care that they require is huge. The drain on society is going to be much, much bigger than lung cancer was. . . . Just like smokers, overweight and obese patients do not seem to recognize -- or they deny and suppress the notion -- that they are likely to end up in a state of serious ill health and a lifelong dependency on others."

If anything, the medical establishment worries that overweight patients aren't hearing the "you-need-to-lose-weight" message often enough. A study of more than 1,200 physicians that appeared in the journal Preventive Medicine in 1997 found that doctors dealing with obese patients "did not intervene as much as they should, were ambivalent about how to manage obese patients and were unlikely to formally refer a client to a weight loss program."

It is not clear where the happy medium is. On the one hand, you have patients like Mahler, who demand that the system change to fit her: "You need to have a table that can hold somebody, even somebody who weighs 500 pounds." On the other hand, you have doctors like Wellbery, who suspect that accepting the fat may actually contribute to the problem. "Think of smoking," she says. "The negative connotation helped curb the habit."

And yet everyone agrees something is wrong. "When occasionally I have a patient who lost a lot of weight," says Barzel, "I am happy like a kid who has found a toy. But it is so rare. The fact is, we all talk about it, but while we all talk about it, society gets heavier and heavier."

I have no glib answers. But you do have my confession.

Doctors struggle to convey risks of diabetes

The medical community wants you to be scared of diabetes -- but not too scared.

An estimated 16 million people are on the verge of developing diabetes, a serious condition that can lead to blindness, limb loss, kidney failure and early death. Yet new research shows that more than half of new diabetes cases can be prevented with some fairly simple lifestyle changes, such as losing a few pounds.

After years of reassuring diabetics that the disease is one they can live with and manage, doctors and health workers are struggling with how to also send the message that diabetes is a deadly, terrible disease -- so that more people will be motivated to take steps to prevent it.

This month, many patients may begin seeing pamphlets and brochures in their doctor's office distributed by the American Diabetes Association as part of its "Weight Loss Matters" campaign, which is trying to spread the word that people have to lose only a little weight to dramatically lower their risk for diabetes.

I can easily argue that for internists, diabetes prevention should become a major focus of adult care. Clearly prevention should work better than treatment. However, prevention generally requires more than a pill. It requires lifestyle change. And few people seem to succeed with major lifestyle changes. And we get frustrated. And patients still develop diabetes mellitus type II.

We have had spirited debate on the article about which I ranted earlier today. In that article, a Dr. Gottlieb discussed her administrative fees for her general internal medicine practice. I am in favor of administrative fees and will advance the following argument - expecting more comments.

As professionals, we do our best to care for our patients. This includes the visit (either office, hospital, home or nursing home). Recently, we have only charged for the visit, and have provided extra time (reviewing charts, dictating, telephone calls, filling out forms) gratis. We could do this when the visit reimbursement included (albeit implicitly) enough money to cover the administrative expenses.

As one decreases visit reimbursement and overhead increases, income begins to decrease. Since (as I stated repeatedly) we have almost no control over visit reimbursement rates, and we also have little control over overhead, the impact of overhead becomes a pure bottom line impact.

What physicians want is a fair reimbursement for time spent. We deserve reimbursement for all the time spent towards the patient's benefit, not just the office visit. The solutions are obvious. We either need an increase in visit reimbursement (to subsidize the non-visit time), or we need explicit financial recognition for "other time".

We have an appropriate model - the law office. If you call a lawyer about a problem, the clock starts ticking. You make an explicit decision as to whether calling the lawyer is beneficial. One could argue (within a sound ethical and moral framework) that the same should apply to physicians.

For most generalists, our only commodity is time. We help patients when we spend time working with them on their health care. That time should have the same value whether the patient is present in the room, or we are reviewing laboratory work, or sending a note about the lab work, or calling the patient to discuss that lab work. A fair system would recognize this time fairly. We do not have a fair system. Physicians like Dr. Gottlieb are making this point explicitly, and it seems to bother some readers. It does not bother me. She deserves reimbursement for her time. She is trying one such method. We do need a method, if not this one, then we must discover another one. The current imbalance is not working.

This article requires free registration - Doctors give extra fees a shot

At a time when health insurance premiums and co-payments for medical care are rising quickly, some doctors have started asking patients to pay even more in fees and special surcharges.

Physicians who say they do not recoup enough money from insurance companies to cover their costs of doing business are beginning to introduce new fees for patients, beyond the traditional out-of-pocket costs such as co-pays and deductibles.

Doctors say the fees, costing some patients $300 a year or more, are needed to defray soaring administrative costs and rising malpractice premiums and to make up for flat payments from managed-care companies.

Without the fees, some say, they would be forced to short-change medical care or be forced out of medicine.

"The cost of doing business continues to rise," said Dr. Emily Gottlieb, an Evanston internist who is billing some of her patients between $200 and $300 annually for a "practice maintenance fee."

"This fee is allowing me to continue to practice medicine. I would go broke otherwise or have to retire," said Gottlieb, who is 60 and has practiced in the Chicago area for more than two decades. "The only other way I could cover my medical costs is to see more patients in a shorter time, and that would be shabby medical care, and I won't practice medicine like that. I call my patients back on the phone, and a lot of doctors don't."

Gottlieb is one of the early adopters of the fees, which are controversial and risky for physicians. The surcharges could alienate patients and, legal experts warn, such surcharges could violate contracts physicians have already signed with insurance companies.

Blue Cross and Blue Shield of Illinois, the state's largest health insurance company, said it is aware of about a half-dozen doctors in the Chicago area are now charging the fees. The insurer said it would investigate Gottlieb's surcharge and others the company hears about.

This practice goes half-way towards retainer medicine, but is couched in softer terms. Nonetheless, the physicians have a reasonable point. Current fees do not allow one to provide desirable medical care. I find this solution palatable. And I believe that the insurance companies should pay the fees.

One-Day Quadruple Therapy Effective for H. pylori Infection

One-day quadruple therapy is effective for Helicobacter pylori infection, according to the results of a prospective, open-label equivalence trial published in the Sept. 22 issue of the Archives of Internal Medicine. This regimen was comparable to seven-day triple therapy in patients with dyspepsia and a positive urea breath test.

"Eradication of [H. pylori] infection has had an impact on the treatment and recurrence rates of peptic ulcer disease and malignancies such as mucosa-associated lymphoid tissue lymphoma," write Luis F. Lara, MD, from the Wake Forest University School of Medicine in Winston-Salem, North Carolina, and colleagues. "Treatment options are cumbersome, expensive, and associated with side effects."

In this parallel-group design trial, 160 patients with dyspepsia, a Glasgow Dyspepsia Severity Score of at least 3, and a positive urea breath test were randomized to a one-day, four-drug regimen, or to a seven-day, three-drug regimen.

At five weeks, eradication percentage was 95% in the one-day treatment group and 90% in the seven-day treatment group, which was not a statistically significant difference. In both groups, mean decrease in the Glasgow Dyspepsia Severity Score was 7.5 points, and adverse events were similar.

Four patients in the one-day treatment group and seven patients in the seven-day treatment group failed treatment and were retreated for 10 days. One patient in the seven-day treatment group still tested positive for H. pylori after retreatment.

"The approach to H. pylori eradication reported in this study is cost-effective, promotes patient compliance, and could simplify the role of primary care physicians in the treatment of H. pylori infection," the authors write. "Further evaluation will be necessary to determine whether the one-day regimen is adequate for patients with peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, or gastric adenocarcinoma."

For those who subscribe to the Archives of Internal Medicine, the reference - One-Day Quadruple Therapy Compared With 7-Day Triple Therapy for Helicobacter pylori Infection . And the regimen use:

The treatment group received a 1-day regimen consisting of two 262-mg tablets of bismuth subsalicylate 4 times daily (qid); of one 500-mg tablet of metronidazole qid; of 2 g of amoxicillin suspension qid; and of two 30-mg tablets of lansoprazole once daily.

Beyond the Blame: A No-Fault Approach to Malpractice

The truth, of course, is more complex. Most physicians, even those whose skills are excellent, make terrible mistakes at some point in their careers.

Most doctors are genuinely committed to their work and carry their mistakes with them, secretly, for the rest of their lives. Unfortunately, a vast majority do not tell their patients when they have made mistakes that harmed them.

It is not surprising that so many doctors who are successful and usually ethical will cover up their mistakes. And it is not surprising that many doctors, as well as patients, find the current system of accountability unworkable, especially in medical malpractice cases.

Fear of malpractice is rampant. Research studying physicians' responses to being named in malpractice suits has revealed that the experience is traumatizing for most and that 20 percent of doctors who are defendants describe the experience as the most traumatizing of their lives.

Part of the trauma is financial; doctors are personally responsible for damages beyond the amount that malpractice insurance will pay.

The trauma is also psychological, as most physicians derive much of their self-definition from their knowledge that they are good doctors. In suits, it is to the plaintiff's advantage to characterize the doctor as uncaring, negligent and unskilled. Physicians who have been trained to expect perfection from themselves usually find this battering.

This may explain why so many mistakes go unreported. In 1999, Dr. David Studdert, a Harvard researcher, published a paper in which doctors and nurses reviewed 14,700 medical charts from Utah and Colorado for evidence of negligent care.

Then Dr. Studdert and his colleagues tracked how often bad medical care resulted in malpractice suits. "Of the patients who suffered negligent injury in our study sample, 97 percent did not sue," they wrote.

The author goes on to suggest a solution.

A better plan would call for motivating physicians to report their own mistakes by offering them no-fault judgments in exchange for their disclosures. This will work as a "carrot" only if there is also a "stick" waiting for those doctors who chose to cover up their errors.

In such a system, instead of physicians' paying for malpractice insurance, the doctors and patients would pay into local injured-patient compensation funds. In this way, the burden of reimbursing injured patients would be shared, and everyone would enjoy the benefits of better care resulting from changes in the way medicine is practiced.

Physicians making serious mistakes would voluntarily report them to local commissions.

The commissions, which would consist of physicians and patients, would strive to compensate the injured patients according to guidelines established to ensure that reimbursements were uniform.

In exchange for disclosing mistakes, physicians would be granted no-fault judgments and avoid liability. If the commission agrees with the physician that harm has occurred, the patient will be compensated according to guidelines designed to ensure uniform compensation.

The compensation would be more modest than the occasional enormous judgments in the courts today, but many more patients would be compensated, because the reporting onus would be on the doctor (who is in a better position to perceive the mistake), rather than the patient.

Very interesting ideas are presented here. I am skeptical that they would work, and even more skeptical that the trial lawyers would allow such a system (which would apparently take them out of the financial loop). But I do recommend that we all consider this proposal, and perhaps even debate the ideas.

`Tired Blood' Warning: Ignore It at Your Peril. Jane E. Brody does a nice job summarizing recent information on the health effects of anemia. As a ward attending, I emphasize the importance of anemia much more than I did 5 years ago.

Anemia is this country's most common blood disorder. Statistics indicate that 3.4 million Americans are anemic, but experts say this is a gross underestimate. As Dr. Allen R. Nissenson and his co-authors said recently in The Archives of Internal Medicine, anemia has been viewed for far too long as an "innocent bystander," considered almost normal in certain groups, like menstruating women and the elderly.

On the contrary, Dr. Nissenson, a nephrologist and professor of medicine at the University of California at Los Angeles, said in an interview. A growing body of research indicates that anemia can seriously compromise the quality of a person's life, make sick people sicker and even speed deaths, he said.

It is time to take anemia much more seriously, he added, making sure people have routine blood tests and are treated to restore healthy supplies of red blood cells. The testing is done either by a finger prick or by drawing blood from a vein. The finger test usually measures the hematocrit level, or percentage of red blood cells in plasma. A normal count is 36 to 46 percent for women and 46 to 56 percent for men.

A more accurate assessment measures the oxygen-carrying hemoglobin in blood, expressed as grams of hemoglobin per deciliter of blood. A normal hemoglobin for women is 12 to 13 grams and for men, 13 to 14. Hemoglobin has traditionally been measured in blood from a vein, but a finger-prick test is now available.

Many physicians have accepted low hemoglobins (in the 10-12 range) as acceptable and a result of chronic disease. Recent information suggests that we may become more aggressive as treating these patients to raise their hemoglobins towards normal - improving both quality of life and survival.

You Took a Pill. You Still Hurt. Here's Why.

Regularly, I have post workout muscles pains. I never take medications for these pains. I view these pains as a price that I must pay for increasing fitness.

Medications probably would not help anyway.

Sports-medicine experts agree that Nsaids are by far the first choice among athletes and doctors who treat their injuries. According to conventional wisdom, inflammation is at the root of exercise-related pain ? and stopping it brings relief.

In the last year, however, review papers published in several sports-medicine journals have questioned athletes' heavy reliance on these drugs. One paper casts doubt on the superiority of Nsaids over other pain-relief therapies, while another argues that some widely used anti-inflammatory drugs simply do not work when it comes to treating the most common forms of pain experienced by weekend warriors.

"There's a public perception that the pain from muscle soreness is related to inflammation, and if one can decrease the inflammation, then that will solve the problem," said Dr. Steven D. Stovitz, an assistant professor and director of sports-medicine education at the University of Minnesota in Minneapolis.

But not all the pain we feel after exercise is caused by inflammation. "Inflammation does cause pain, but a lot of other things do, too," added Dr. Stovitz, who is a co-author of a paper questioning the use of these medications for treating athletic injuries, which appeared last January in The Physician and Sportsmedicine, a medical journal.

Earlier this year, Dr. Declan Connolly, an associate professor of exercise physiology at the University of Vermont, and two colleagues wrote a review paper in The Journal of Strength and Conditioning Research that analyzed the scientific evidence supporting various treatments for the muscle pain, stiffness and weakness that occurs a day or so after performing an intense exercise for the first time or following extended inactivity.

Dr. Connolly and his colleagues looked at studies involving more than 50 therapies for treating this kind of pain, known formally as delayed-onset muscle soreness , including the use of various anti-inflammatory drugs. They found that in four out of five clinical trials, ibuprofen, even at more than double the recommended daily dose, failed to prevent muscle soreness and loss of muscle function in subjects who were made to perform strenuous exercises designed to induce delayed-onset muscle soreness.

If you get this syndrome, read the article. If you decide to take NSAIDs, please do not exceed recommended dosage.

One problem with supplements and herbals is that the physician often does not know that the patient is using them. Sometimes that can cause problems. Warning on herb widens

Patients who take St. John's wort to treat mild depression may be setting themselves up for even greater problems, especially if they don't tell their physicians about their use of the herb.

Doctors have long known that the supplement, derived from the blooming Hypericum perforatum plant, shouldn't be mixed with some AIDS drugs or the blood thinner warfarin, among others. The herb can dramatically reduce blood levels of those medications, rendering them ineffective and potentially jeopardizing the patient's life.

Now a study suggests that the popular botanical supplement could interact negatively with far more drugs than most people thought.

Researchers at the Medical University of South Carolina in Charleston found that St. John's wort could, at least theoretically, impair the effectiveness of scores of other medications, including some used to treat blood pressure, cardiac arrhythmias, high cholesterol, cancer, pain and psychiatric disorders.

"Consumers need to get the message that they could be putting themselves at risk if they don't tell their physician, pharmacist or health-care providers" about their use of the herb, said lead study author John Markowitz, an associate professor of pharmaceutical sciences.

Even if the interactions aren't life-threatening, some could have a dramatic impact on patients. Just last week, a researcher heading a small, federally funded study of St. John's wort reported that there may be some interactions between the herb and low-dose birth-control pills.

St. John's wort does have a modest effect on mild depression. However, it really works as an active drug. When I prescribe several drugs, the pharmacy runs them through an interaction program and notifies me (if I did not know already) of a potential problem. This rarely occurs with herbals.

Lisa Sanders writes well, and writes about important stuff. Morbid Obesity, Difficulty Breathing, Drowsiness

As usual we have a strong disagreement with Bernie. Perhaps I can never win this discussion, but I do love the repartee. To understand Bernie's viewpoint, visit his blog - The Careless Hand and scroll down to September 16, 2003 (his links do not work).

People are smart enough to figure out on their own what works and what doesn't. They buy a product and if it works, they buy it again and tell their friends. If not, they stop buying it and advise their friends to not use it. Noni juice is being touted as the cure for everything from sinus problems to toenail fungus. Does it work? I've got no idea, but in a couple of years the market will sort the question out. What's lost except a few bucks out of peoples' pockets if it turns out not to be true? Why double the size of the FDA to solve such a small problem? Magnets for healing seem to be on their way out. A few years ago, everyone was telling me how great they were. Now I don't hear much about them. And a new study fails to find any benefit to shoe magnets.

Bernie is wrong. People do not always know if something works. If you have heartburn, and try a remedy, you know if it works. But if you have breast cancer you cannot tell. Nor if you have congestive heart failure, or cirrhosis, or osteoporosis.

If patients want to try unproven remedies, why should I care? My problem with this approach is that they might use unproven substances when a proven substance exists. So anyone who encourages them to try a supplement rather than obtain medical advice, may be offering them false hope and inferior care.

If you work at a health food store , and give medical advice (and the advice they are giving is in fact medical advice) then you are implying that your supplements will work better than the medications I prescribe. This position is untenable. This industry leads to inferior medical care for many patients.

Those who sell supplements will always argue without using scientific principles. Once we accept the scientific method, they always lose. Now I do understand that many people do not believe in science . I find that unacceptable, and believe those who support medical decision making which does not stem from scientific principles dangerous.

I hope that I have made my point clear enough. You can sell any junk you want, but please do not put my patients in danger with your con artist marketting.

We are rarely taught phone medicine. We do need to provide some service in this manner. This article makes that more explicit - Doctors treating more patients over the phone

This article refers to a careful study of phone call decision making.

Use caution in health food stores What do you really expect? Do you think that health food stores expect credentials prior to hiring employees? Have you ever heard of the test on supplements?

Another study has been released showing that consumers need to be cautious regarding advice they receive in health food stores. Researchers posing as typical consumers found employees of these stores readily giving information and product recommendations ? often without mentioning possible adverse reactions or interactions with medical treatments.

CANCER PATIENTS, who may see health food stores as the extra help they desperately want, should be especially cautious. The recent report in Breast Cancer Research involved visits to 34 stores where the researcher posed as someone whose mother had breast cancer. Overall, 33 different products were recommended. Of particular concern is the fact that 68 percent of the store employees never even asked what medical treatment was being used.

I hope this study does not surprise anyone. I occasionally have visited such stores and observed. I see probable high school graduates telling innocent victims how to part with their money. The owners of such stores are, in my mind, true con artists. But as Nicholas Cage says in Matchstick Men - (and I paraphrase) - "I never take their money, they give it to me!".

RG Lacsamana (one of most loyal readers) writes:

I, like most Americans, believe in capitalism. But I disagree with DB in terms of treating health care as an economic product, to be divvied to those who can afford it and denied to those who cannot. To put it in more brutal terms, the concept of concierge medicine is elitism, a form of commercialization of medical care to be auctioned to the highest bidder.

I often suspect that those who try to justify this type of medical practice under the rubric of better and more accessible care do so mainly to better their life styles, that is, work less, get paid more, and absent all the hassles of everyday medical practice. I am not sure that is what most of us went to medicine for.

As physicians, I feel that our paramount concern is to ensure access to medical care to everybody, regardless of income. Nobody here rejects the notion of the rich spending their money as they wish, but to create an exclusive system for them is contrary to all the ideals that we as physicians were taught from the beginning of our studies. In the process of restricting membership in concierge medicine to a country-club atmosphere, we deny access to the rest of those who may not qualify because they don't have equivalent income.

Is that really what we want to do? Foster an atmosphere of a two-tiered system where we put signs on the door like SORRY, NO ADMITTANCE UNLESS YOU HAVE THE MONEY?

Let me pose another question: What if most primary care physicians decide they want to do nothing but practice concierge medicine? Would those who now defend the few concierge practices object to this? Don't you feel Americans would rise up in arms to demand the scalps of all physicians? You may say this is not going to happen, but it is foolhardy to defend a concept for a few physicians unless you feel this is equally good for the rest of us.

We are all familiar with the problems and hassles of medical practice, but in trying to get away from them, I feel it is important for us not to forget the core values of our profession. Medical care, already inaccessible to millions of Americans, ought not to be peddled like a commercial product.

This missive captures the thoughts of many. I have had several such discussions with colleagues in the past 24 hours (since the newspaper article came out).

I believe that we will have an increasing access problem in this country over the next few years. Retainer medicine will not cause the problem. The problem comes from the economics of generalist care.

We should not fool ourselves. While we do have altruistic goals, we also would like to make a decent living. This requires a fair return on our investment of 8 years of schooling and at least 3 years of residency. We often have school debts to pay when we start practice.

As intelligent professionals, we will make some decisions based on economics. Unless the economics of generalist care improve, you will see either a decrease in access or a decrease in quality.

Currently, retainer medicine provides niche care. There are a few patients who gladly pay the retainer few to get the access that all patients used to receive. We would love to provide that access to everyone. If we could afford it, we would have plenty of new graduates doing generalist medicine.

I urge us to look at why retainer medicine has emerged. It brings a message. Do not attack the messenger, attack the problem.

U.S. Medical Journal Questions Herbal Remedies

The editor of a leading U.S. medical journal called on Tuesday for tighter regulation of herbal remedies because of "potentially misleading" health claims made by distributors of the products.

"Because many dietary supplements have or promote biological activity, they must be considered active drugs and regulated as such," wrote Dr. Catherine DeAngelis, editor of the Journal of the American Medical Association.

Classified since 1994 by federal regulators as untested dietary supplements, U.S. sales of such popular herbal remedies such as ginkgo biloba, St. John's wort, echinacea, ginseng, garlic, saw palmetto and kava kava have risen nearly fivefold in the past decade to $18 billion in 2001, a study appearing in the same journal said.

Researchers Charles Morris and Jerry Avorn of Boston's Brigham and Women's Hospital analyzed hundreds of Web sites pertaining to health-related uses of herbal products. After linking to vendors' sites, they found four out of five made one or more health claims and half of those omitted the standard Food and Drug Administration disclaimer the product "is not intended to diagnose, treat, cure, or prevent any disease."

"The study ... provides evidence for the easily accessible and widespread potentially misleading claims made by vendors of herbal products on the Internet," DeAngelis wrote in her editorial.

She is right on this issue. This industry threatens our patients' health. We must speak out, and continue to speak out. Bravo!!

Read this - you just may not believe it. Oh, that medical privacy

Medicaid Mandarin (hint you may have to scroll down the page). Medpundit has struggled with the problem of whether to accept Medicaid or not. Read her story!

One of my colleagues will start our new retainer practice. UAB plans exclusive clinic access, for a price

"The health care is the same, but they will get amenities," said Dr. Douglas Tilt, who will start and head the Camellia Medical Group Practice. "There's a market for it."

The concept of boutique medicine, a trend that has been confined mostly to private practices in the Northeast and Northwest, has attracted criticism over medical favoritism. At the UAB Health System, officials said no state money will be spent on the clinic, while the service will make a profit for the system.

National health authorities have been debating the ethical and legal complications of providing concierge care to patients who are willing to pay a hefty price. There's concern about creating a medical system that caters to a small group of elite patients while most others wait in line to deal with harried doctors and nurses.

The American Medical Association in June gave a tepid approval to boutique medicine but warned that it could not be promoted as better care.

Dr. John Goodson, an internist at Massachusetts General Hospital and associate professor at Harvard School of Medicine, expressed concern about an academic medical center such as UAB going into boutique medicine.

Tufts-New England Medical Center recently became the first U.S. academic medical center to announce that it will provide boutique services to wealthier patients.

"These are really country clubs," said Goodson, an outspoken critic of boutique medicine. "I think it's very discriminatory."

But Tilt described boutique medicine as a movement back to the old-fashioned, close relationship between doctors and patients. It is being fueled by widespread frustration over the assembly line quality of modern medicine.

For instance, Tilt, a doctor of internal medicine, said he normally would have up to 3,000 patients and would see about 25 a day.

His boutique practice will be limited to about 300 patients, and he expects to see five or six a day. For patients, that will mean short waits and long visits with the doctor.

"There's not going to be a cadre of five or six people between you and the doctor," Tilt said.

For Tilt, it will mean getting back to the basics of medicine - really knowing patients and their personal needs.

Sounds a lot like Marcus Welby. The "debate" is always interesting to me. We live in a capitalistic society. If you want to spend more on something, you often get more value. This is true for legal advice (perhaps), automobiles, houses, clothes, and the list goes on.

If a patient wants to spend money to ease access to care, to have the physician's cell phone number, to receive house calls, why is that immoral? If one states that retainer medicine is immoral, then it follows that capitalism is immoral. Since I believe that capitalism is the fairest system (although one could certainly point out some flaws), then retainer medicine is fair.

Our hospital and clinic do much indigent care. We care for "all comers". We want the clientele who would want and pay for retainer medicine. They already support the institution and I suspect that their involvement will enhance our charitable receipts.

But, what we are really talking about is how miserable our current system of care has become. Money has not caused this movement, the practice climate has.

If any reader would like to write a dissenting view, given coherence and logic, I will gladly publish that view as a rant (with the proviso that as always I get a rebuttal).

The key - blame America. And perhaps we are to blame. We have pioneered the supersize. We have defined a lack of portion control. And this is the real problem!! 'Big portions' health warning

"Most weight loss success stories centre around reduced portion sizes. It's a simple fact, if you eat less, you'll lose excess weight."

And how many times have you heard a restaurant criticized because their portions are too small. And how many times have you heard a restaurant praised because of their generous portions.

Canada's medical marijuana leaves bad taste

Unfortunately many patients say the government's marijuana is terrible, with one saying it made him physically ill, another reporting it to be so weak and unpleasant he is returning it to the government with hopes of getting his money back.

One medicinal marijuana lobby group also says test results show the official supply has little active ingredient and is contaminated with lead and arsenic.

The health minister says she is willing to have her officials meet with patients to discuss the problems.

But patients say the government really needs to rethink its marijuana strategy, which they say is costing millions of taxpayers' dollars and is producing a drug that is worse than most street product.

I cannot even pretend to comment intelligently about this issue.

Medical Privacy Laws Frustrate Police

Privacy advocates say police have the same access to information as before the law took effect and can get anything they need with a warrant. But police predict it is only a matter of time until a case falls apart or a suspect escapes because of bureaucratic roadblocks.

HIPAA specifically allows hospitals to release information if police believe a crime has been committed. But legal experts say the new rules are so dense and the threat of liability so great that most hospitals are choosing silence in the name of HIPAA.

I love that quote. The rules are so dense!! I suspect the rules' density reflects the density of the rules' authors.

What Crisis?

But a new study by the General Accounting Office (GAO), the investigative arm of Congress, has reached a very different conclusion about the effect of rising malpractice premiums on consumers. Investigators who studied nine states found instances of localized but not widespread problems of access to health care mostly in "scattered, often rural, areas" that have long-standing problems attracting doctors.

And many of those highly publicized accounts of doctors who have retired or moved are, according to the GAO, either "not substantiated," temporary or involved only a few physicians.

Great, we will wait until we have a major crisis in health care rather than an impending crisis. The GAO both asked the wrong questions and used the wrong analytic techniques.

The AMA news also covered this story - GAO report calls liability crisis localized.

Media 'distorts risks to health'

News coverage of health issues gives a lopsided view of the risks faced by the public, a report says.

It claims disproportionate coverage is given to diseases such as vCJD, which affect few people.

While issues such as smoking, which do cause widespread poor health, it says, get relatively little attention. The study, by the King's Fund charity, analysed health reporting by the BBC, the Daily Mirror, the Daily Mail and the Guardian.

It compared the volume of reporting on specific health risks with the number of deaths attributed to those risks.

For example, 8,571 people died from smoking for each news story on the health risks of smoking, compared with 0.33 deaths for each story on vCJD (the human variant of 'mad cow' disease).

The study concluded that the news agendas of the print and broadcast media were skewed heavily towards dramatic stories, rather than issues that statistically have a greater impact on health, such as smoking, obesity, mental health and alcohol misuse.

Hmm, let me see if I understand. The media is not just concerned with reporting. Rather they want to garner market share - thus they pick dramatic stories in lieu of important stories. And they claim to be the fourth estate, keeping the government honest.

Exercise Is a Habit; Here's Why to Pick It Up This article reviews some very good studies on exercise benefits for women. It does ignore us men. I can only say, exercise is very good for us also!

My colleague, Dr. Amos Bailey, specializes in palliative and hospice care. He has written a textbook on palliative care - which you can read on-line - PALLIATIVE RESPONSE. Recently, he has discussed the problem that new interns have with the death declaration. We had discussed how to teach interns the proper way to go through this ritual. This piece (available for those who subscribe to the Annals of Internal Medicine) makes his point poignantly. Death Rituals . The author finishes:

All of this death flashed in my mind as poor Dr. Ernst crumpled in front of my father?s body. It was a pity that he had not known my Dad had been in the hospital. He might have said hello, might have told my dad what he now told my mom, my brother, and me?that my dad was a great doctor, a true family doctor. How touching, how real, how full, like the quilt of family life, Dr. Ernst?s month of days with my dad had been.

I wondered how Dr. Ernst would go through the nonritual of declaring death with us watching, we medical experts, we intimates of my father?s heart. I was aggrieved for this new doctor, laying a stethoscope on a nonrising chest, auscultating for heart sounds he knew he wouldn?t hear, pulling back the closed eyelid and shining his penlight at the nonreactive pupil. This ritual had no power to convince me that my father was truly gone. It had nothing to teach Dr. Ernst of what death truly means. My heart ached for myself, for my family, and even for the young doctor. I had never declared a doctor dead. I had never even declared a death in front of the family. Nurses ushered out every family to let me perform the impotent act without the presence of questioning words, wondering eyes, or aching hearts. Finally, toward the end of my residency, I taught myself what my medical training had failed to teach me. I learned to stand at the head of a deathbed and claim small moments of reverence for death and the life it leaves behind.

Do you ever wonder why students select specialties? Many factors matter, one is income and debt. I received this email today:

Good afternoon from the AAMC,

Below are student loan indebtedness figures for the Class of 2003. Note the source for this data is the AAMC 2003 Graduation Questionnaire.

Indebted Graduates, Class of 2003*
Mean All Schools $109,457 (up 5.4%)
Median All Schools $105,500 (up 5.5%)
Mean Public Schools $97,275 (up 6.4%)
Median Public Schools $100,000 (up 8.7%)
Mean Private Schools $129,392 (up 4.5%)
Median Private Schools $135,000 (up 6.3%)

Percent at $100,000 or higher*
All Schools 58.0%
Public Schools 51.7%
Private Schools 67.8%

Percent at $150,000 or higher*
All Schools 25.4%
Public Schools 13.2%
Private Schools 44.2%

Percent at $200,000 or higher*
All Schools 7.5%
Public Schools 2.8%
Private Schools 14.8%

Miscellaneous Information*
Percent graduates all schools with debt 82.1%
Percent graduates public schools with debt 84.0%
Percent graduates private schools with debt 79.4%

* Source: AAMC 2003 Graduation Questionnaire

Besides Prescription Drugs

MEMBERS OF CONGRESS are pretending that the Medicare bill, currently bogged down in conference negotiations, is simply about prescription drugs. Not quite. Both House and Senate versions of the bill contain provisions designed to help particular companies and congressional districts, benefiting everyone from Weight Watchers International to marriage therapists to doctors in Alaska. The legislation also contains measures to shore up rural health care, adjust doctors' pay and patch up bits of the Medicare system that don't work. And it has new rules allowing the re-importation of prescription drugs from Canada and elsewhere. Some of these measures are justified, some not.

The most expensive provision in the House bill would create "health savings accounts" -- in effect, tax shelters. While it is a good idea, in principle, for people both to save for health care costs that health plans don't cover and to manage some of their health-care money themselves, this is an extremely expensive program. The cost to the budget is more than $170 billion over 10 years, which comes on top of the $400 billion that the bill is already going to cost -- and this at a time of soaring budget deficits. The creation of costly health savings accounts should be considered as part of a fundamental restructuring of health care, not tacked on as an afterthought.

Regular readers know that I favor health savings accounts. I would like to see a tighter linkage between the patient and health care cost decisions. While I have written often about this concept, Robert Prather - Insults Unpunished - has written even more often. For a feel for this issue check out - Health Care Costs Yet Again.

I believe that the Washington Post has this issue wrong. In the meantime, I do not expect any compromise on these issues. We will go another year with politicians dancing their dance. And our single payor system for the elderly gets more unfair to both patients and physicians.

The NY Times discusses this Texas vote today - Malpractice Suits Capped at $750,000 in Texas Vote. But the proposition is even better than the headline.

The passage of the measure by 51 percent to 49 percent enshrines in the voluminous Texas Constitution a legislative limit of $750,000 per case on noneconomic claims for medical malpractice. Under this limit, a patient injured by faulty medical care can collect a maximum of $250,000 from a doctor and an additional $500,000 from one or more hospitals or health care providers for pain and suffering, disfigurement and other compensation. Awards for loss of income and medical expenses are not capped. The $750,000 cap cannot be appealed to the courts.

Good news for Texas!!

One might even send this article to new patients prior to their first visit. Doctor visits better with readiness

Fear and embarrassment, time constraints and forgetfulness were the top reasons people in the survey cited for not being more inquisitive with their doctors. Experts said it is critical to spend a few minutes before an appointment making a list of questions, since studies have shown 80 percent of doctor's diagnoses are based on what patients tell them about their symptoms, history and lifestyle.

Amen! We must get a good history. We can only ask questions when you give us the proper clues. Do not hide information from us.

Texans narrowly pass Prop. 12. If you are not familiar with Prop 12, read RangelMD - Regarding proposition 12; Trial Lawyers = Roaches

Wow! I wish that I had written this piece. Kudos! I'm Sorry, Your Illness Is Coded for Only 15 Minutes. Please read the entire article. Here is a taste:

Whatever happened to simple doctoring? For me, and for many other physicians I know, it has evolved into a complex balancing act, impossible to pull off, as we try to give patients the care and attention they need while struggling to maintain income and personal time under a host of new pressures. Sometimes it seems as if everybody is losing out. And with Medicare poised to lower doctors' fees an additional 4.2 percent in 2004, it's only going to get worse.

The daily squeeze hit me hardest the morning I saw a likable 68-year-old patient of mine waving at me through my waiting-room window. I'd been treating him for years, but he didn't have an appointment and I barely recognized him with his newly bald head, yellowed skin and shaking hands. My office staff wanted to turn him away because the day's schedule was already packed, but I sensed his desperation and made time for him. In the examination room, he told me that his oncologist had informed him bluntly that his cancer had spread and then dismissed him. I was the man's internist, his gatekeeper to the medical world, and he had returned to me -- not for expertise, but for warmth.

I ended up spending an hour with him and told him that he could come in again any time, with or without an appointment. And I felt good about this -- until the swelling crowd in the waiting room reminded me that my other patients had what in their eyes were equally important problems and equally urgent claims on my ever-shrinking time.

The pressures are fierce for doctors to compromise their professionalism, their humane instincts, for business reasons. The Medicare Payment Advisory Commission suggested last year that the United States needs a payment system that more accurately reflects doctors' rising costs. Most doctors would agree. While it is true that we still make a decent living, at the same time we must hire more and more staff members to handle certifications, pre-certifications and referrals while also accepting lower payments. And with the new fee reduction almost certain to filter down from Medicare to the HMOs the way such reductions have done in the past, it will become increasingly harder to stay level.

This is powerful stuff. I rant about these problems regularly, but this article really does a great job of explicating the problem. Oh, and did I remind you to please read the whole article?

Half-Full or Half-Empty?

I was drinking too much, and I had to cut down soon or check myself into a rehab with a tight curfew. My liver enzymes were high, my spirits low and my prospects in life profoundly middling. I tried all the tricks: no drinking before dinner, no hard liquor except on weekends, no beer unless accompanied by food or a televised sporting event of national import. Still, every time, that first drink proved too many, as it does for many of my kind. For us, there is no cutting down. We have to quit -- one day at a time, as corny as that sounds. And so, with the help of prayer and other people, I've been sober for more than 10 years. It hasn't been easy.

Recently, it got a little harder, thanks to the very latest medical research. I've grown to loathe the latest medical research. As someone who likes to think he banished booze partly as a way to save his health, imagine my consternation at the reports, newly released and widely disseminated, that a glass of wine a day -- just one, mind you (not 11, as was my wont), and only if the wine is made from certain varieties of grapes -- may significantly increase your life span. Thanks a lot, doctors. Just what I needed to hear right now. I've accustomed myself to the taste of diet root beer, to no longer being any fun at parties and to rudely turning back sommeliers when they glide up to my table in ritzy restaurants, and for what? So I can expire before my time -- or at least before what would have been my time had I been able to drink in moderation.

Our culture does seem to reward and support moderation. Somehow we need to make drinking less important, and more acceptable. Many cultures accept drinking in moderation for the majority. Our culture has a strange attitude about drinking - which I think leads to our binging. Unfortunately, the author has proved to himself that he cannot handle moderation.

Patients in Florida Lining Up for All That Medicare Covers

Boca Raton, researchers agree, is a case study of what happens when people are given free rein to have all the medical care they could imagine. It is also a cautionary tale, they say ? timely as Medicare's fate is debated in Congress ? for it demonstrates that what the program covers and does not cover, and how much or how little it pays, determines what goes on in a doctor's office and why it is so hard to control costs.

South Florida has all the ingredients for lavish use of medical services, health care researchers say, with its large population of affluent, educated older people and the doctors to accommodate them. As a result, Dr. Elliott Fisher, a health services researcher at Dartmouth Medical School, said, patients have more office visits, see more specialists and have more diagnostic tests than almost anywhere else in the country. Medicare spends more per person in South Florida than almost anywhere else ? twice as much as in Minneapolis, for example.

But there is no apparent medical benefit, Dr. Fisher said, adding, "In our research, Medicare enrollees in high intensity regions have 2 to 5 percent higher mortality rates than similar patients in the more conservative regions of the country."

Doctors say that Medicare's policies are guiding medical practice, with many making calculated decisions about whom to treat and how to care for them based on what Medicare covers, and how much it pays.

"The bottom line is that the stuff that reimburses well is easier to get done," Dr. Carl Rosenkrantz, a Boca Raton radiologist, said.

Thomas A. Scully, administrator of the Centers for Medicare and Medicaid Services, said he knew the situation all too well.

"We have a system that does nothing to look at utilization," Mr. Scully said in a telephone interview. "If you send in a bill and you are legitimate, we pay it."

And patients do not consider the cost of health care. When the consumer (the patient) spends money without accountability, we get the expected outcome. Our system (and not just Medicare) is broken because we have no relation between the cost of care and what the patient pays. This issue has complexity. We want everyone to have access to good health care. However, we would all agree that one can have excessive health care. We have choices that one could make, but no incentive to make them. In fact, physicians often have a perverse incentive - getting paid for doing more rather than doing less (when less may be indicated).

Read the remainder of the article. It points out the plight of generalist care very well. It concludes:

Dr. Colton, the internist here, is frustrated, too.

"The system is broken," he said. "I'm not being a mean ogre, but when you give something away for free, there is nothing to keep utilization down. And as the doctor, you have nothing to gain by denying them what they want."

We do need a better system. And that better system is not a one payor system. It is a system with patient accountability.

Smoking Killed Five Million Worldwide in 2000

Nearly five million people died from smoking-related diseases in 2000, accounting for almost equal numbers in the developed and developing nations and painting a bleak picture for the future, researchers said on Friday.

Men accounted for three-quarters of all the deaths, a figure rising to 84 percent in the developing nations where 930 million of the world's 1.1 billion smokers are to be found, researchers from Harvard School of Public Health in Boston, Massachusetts and Queensland University, Australia, said in The Lancet.

The main causes of the tobacco-related deaths were heart and lung diseases, they noted.

The news comes as the major tobacco companies, increasingly under siege in the industrialized world, switch their sales efforts to emerging nations with their expanding populations and rising spending power.

Do not smoke. If you smoke, stop. If you know someone who smokes, get them to stop.

Doctors should not discuss resuscitation with terminally ill patients - FOR. Their argument:

Patients increasingly want to participate in decisions about their medical treatment. Although this is appropriate in most circumstances, discussing cardiopulmonary resuscitation with terminally ill patients is not practical, sensible, or in the patient's best interests. In these special situations, patient involvement is tokenism and entirely of negative value.

The UK guidelines on cardiopulmonary resuscitation require doctors to attempt resuscitation in all patients who have a cardiac or respiratory arrest unless a do not resuscitate order exists. Doctors are required to discuss the value of resuscitation with their patients before making a do not resuscitate order (box). However, discussion about cardiopulmonary resuscitation forces the patient to confront the inevitability of their fate, with negative consequences. Patients need to maintain some hope?if not for a cure then at least for some comfort. It is not appropriate that all comfort is lost as a result of the inappropriate blanket application of a facile rule. This is particularly true when the rule forces patients to make a choice, when in reality they have no choice.

Their opinion goes on for several more paragraphs. I strongly disagree with this opinion, as does this response - Doctors should not discuss resuscitation with terminally ill patients - AGAINST This opinion in brief:

Patients with chronic illness and cancer have special needs. Their treatment options are complex, are offered over longer periods of time because of improved survival, and have benefits and risks that are difficult to weigh. Terminally ill patients often have to make decisions about their final treatment after a protracted period of illness, investigation, and treatment. But this does not mean they don't want to be involved. Poor communication and information leads to poor patient satisfaction, symptom management, and compliance. New guidance on effective models of supportive and palliative cancer care suggests that effective training in communication can improve patient satisfaction and some outcomes.

Discussion about cardiopulmonary resuscitation is as important as discussion about any other treatment in terminally ill patients. Some doctors may avoid talking about do not resuscitate orders because they feel it is important to offer a positive outlook. However, silence or incorrect information has been shown to heighten the fear, anxiety, and confusion experienced by patients and families. Uncertainty and anxiety can be worse if patients receive mixed messages. Therefore, everybody caring for the patient and family needs to be kept fully informed of important decisions and wishes.

Doctors have been shown to be inaccurate at predicting the views and wishes of patients and may thus be unlikely to guess patients' desire for resuscitation. A recent study of 255 patients who were designated do not resuscitate in the nurses' files (investigators were unaware of patient wishes, or the extent they were involved in discussions) found that 48% of patients rated their quality of life as good, whereas physicians rated it good for only 9%; 71% of physicians relied on their assumptions about patients' quality of life when making a decision about resuscitation. These results show the importance of involving patients in decisions about resuscitation.

The article continues with other important points.

I am somewhat surprised to see this debate. I had thought that we had resolved this issue over the past 15 years. Perhaps this debate is peculiar to Great Britain. I am not aware of such a debate in the United States. But I might have missed signs of these feelings.

I feel so strongly about the value of palliative care, and advanced directives that I have assumed my feelings to be the norm. Let me know if they are not.

May he rest in peace. This one shakes me. John Ritter was the same age as me. He looked healthy. He suddenly died. This article explains why. For me knowing why is helpful. Aortic Tear That Killed Ritter Is Rare

A tear in the aorta, the heart condition that killed actor John Ritter, is a rare medical disaster that can strike without warning.

The condition, called an aortic dissection, is a break in the main artery that carries blood from the heart. The lining of the aorta tears, separating -- or dissecting -- the middle layer of the vessel wall from the still intact outer layer.

About three-quarters of these occur in people age 40 to 70, and the peak years are 50 to 65. Ritter was 54.

About one-third of patients die within the first 24 hours, and half die within two days.

Typically doctors treat patients in intensive care with drugs to reduce heartbeat and blood pressure. Surgery can sometimes repair the tear, although the risk is substantial.

A variety of medical conditions can cause the artery wall to deteriorate, leading to the tear. The most common is high blood pressure. Others include inherited connective tissue disorders and birth defects.

Symptoms usually begin with sudden severe chest pain. As the tear progresses, it can block off the points at which other arteries branch away from the aorta, stopping blood flow. This can trigger a stroke or heart attack, among other things, depending on which arteries are affected.

Prior to this, the most famous person that I know had died of aortic dissection was Flo Hyman, who had Marfan's Syndrome - Marfan Syndrome: A Silent Killer.

I suspect the John Ritter had known or unknown hypertension.

Acute aortic dissection is one of the 7 deadly causes of chest pain that I use as a teaching session each month. These are all potentially treatable and potentially fatal. My list:

• Acute myocardial infarction
• Aortic dissection
• Pericarditis with tamponade
• Pulmonary thrombolembolic disease
• Pneumonia
• Tension pneumothorax
• Boorhave's syndrome (ruptured esophagus)

As a physician, when someone famous dies of an unusual cause, I try to learn and teach. In the future, when I discuss the 7 causes, I will include John Ritter's aortic dissection in the discussion.

Surprise!!! Exercise and diet work. Exercise Plus Weight Loss Reduces Blood Pressure in Syndrome X Patients

A program of exercise and weight loss is an effective treatment for hyperinsulinemia and significantly reduces diastolic blood pressure in patients with syndrome X, according to a report in the September 8th issue of the Archives of Internal Medicine.

"Patients with high blood pressure often exhibit syndrome X, an aggregation of abnormalities in carbohydrate and lipoprotein metabolism associated with increased risk of coronary heart disease (CHD)," Dr. Lana L. Watkins, of the Duke University Medical Center, Durham, North Carolina, and colleagues note.

The researchers examined the effects of a 6-month intervention with either aerobic exercise training alone or a combination of exercise and a structured weight loss program on CHD risk factors associated with syndrome X. Fifty-three patients with hyperinsulinemia, dyslipidemia, and high blood pressure, characteristics of syndrome X, were included in the study.

Twenty-one patients were randomly assigned to exercise only, 21 to exercise plus weight loss, and 11 to a control group. The team measured glucose tolerance, lipid levels, and blood pressure at baseline and after treatment.

Significant reductions in hyperinsulinemic responses to glucose challenge were observed in both the exercise-only (p = 0.003) and exercise plus weight loss groups (p < 0.001).

Panel Rejects Pleas to Curb Sales of a Widely Abused Painkiller

Federal drug advisory panel yesterday rejected pleas from members of Congress and drug enforcement officials that sales of the widely abused painkiller OxyContin be severely restricted.

But officials from the Bush administration told the panel they were seriously considering even broader rules requiring doctors to get special training before being allowed to prescribe OxyContin or any other controlled narcotic. The changes are intended to stem a growing tide of prescription drug abuse.

OxyContin is responsible for 500 to 1,000 deaths a year, a panel member estimated yesterday. Some two million people used narcotics recreationally in 2001, the last year for which figures were available, up from 1.5 million in 1998 and 400,000 in the mid-1980's, according to data presented to the panel.

Introduced in 1995, OxyContin is a pill that gradually releases steady amounts of narcotics for 12 hours. Before OxyContin, patients were required to take pills every four hours to achieve significant pain relief. By crushing OxyContin pills, drug abusers can get the full, 12-hour narcotic effect almost immediately. Snorting or injecting the crushed pill can lead to overdose and death.

Some panel members suggested that the death rate could swell substantially if Purdue Pharma, the maker of OxyContin, was allowed to sell Palladone, a new, more powerful painkiller that Purdue has asked the Food and Drug Administration to approve for sale. Most panel members, however, gave tepid support to Purdue's plan to introduce Palladone slowly. Several suggested the drug's initial introduction period should be extended to a year from the company's proposed four months.

The active ingredient in Palladone is identical to that in Dilaudid, "the drug of choice for addicts," said Laura Nagel, deputy assistant administrator of the Drug Enforcement Administration's office of diversion control, who participated in the panel discussions.

Wow! Let me frame the debate. What is more important? Should we have a great option for pain relief - especially for those with chronic pain? Should we have a valuable option for palliative care? Do these concerns outweigh the abuse concerns?

Kudos to the committee for worrying more about the deserving patients. Maybe this committee could consider medical marijuana.

The panel and the Bush administration do want physicians to use these drugs more intelligently.

Under the administration's proposal, doctors would have to prove that they had taken a painkiller class before receiving permission from the Drug Enforcement Administration to prescribe controlled narcotics. Such permission is now granted routinely without special training. The agency requires that doctors register for this permission every three years, and under the administration's proposal, the agency would require that doctors undergo refresher training every three years.

"We should restrict the prescriptions of these drugs to the educated physicians," said Dr. Carol Rose, a panel member and an anesthesiologist from Presbyterian University Hospital in Pittsburgh.

Sometimes we forget that we really never take care of one patient. We are always caring for the patient and those who love him/her. I just read this poignant tribute to a father - it reminds me. Everything Is Gonna Be All Right...

Dad peacefully embarked on the next leg of his journey this morning, just a few hours after I last kissed him and touched his warm forehead. It saddens me that I was not with him when he took his leave, but perhaps he wanted to spare me that. And that is kind of cool. It was his way, you see: Dad was a proud, stubborn, fiercely independent person, and that is how he made his exit. I am so proud to be his daughter and to see his face when peering into the mirror. I will treasure many wonderful memories of him and will always hold him in my heart. But I doubt i'll ever get over this unbearable ache in my soul...

Regular readers know my position on drug legalization. While I admit that I do push the edge with that position, I am most adamant on the medical marijuana issue. Arnold agrees, as does this National Review writer. Terminator on Pot

The flash point in the marijuana wars at the moment is the fight over the medical use of the drug. Schwarzenegger is in favor of legalizing it, as are most Californians. The state passed a ballot initiative permitting the medical use of marijuana with 55 percent of the vote in 1996. Eight other states have legalized it as well, creating friction with the feds, who don't want grievously ill patients to get relief if it means taking the untoward expedient of lighting a joint.

Of course, if the congressmen who maintain the federal prohibition on medical marijuana had to put their heads in toilet bowls several times a day to vomit from the effects of chemotherapy, they might be less categorical in condemning what some patients do to relieve their nausea. But the federal government has never been famous for its common sense or flexibility, so the war against medical marijuana lumbers on, even in the states that have legalized it.

Since the feds systematically suppress attempts to study the potential medical benefits of marijuana, the most important datum in the debate is simply this: Some patients say smoking marijuana is the best way that they can get relief from the nausea associated with chemotherapy and the wasting illness associated with HIV/AIDS. Smoking the drug works better for some patients than Marinol pills, which contain pure THC and have more side effects.

The New England Journal of Medicine has advocated the legalization of medical marijuana. In May, the journal Lancet Neurology reported that marijuana's active components alleviate pain in almost every lab test, and called it potentially "the aspirin of the 21st century." Earlier this year, the New York State Association of County Health Officials came out in favor of medical marijuana.

The ill health effects of marijuana come from inhaling the smoke into the lungs. This isn't a problem if the use is only short-term, or if the user has a terminal disease. Consumer Reports (no less) writes "that for patients with advanced AIDS and terminal cancer, the apparent benefits some derive from smoking marijuana outweigh any substantiated or even suspected risks."

Drug warriors worry that permitting medical marijuana "sends the wrong message" to teenagers. But the popularity of various drugs among youth moves in broad patterns that are not readily influenced by what federal "drug czar" John Walters says or does. And the fact is that ? God bless them ? cancer and AIDS patients aren't glamorous, and are unlikely to prompt an epidemic of youth pot smoking.

Might medical marijuana be abused? Of course. That's also true of a host of prescription drugs. But don't tell Walters. Next he will be trying to deny patients the use of morphine and OxyContin.

What drug warriors really fear is that if medical marijuana is permitted, it will harm their effort to depict marijuana as utterly nefarious and create the opening for a more rational debate about the legal status of the drug. The drug warriors are already losing ground. The National Organization for the Reform of Marijuana Laws recently celebrated a vote in Congress that had 152 members voting to ease the federal crackdown on medical marijuana.

That's progress, although the cause still needs a high-profile spokesman. If it happens to be a formerly swinging California bodybuilder who enjoyed the 1970s a little too much, so be it.

As a major advocate for palliative care, I worry that the governmental position (which has existed over several administrations) decrease the ability of some patients to achieve their best possible palliation. We have no compunction about prescribing high doses of morphine (or similar such drugs). In fact, we are appropriately criticized when we do not help these patients achieve adequate pain control Narcotics are drugs of abuse, but they are also drugs of palliation. We should all understand that medical marijuana fits in the same definition. We need brave politicians who understand this issue and champion doing the right thing. One can wish.

Most physicians believe that the United States has the best health system in the world. I am aware of those who argue against that idea, but I dismiss them as a very vocal minority.

They would argue that outcomes are the same or better in Canada and Great Britain. This article should make them pause.

Op death rates 'far higher' in UK

Patients undergoing major surgery in the UK are four times as likely to die as those in the US, researchers have found.

The most seriously ill NHS patients are seven times more likely to die than American patients who are as sick.

University College London and Columbia University New York researchers looked at 1,000 patients in each country.

They said a shortage of specialists and intensive care beds and longer waiting lists in the UK affected outcomes.

The NHS carries out around three million operations each year, including around 350,000 emergencies, which carry a higher risk of complications.

As the health care cost debate accelerates, I hope we physicians make the case that better health care does cost more. I have argued before that improved health will take a greater share of GNP, and be worth it.

Now I am not so naive to think that we could not decrease some expenses - especially administrative expenses. However, this article reinforces my belief that our system is far greater than a single payor system.

Professor Monty Mythen, head of anaesthetics at University College London, who led the study, told the Daily Mail: "In America, after surgery, everyone would go into a critical care bed in a highly monitored environment.

"That doesn't happen in the UK.

"In the Manhattan hospital the care (after surgery) is delivered largely by a consultant surgeon and an anaesthetist.

"We know from other research that more than one third of those who die after a major operation in Britain are not seen by a similar consultant."

Professor Mythen said NHS waiting lists put patients "at greater risk".

He said: "We would be suspicious that the diseases would be more advanced simply because the waiting lists are longer."

This article should make those who favor one payor systems reconsider their positions. The coming articles should shed even more light on this issue. Kudos to the physicians for performing this important research.

Bernie writes

The contentious and adversarial system by which we investigate, prosecute and compensate for medical errors is at the heart of our incapacity to build an effective performance and quality improvement system in this country.

Maufacturers don't seem to have any problem improving the safety and reliability of their products despite the fact they are liable to be sued over these issues. Why is it so different for medical practitioners?

Bernie, Bernie, Bernie. You still do not understand.

Manufacturers have several advantages. They can raise prices to pay for safety (or increased insurance costs). Physicians have fixed pricing (with variable expenses). Manufacturers generally control a significant portion of a market. Each physician represents a very small business. Manufacturers focus on making a specific product (or two or even 10). Physicians have patients with unknown problems coming for diagnosis and treatment. The complexity of the human body leads to a real probability of undesirable outcomes - even when we do everything right.

Medicine is complex. We can do better. We should do better. But we will only improve when the system rewards us for quality. And currently there is no clear way to measure quality consistently nor is there a way to reward quality. If a car manufacturer really has better quality - many consumers learn and preferentially buy cars from that manufacturer. The individual physician cannot expand his/her practice to accept the increased business.

There are just too many dissimilarities here to even consider this question. We are not manufacturers. We are physicians - and there lies the beauty and the problem.

Strength vs. Power

Admit it. You thought the terms were synonymous. Wrong, say exercise scientists. "Strength" is a measure of how many pounds you can move in one push or pull. "Power" measures how fast you can move a weight in a given amount of time.

The different properties are functions of the two kinds of fiber in skeletal muscles: slow-twitch fibers, which are mostly responsible for strength, and fast-twitch fibers, which supply power, says Scott Trappe, director of the human performance laboratory at Ball State University in Muncie, Ind.

Novices can build strength in major muscle groups by lifting about 60 percent of the maximum they can heft one time, performing eight reps each once or twice weekly, then working up, after a month, to three or four sets weekly. That's from a meta-analysis of 140 strength training exercise studies published this year in the journal Medicine & Science in Sports & Exercise.

To gain power, recommends the American College of Sports Medicine, perform weight-lifting sets that load weight on more than one joint, such as holding dumbbells while lunging or lifting a free bar while rising from a squat.

A good weight training progam will work on both strength and power. As we age we want to maintain power. Power requires strength, therefore work on strength first.

Some readers do not believe in PTSD. Perhaps the argument centers more around labels than observed behavior. How do we label that behavior? And does that label influence (in a positive way) our treatment options.

The following article, in my reading, points out the pros and cons of the debate we have had over the past few days. Calculating the Toll of Trauma

New trauma reawakens old trauma, or so mental health professionals have often asserted. And in the aftermath of Sept. 11, many experts predicted that the terrorist attacks would exacerbate or rekindle psychiatric problems in people with a history of post-traumatic stress disorder or other mental illnesses, and increase the demand for psychiatric treatment.

But a new study has found that the use of mental health services at medical centers run by the federal Department of Veterans Affairs in New York and Washington, the cities most directly affected, did not rise after the attacks on the World Trade Center and the Pentagon.

Dr. Robert Rosenheck, the lead author of the study and the director of the V.A.'s Northeast Program Evaluation Center, said the study indicated that "people who had P.T.S.D. were upset by the events of Sept. 11, just like other people, but it didn't add to their mental illness."

The findings, he added, raise questions about how researchers define trauma and suggest a need to distinguish more clearly between emotional distress, a normal response to horrific events, and stress disorder, a pathological response.

"It's ingrained in our culture to express the horror of something by saying it's so bad that it causes mental illness," said Dr. Rosenheck, a professor of psychiatry and public health at Yale.

But the study, in the September issue of The American Journal of Psychiatry, is controversial because some clinicians who work with veterans say they believe that more patients came in for treatment after the attacks. And another smaller study of V.A. medical centers in the New York area found that more cases of post-traumatic stress disorder were diagnosed among veterans than expected in the nine months after Sept. 11.

One can easily explain the disparate findings. The first study looked for trends in patients who already carried the diagnosis of PTSD. It avoided anecdotal evidence, but rather collected data. And the data refuted the new trauma hypothesis.

The latter study recorded more new diagnoses of PTSD. And that is no surprise. We make diagnoses that we expect. We often use the following expression: "If the only too a carpenter has is a hammer, then everything looks like a nail!". If after 9/11 psychiatrists expected PTSD, they would likely make the diagnosis more often.

This article does not resolve our debate. It does clarify the issues a bit.

Can't we all just get along? Let's talk more, litigate less

This interesting article written by two negotiation experts, tries to bring common sense to the malpractice crisis.

The irony of course is that, bottom line, most stakeholders voicing an opinion on these issues want slight variations on the same theme: high quality, cost-effective care that is accessible and affordable to all.

Getting there is the problem. We have been fighting about health care in this country for years. Might this not be the time to propose a health care cease-fire, to get the sides talking, and out of it, to find solutions reflecting what is best for and best about the country?

The matter of performance improvement provides a pragmatic illustration. Performance improvement is directly tied to adoption of a linked series of clinical protocols, behaviors, expectations and routines. Clinical decision-making must be based on evidence and sound science. Care must be measured and caregivers must be accountable for their decisions and actions. The measurement process must create information that can be used to meaningfully assess and improve the quality of care.

Problems and errors in the course of care are likely and perhaps even inevitable. Every reasonable effort should be invested to reduce their likelihood, and when they do occur, what is learned from those errors should be used to generate information, corrective actions, and changes that will decrease the likelihood of recurrence.

These activities taken together represent a simple formula that would save lives, money, and an enormous amount of distraction. And yet, adoption of such a recipe has been elusive at best. Why?

People are not talking. The mantle and impact of medical malpractice is about far more than just the verdicts and awards in the courtroom or negotiations on the courthouse steps. And it is about far more than the high costs involved in financing this expensive system.

The contentious and adversarial system by which we investigate, prosecute and compensate for medical errors is at the heart of our incapacity to build an effective performance and quality improvement system in this country. The tort system essentially creates a "wall of silence." Physicians are discouraged from discussing a medical situation openly and honestly for fear of harsh and punitive legal ramifications. As a result, the litigious nature of error identification and assessment has hindered efforts to fully disclose and translate important findings into new knowledge that can be shared, learned and adopted.

Go back and read that last paragraph one more time. The tort system paradoxically decreases well intentioned attempts at improving health care. The threat of lawsuit (as much as the lawsuits themselves) create a paranoia and block improvement processes.

We have written in previous columns about the methods and advantages of alternative dispute resolution as a means to encourage patients and physicians to talk safely and constructively with one another. Mediated conversations between patients and caregivers following an unexpected outcome have been found to reap important advantages for both sides.

Our research indicates patients are eager for three key outcomes:

• To know what happened.
• To receive an apology or an acknowledgement from the caregiver.
• To see that corrective actions are taken so that what happened to them will not recur.

These objectives are in keeping with those of the caregiver, who is:

• Eager to reduce anxiety related to the unresolved claim or complaint.
• Wanting to communicate on a human level with the patient.
• Encouraged and assured by the prospect that corrective actions can be taken to reduce the likelihood of a repetition.

For both sides, the notion that something good can emerge out of something that was unintended and bad provides just the sense of hope and resolve that is essential, both to the conflict resolution and to the patient safety processes.

This philosophy makes much sense. I fear that my skepticism does not allow me to believe. Until we have true tort reform, I do not know how we can get to this point. But for a moment, let me dream.

Some comments require their own space. Stef has provided the following comment concerning PTSD (I am moving it here for those who do not read many comments).

I am struck by the comment of RG Lacsamana referring to a tendency in the United States, to "medicalize a number of normal human responses to the assaults (sometimes unbearable) of daily living. Yet, over periods of history when there were wars, famines, earthquakes and other natural forms of destruction, I did not feel that we were stressed to the point that a lot of us could not function..."

There really are 2 issues here.

Tne is a question of epidemiological history, and the other concerns our present use of formal designations (like diagnoses) to allot social resources.

The history question is whether we have objective evidence for something like post-traumatic stress disorder manifesting in historical times prior to now. I really don't know.

The second issue, and to me more intriguing one, is the way in which a medical diagnosis is required today, as a kind of gate pass for benefits and services. I submit that our society's reliance on formal diagnostic designations is merely an inverse reflection of the rather formal way in which our society rations its resources in response to persons who really don't fit in or need help.

1000 years ago, someone with a serious psychiatric disorder might have been excluded from society as "crazy", or prosecuted and killed as a witch, or they might have been pitied as a "poor loon," perhaps tolerated and fed on the edge of an English village. Of these possible social responses, only killing the misfit required a formal review and designation, in the form of a witch trial, and sometimes the trial began with the excecution itself (ie "if she doesn't burn, then she is not a witch").

What makes today's society wildly different is its reliance on bureaucratic mechanisms for allotting not just criminal penalties, but its help as well. Such bureaucracies, including the Veterans Health Administration, generally require formal designations to sort out who to help and who they wish not to help, and leave for some other bureaucracy to handle. Every doctor is painfully familiar with these bureaucracies; health insurance plans insist on diagnostic terms to justify every lab test we order, even when we have no idea what the diagnosis is!

If there were strong informal communities where we took in, housed and fed our misfits (and that is rarely the case today), then the labels would not be needed.

Conversely, the bureaucratic forms of help-giving (VA, SSDI, etc.) necessitate labels. Why our reliance on bureaucracy? One aspect has to do with the vast amount helping resources to be managed. It is no longer simply a question of whether or not to throw some food scraps over to the poor "loon" on the edge of our prototypical English village. Modern states have immense economic resources to manage, and high expectations for order--we have the power to house those who can't succeed in our economy in a subsidized apartment, and if we elect not to house him, then we may elect to jail him on charges of vagrancy, or admit him to a medical ward for a few weeks a year (all costing about the same, incidentally). Each one of these steps requires some kind of formal designation. The one thing our society finds uncomfortable is leaving a person undesignated and alone, perhaps to die helplessly alone on the edge of a village or under a bridge.

So we have at least 4 forces that will contribute social impetus to use diagnostic terms like PTSD

• (A) Great power to help, matched by
• (B) Discomfort with informal social mechanisms for allotting such resources as modern apartments and health insurance, complemented by
• (c) Distaste for leaving our misfits undesignated and alone (perhaps to die)...
• all of these things create an impetus to assign bureaucratically useful labels.

The concept of PTSD has implications as both (a)a serious medical diagnosis and (b) a socially-useful label for the rationing of costly social resources such as housing benefits, hospital beds and prison cots. If the 2 implications were not related, then of course, the term would be useless.

The actual application of the designation "PTSD" to any given person, however, reflects an interplay of both types of consideration. The discomfort we feel in response to application of a term like PTSD probably reflects our ambivalence toward the actual persons in question and toward the bureaucracies we have set up to handle them.

Knowing Stef (we actually work together) I would note that this commentary reflects a recent lunch conversation. I believe that he does a great job of explaining why many physicians use the label - labels make it easier to achieve our desired goal of helping these unfortunates. However, I wonder about the medication implications of this particular diagnosis. I see too many patients who receive this diagnosis and then an extraordinary cocktail of CNS active medications. How do we separate the bureuacratic need for PTSD with a more firm understanding of appropriate CNS active treatments?

Unholy medicine

We now know where the "prestigious" New England Journal of Medicine (NEJM) can be found, at least on one issue. And while we applaud its honesty, we must point out that in the issue of human cloning, honesty without objectivity is not the best policy - for medicine or humanity.

In the July 17 issue of the NEJM, editor Jeffrey M. Drazen, M.D., took issue with the House of Representatives' decision to ban research on and medical use of treatments "derived from embryonic stem cells." He then wrote:

"The editors of the Journal will do our part by seeking out highly meritorious manuscripts that describe research using embryonic stem cells."

Two weeks later, Wesley J. Smith, a fellow of Seattle's Discovery Institute, pointed out in National Review Online the downside of this honest advocacy. While everything the NEJM might publish on the subject could be entirely true, it would be far from the entire truth. What would happen, he wondered, "if the Journal received a manuscript reporting that an attempt to use embryonic stem-cell therapy in mice to treat, say, diabetes, had failed? Disclosing failures is as essential a part of the scientific process as touting successes. Or, what if a submission for publication indicated that embryonic stem cells' known propensity to cause tumors when injected into animals may be insoluble? What then?"

Smith's questions expose the dreadful problem of conflating objective science with political advocacy. They also demonstrate how "peer review" can be suborned to non-scientific agendas. But they also reveal two other problems rampant in the medical and scientific communities.

The first is Political Correctness. We've been writing for years that peer review as practiced by the editors of the NEJM often includes an ideological review to be certain that the manuscript agrees with its worldview or agenda. Public news media of all persuasions have similar policies. But they don't do science.

...

Second, there's the matter of snobbery. Most practicing physicians in this country are quite aware that unless a manuscript is from a "prestigious" Eastern or elite medical school and is consistent with the editors' worldview, there is little chance of being published. The NEJM has abused this editorial privilege filtering out medical science for years, just as the New York Times and CNN have filtered out the news. Rather than "All the News That's Fit to Print" these media giants disseminate "All the News That Fits."

But again, scientific and medical publications aren't mass media, and when PC snobbery joins with the hauteur of the scientist, it's doubly troublesome.

While I believe the authors engage in hyperbole, their message is important. Too often our medical journals choose amongst many important and interesting submissions, those which excite them. The editors do have political agendas, and those agendas are manifest in article selection.

How does this impact medical knowledge? The more presitigious the journal, the more likely that other scientists will read your article. If you choose to submit to prestigious journals, you often go through a cycle of submission, rejection, resubmission, etc. Sometimes an important article will take multiple journal submissions prior to acceptance. Let me give a personal example.

I, along with several co-authors, have an article which is currently in press in the Journal of Clinical Epidemiology. This article was read and reviewed in multiple clinical journals prior to submitting to this journal (which, by the way, is very prestigious amongst clinical epidemiologists). I believe the message was one which the journal editors and reviewers did not want to hear.

This article describes physician adoption of a guideline prior to the guideline's creation . The article explores who physicians adopt new information, and asks whether guidelines might sometimes just reflect practice. The article focuses on an important question - how does technology diffuse?

We are please with the journal and the impending publication. We first thought of "prestigious" general journals because we thought the the findings would stimulate debate about guidelines. Perhaps the article is not as interesting as we thought. Perhaps the message is threatening to the establishment. And we will never know.

Once the paper is published, I will post the details of the study for reader comment.

In the meantime, remember that we should evaluate each article independent of the journal in which it is published. I have seen weak articles in the New England Journal of Medicine, and strong articles in supposedly weaker journals. We must never assume that the article is important because an important journal publishes it.

I have not ranted on this subject for a long time (malpractice, the insurance industry and the pharmaceutical industry kept getting in the way). This article stimulated my interest. For new readers, just search on "glycemic" and you will find a number of previous rants on this subject. Good carb, bad carb? Experts debate labels

The debate involves an idea called the glycemic index. It is a way of rating how quickly carbohydrates are digested and rush into the bloodstream as sugar. Fast, in this case, is bad. In theory, a blast of sugar makes insulin levels go up, and this, strangely, leaves people quickly feeling hungry again.

The debate over whether every person who puts food in his mouth should know about this is fervid even for the field of dietary wisdom, where fierce opinions based on ironclad beliefs and sparse data are standard.

Despite its detractors, the idea seems to be gaining momentum, in part because it is offered as scientific underpinning by the authors of a variety of popular diet schemes, mostly of the low-carb variety. However, some painstakingly argue that the glycemic index is just as important for the carbohydrate-loving brown rice aficionado as it is for the most carbo-phobic, double-bacon-cheeseburger-hold-the-bun Atkins follower.

The glycemic index refers to the speed of absorption and conversion to glucose. The higher the glycemic index the faster. High is bad, low is good.

The idea has already entered the scientific mainstream in much of the world and is endorsed by the World Health Organization, but it remains deeply controversial in the United States. It is dismissed by some of the country's weightiest private health societies, including the American Heart Association and the American Diabetes Association.

And if the AHA and ADA dismiss the idea, then we have no major campaigns to educate the public. Without these influential organizations, we are unlikely to have food labelled for glycemic index (or even better glycemic load).

The GI of at least 1,000 different foods has been measured, in the process knocking down many common-sense dietary beliefs. For instance, some complex carbohydrates are digested faster than the long demonized simple carbs. Foods such as white bread and some breakfast cereals break down in a flash, while some sweet things, like apples and pears, take their time.

...

To make matters even more confusing, the glycemic index measures only the carbohydrate in food. Some vegetables, such as carrots, have quite high GIs, but they don't contain much carb, so they have little effect on blood sugar.

Therefore, some experts prefer to speak of food's glycemic load, which is its glycemic index multiplied by the amount of carb in a serving. Considered this way, a serving of carrots has a modest glycemic load of 3, compared with 26 for an unadorned baked potato.

So now you understand the concept. We theoretically want to decrease glycemic load. The theory goes like this: the lower the glycemic load, the longer you stay satisfied. Therefore, you are less hungry at your next meal. Some research suggests this theory works.

In one, he tested the idea that a high-GI breakfast makes people hungrier at lunch. A dozen obese boys were fed three different breakfasts, all with the same calories -- a low-GI vegetable omelet and fruit, medium-GI steel-cut oats or high-GI instant oatmeal.

At noon, they could eat as much as they wanted. Those who started the day with instant oatmeal wolfed down nearly twice as much as those getting the veggie omelet.

Ludwig says overweight people do not need to starve themselves. On a low-GI diet, they can eat enough to feel satisfied and still lose weight.

In a pilot study, he tested this on 14 overweight adolescents. They were put on two different regimens -- a standard low-cal, low-fat, high-carb diet and a low-GI plan that let them eat all they wanted. After one year, the low-GI volunteers had dropped seven pounds of pure fat. The others had put on four. Now he is repeating the study on 100 heavy teenagers.

Even such small experiments have been rare. Most support for the idea comes from big surveys that follow people's health and diets over time. Some of these show that those who consistently favor low-GI fare are less likely to become overweight or to get diabetes and heart disease.

The evidence is strong enough for authors of some popular diet books, who use the glycemic index as one of their primary rationales. "It's a new unifying concept that brings nutritional habits out of the dark ages and says it's all about the numbers," says Barry Sears, author of the Zone series of diet books. "It says diet does not have to be based on philosophy. It can be based on hard science."

Major U.S. health organizations are less impressed. Ludwig expects this to change, in part because paying attention to the glycemic index can help everyone choose healthier carbs, whether they go low-fat or high.

But that seems unlikely any time soon at the heart association. The head of its nutrition committee, Dr. Robert Eckel of the University of Colorado, says the theory that high-GI foods make people hungry is "ridiculous" and argues that a scientific case can be made for just the opposite.

So now you see the nutritional debate. I believe the glycemic load proponents' side.

Dr. Lisa Sanders writes regularly for the NY Times magazine. Each case that she presents makes one think, and generally teaches a good lesson. Hip and Buttock Pain, Difficulty Walking, Normal X-Rays

The middle-aged man limped slowly from the waiting room to the examining room. His normally tanned face was nearly gray with the pain and effort this simple act entailed. His physician, Dr. Andre Sofair, had called that day and asked him to come in after hearing that he'd been in the emergency room twice in the past two days because of this pain.

It started four days earlier, the man said. At first the pain was an ache, a pressure in his left hip and buttock. ''But soon it changed. I can't even describe it,'' he told me later. ''It was like --'' He stopped and gripped his thick fist tightly, crushing his knuckles until they were white. ''And every day it's worse.''

Although walking was very painful, he could sit or lie comfortably -- so long as he didn't move. It was hard for him to locate the pain exactly. He'd never had a pain like this before, he said. And he hadn't engaged in any physical activity that may have injured his back. He'd had no fevers, nausea or vomiting.

The physician knew the man and his history well. At 53, the patient had quite a few medical problems: diabetes, hypothyroidism and an abnormality in his bone marrow that led to anemia. He'd recently been released from the hospital, where he'd been treated for a bacterial infection. Still, he lived a pretty active life, and the doctor had never heard him complain.

The doctor examined him carefully. His normally tidy hair was uncombed, and his handlebar mustache was well trimmed, but the face behind it was pale and unshaven. The man's temperature and blood pressure were normal. His heart was slow and regular, his lungs clear. His back itself was straight and symmetrical. There was no rash, no redness, no swelling of the back or the hip. The doctor felt along the bony prominences that delineate the spine, looking for tender points, and found none. The muscles that flank the spine felt firm and smooth.

The remainder of the article discusses the evaluation, the diagnosis and the treatment. I like to "play along" on these presentations and see if I can figure out the problem myself. You might want to at least think through the presentation prior to reading the entire article.

Working at a VA I see many patients who carry the label of PTSD. Some of them clearly have this disorder. This article raises a healthy skepticism about making this a psychiatric diagnosis. Is Trauma Being Trivialized?

Both the Democrats and the Republicans take positive positions. Unfortunately, they both also take negative positions. The Republicans clearly win this one - Limits in medical malpractice cases high on agenda for GOP this fall

Republicans intend to stage another Senate clash this fall over legislation to limit damage awards in medical malpractice cases, undeterred by a congressional report that says rising insurance costs for doctors are not causing widespread denial of care.

While Democrats this year blocked a bill to limit damages across a range of cases, some Republicans say they may sharpen the issue next time by proposing caps only on one type of medical malpractice suit -- those involving obstetrical care -- or in a limited geographical area.

Even a limited bill could face a Democratic filibuster. Still, Sen. Mitch McConnell, R-Ky., said rising insurance premiums have led to a "national crisis" and he added that the GOP sees political gain in pursuing the issue. "One of the reasons we have votes around here is to put people on the record," he said Wednesday.

President Bush long has supported medical malpractice legislation, arguing it could help reduce unnecessary lawsuits that make it harder for doctors to practice. The GOP-controlled House approved a measure on the issue this year.

In the Senate, McConnell and many Republicans cite American Medical Association claims of widespread problems resulting from rising malpractice insurance premiums. The doctors' organization said in March that 18 states were in a "full-blown medical liability crisis."

But a General Accounting Office study released last week of nine states -- five of which are AMA-labeled crisis states -- came to a much different conclusion. Congressional investigators cited "localized but not widespread access problems." The report added that these instances "often occurred in rural locations, where maintaining an adequate number of physicians may have been a long-standing problem."

I hope that we do not wait to solve this problem until the crisis has major effects. Unfortunately, I suspect that our government does not respond will to projected threats. They (especially in this case the Democrats in the Senate) will wait until the crisis becomes obvious. And as usual their constituency will suffer. And as usual they will blame the Republicans.

Found this link on Drudge Report! Judge Throws Out Obesity Suit Against McDonalds

In dismissing the current suit, Sweet said that the plaintiffs had not followed his detailed instructions and he barred them from filing another version, quelling litigation fears the suit had sparked in the food industry, .

"The plaintiffs have made no explicit allegations that they witnessed any particular deceptive advertisement and they have not provided McDonald's with enough information to determine whether its products are the cause of the alleged injuries," Sweet said.

"Finally, the one advertisement which plaintiffs implicitly allege to have caused their injuries is objectively non-deceptive," he said.

I suspect more articles about this ruling tomorrow. This is a victory for commonsense!

Another excuse, another target, we now can blame obesity on suburbs. As Suburbs Grow, So Do Waistlines

As a long time suburbanite, I find this research line, and this reporting, bordering on silly. I have patients who live in the city tell me that they cannot walk in their neighborhood (because it is too dangerous). One can always find an excuse for being a cough potato.

Walking trails are good; sidewalks are good; getting off ones butt is good. Blaming suburbia is silly.

We each must take individual responsibility ... (excuse me for my political incorrectness here) ... for our actions and the results of our actions. Quit blaming society!

Study Finds Appetites Reduced by Hormone

The hormone, PYY (for peptide YY 3-36), is of particular interest because it appears to be the intestine's signal of satiety and because overweight people normally make less of it than thin people. Researchers are trying to learn whether some people grow fat because they do not produce enough of it and thus get only a weak chemical signal to stop eating.

In the study, whose results appear today in The New England Journal of Medicine, 24 volunteers, half of them overweight and half of them lean, received PYY or a saltwater placebo at 8:30 a.m. An hour and a half later, they were ushered in to a buffet lunch. On average, those who had received PYY ate 30 percent less.

"It was dramatic," said the principal investigator, Dr. Stephen R. Bloom, a professor of endocrinology at Hammersmith Hospital at Imperial College School of Medicine in London. "We haven't had anyone who didn't get a result."

The obese subjects ate only 1,810 calories for the rest of the day, compared with 2,456 for those given a saltwater injection. The thin subjects ate 1,533 calories after they had the hormone infusion but 2,312 when they had saltwater.

Dr. Bloom emphasized that the findings were preliminary. PYY is an experimental substance; no doctor can prescribe it. And the researchers have not yet tried to find out whether people lose weight if they get PYY infusions day after day. But obesity researchers say the work, which began just two years ago, is encouraging.

The more we understand about physiology, the closer we get to being able to successfully modify the physiology. This study greatly advances our understanding of one particular hormone.

This study will not translate to a weight loss program in the short run. However, in the long run, we may have better treatments for obesity thanks to this research!

I post this link primarily to create controversy! Health Check: 'During the doctors' strike in the 1970s, death rates fell'

Deaths from heart disease have fallen by more than a third in the last decade, which is a matter for celebration, as a paper on the extensive Grace study, involving 31,000 patients in 14 countries, pointed out last week. But nobody knows quite why. No single factor can account for the size and speed of the fall.

Improved treatment has certainly helped. One finding in the Grace study is that though we are not bad at treating people who have had heart attacks (to prevent a recurrence) we are much less good at treating those about to have one, which looks very like shutting the stable door after the horse has bolted.

But the real puzzle is that we do not know what caused the heart disease epidemic, which began in the 1940s and peaked about 1970. Its subsequent fall is equally mysterious. There has been a sharp decline in smoking and limited dietary changes, which account for some of the fall. History will tell how much medicine has contributed, but it is unlikely to be a great deal.

Treatments come at a price. That is spelt out in a sobering report, also published last week, by the American Institute for Cancer Research, an independentbody that advises the US public on medical issues. It notes that the giant advances in treating childhood cancer, with cure rates now at 78 per cent, are not an unsullied success.

Two thirds of children suffer later complications, often as a result of the radiotherapy or toxic drugs they are given to deal with the cancer, and in a quarter of cases they are severe or life-threatening. The international survivors network for childhood cancer sufferers is about to establish a branch in Britain.

In medicine, the greater the advance, the more it becomes clear how far there is still to go.

Most generalists do not pay enough attention to renal function. Most cardiologists do not pay enough attention to renal function. We should consider renal function as an important risk factor in cardiovascular disease. Mild Renal Dysfunction an Emerging Risk Factor in Cardiovascular Disease

Using the Global Registry of Acute Coronary Events (GRACE), his team assessed the prognostic importance of admission serum creatinine values (and hence estimated creatinine clearance) on outcome in nearly 12,000 patients hospitalized with ST- and non-ST-segment elevation acute MI and unstable angina.

"Confirming our hypothesis, we found a direct relationship between creatinine clearance values estimated by using the Cockcroft-Gault formula and in-hospital adverse outcomes," Dr. Santopinto said.

For patients with moderate renal failure (creatinine clearance 30-60 mL/min), the risk of in-hospital death was twofold greater (adjusted relative risk 2.01) than for patients with normal or minimally impaired renal failure (creatinine clearance > 60 mL/min). Patients with severe renal failure (creatinine clearance <30 mL/min) were nearly four times more likely to die in the hospital (odds ratio 3.71).

"A 10 mL/min decrease in creatinine clearance had the same adverse impact on hospital death rates as a 10 year increase in age," the researchers note.

The risk of major bleeding episodes increased as renal function worsened and there was also a trend towards a higher rate of in-hospital stroke in patients with impaired renal function.

It is noteworthy, Dr. Santopinto told Reuters Health, that before hospital admission, patients with renal dysfunction were, for the most part, properly medicated with antiplatelet drugs, statins, ACE inhibitors, and beta-blockers.

But "surprisingly during hospitalization and at hospital discharge (and paradoxically because it was a high-risk group), they were less likely to be medicated with drugs of proven efficacy," Dr. Santopinto said.

They were also less likely to undergo diagnostic and therapeutic interventions like coronary angiography, percutaneous coronary procedures or coronary revascularization. "We think that this could be one of the major determinants for their worse outcome," the researcher said.

This issue requires more study and more attention.

Oxycontin (aka, redneck heroin) is a major problem in certain states. This editorial addresses the problem directly. Shifting the blame

Imagine the reaction if this corporate announcement were ever made:

"Wonder Drugs Inc. has decided to restrict distribution of its new and highly effective painkiller in rural Kentucky. Unlike the rest of America, Kentucky remains too backward to handle a powerful narcotic like ours.

"The state's rural doctors, pharmacists and law enforcement agencies are not up to meeting their professional responsibilities or providing the public protections our medication requires and receives elsewhere. Thus, our only choice is to protect Kentuckians from themselves by restricting access to the proven pain relief that other Americans enjoy, and we urge all other manufacturers of pain medications susceptible to abuse to do the same.

"Wonder Drugs will henceforth withhold from rural Kentucky our normal marketing, informational and distribution efforts. Corporate policy will be to treat the family physicians and community druggists of rural Kentucky not as the competent professionals the state's licensure boards claim they are, but as the clueless pill pushers the state's record of prescription drug abuse shows them to be."

Kentuckians would rightly be outraged. But this is the logical conclusion of the continuing effort to shift the blame for Kentucky's illicit trade in and deadly abuse of OxyContin onto the marketing practices of the narcotics' manufacturer, Purdue Pharma Inc.

Otherwise serious people continue to ignore Kentucky's long history of widespread abuse of prescription medications and to portray the OxyContin disaster as a sinister corporate plot.

Strong words! This editorial makes it clear that Kentuckians should accept the blame for their drug abuse and not shift the blame to the pharmaceutical industry.

The state's Prescription Drug Abuse Task Force is on the verge of recommending that an electronic prescription monitoring system already in place should be used to initiate investigations of possible abuse and that the reporting of drug sales by pharmacies should be speeded up.

That the state has been collecting this information for years, but doing so little proactive with it is the real negligence Kentuckians should be focused on.

In a state where sheriffs are being killed over drug corruption and doctors were able to operate a regionally famous pill outlet, Purdue Pharma's sales tactics rank low on the list of public outrages.

Several observations are needed. First, thanks to the reader who sent me this link. The article does provoke much thought about prescription drug abuse.

Second, oxycontin is a very good pain reliever. It has an important role in palliative care. Efforts to totally restrict this drug make no sense.

Physicians who dispense large amounts of such painkillers should quickly lose their licenses and DEA numbers. Computers can identify these abusers.

Finally, I am sure glad to read about this as a Kentucky problem and not an Alabama problem.

We already know this from several other studies. I am not sure why it is receiving billing as new information. Nonetheless, the message is worth reinforcing. All patients with coronary artery disease can benefit from an ACE inhibitor Pressure drug cuts heart deaths

The European trial on Reduction of Cardiac Events (Europa study) gave half of those taking part 8 mg of perindopril once daily or a dummy pill in addition to their existing medication, such as aspirin, statins and beta-blockers, for an average of four years.

The risk of death was cut by 11% in the group taking perindopril.

This group also saw a 24% reduction in heart attacks and a 39% reduction in heart failure cases in the patients living with stable heart disease.

The risk reduction was seen in all patient groups, whether or not they had conditions such as high blood pressure or diabetes, and irrespective of age.

We already do this with our patients. Having another study to reference only strengthens the argument.

Long time readers may remember the mneumonic that I developed for diabetes care - the FLECK(S) - I discussed this last year - Managing diabetes, more than the blood sugar. At that time my ending paragraph -

The kidneys require good hypertension control, as well as attention to microalbuminuria, or even proteinuria prevention - using an ACE inhibitor or an ARB early in diabetes. Think about the FLECK, it helps my thought processes, it may help yours.

For a quick refresher, the initials stand for: feet, lipids, eyes, control, kidneys (which includes hypertension) and shots. With our residents we do focus on all the processes. Apropos today's NY Times has an important summary of hypertension management in diabetes mellitus. New Message Emerges in Treating Diabetes

Officials of the major health organizations say they have done their best to get the word out. Three years ago, the National Institutes of Health issued an advisory urging doctors and nurses to treat blood pressure more aggressively in people with diabetes. For several years, the American Diabetes Association has sponsored an educational initiative called Make the Link: Diabetes, Heart Disease and Stroke, aimed at both professionals and patients. Other associations have done the same.

Dr. Eugene Barrett, a professor of internal medicine at the University of Virginia and the president of the American Diabetes Association, acknowledged that even with a good deal of information, the connection between diabetes and heart ailments had not been made. "The message of the A.D.A. and others has been consistent that to prevent cardiovascular disease in diabetics, the goal is to lower blood pressure, cholesterol and blood sugar," Dr. Barrett said.

Getting patients to take steps to lower their blood pressure readings may be a bigger problem than lack of information. Most diabetes patients require more than diet and exercise to get their blood pressure under control.

"It's not uncommon for a patient to require two or three medications to control blood pressure, two or three to control glucose and then if they need to lower cholesterol, that might mean eight different medications," Dr. Barrett said. "Along with the cost, the side effects of the various medications can create problems. And then there's the issue of patients' managing the numbers of pills and remembering to take them."

For the readers who are diabetics, please remember to work to achieve a blood pressure for 130/80. This will require persistence for both the patient and physician.

It's Hard to Do No Harm When You've Had No Sleep

It's difficult to overstate the shock in the medical world last week when the news broke that the ACGME had threatened to decertify the internal medicine residency program at Johns Hopkins Hospital. It would be as if the American League told the New York Yankees they couldn't play baseball. It's inconceivable.

And yet it's happening because the American public (in this case, in the form of the ACGME) is finally getting serious about the relationship between the working conditions of residents and the quality of medical care.

Hopkins's infractions include having residents assigned to the medical intensive care unit be on call every other night for at least part of their month of duty. A resident on call -- especially in the ICU -- is likely to spend most of the night awake, worried and working. Such a schedule is thought to wear down residents physically and emotionally.

Significantly, the ACGME cited some seemingly trivial problems it also wanted Hopkins to correct -- trivial, that is, unless you're on the inside. Specifically, it said the hospital should ensure that residents on call don't spend a lot of time in the middle of the night drawing blood and retrieving X-rays.

Hopkins has already changed its ICU scheduling, and is on its way to addressing the other issues. There is no way it will allow its accreditation to be revoked. The Yankees will stay on the field -- bet on it.

What will start to change, however, is the culture of toughness that pervades the training of medical residents, at Hopkins and elsewhere. ACGME's action will speed the exit of the belief that no demand is too hard or unreasonable because all build character and provide experience.

The author, who now works as a science and medicine reporter for the Washington Post, clearly views his residency differently than I view mine. He did his residency in the late 80s, early 90s, while I did my residency in the late 70s.

His article focuses on the challenges of the work. I prefer to focus on the preparation for your life work. Herein lies the challenge.

Residency should balance responsibility and dedication to patient care with working conditions. Most residency programs have already made the changes that the author discusses over that past 5-8 years. The new guidelines have caused most of us to tweak our residencies. Major scheduling changes have occurred prior to this year.

While the working conditions are an important issue, so is the sense of responsibility to patient care. I worry (as do many practicing physicians with whom I discuss this problem) that in our new zeal to modify the working conditions, we may lose the sense of responsibility to patient care.

Ultimately, we must instill and reinforce the importance of the patient. Sometimes physicians have to work very hard. Sometimes we have to work long hours. Sometimes we cannot avoid that. We must balance all the work changes with an absolute understanding that the patient comes first. The author believes this is not a problem.

Will it be possible to produce confident and assertive physicians who have the fine-tuned sense of personal responsibility needed for the job if you don't make them do a dozen things in the middle of the night along with taking care of sick strangers? Will people push themselves when they have to if they don't have to very often?

Johns Hopkins needed to change. In multiple conversations with physicians and non-physicians this weekend (while attending a lovely wedding) we all understood that Hopkins was different. I would not call them an alpha dog, but rather an anachronism. The threat of losing accreditation signals to Hopkins that they in fact are not different nor superior. They now will join the rest of the programs in the country who already have addressed these issues seriously and generally successfully.

The answer possibly is no, although personally I think it is yes. But in one sense the question is moot. There is no going back to the old system. The alpha dog got a whip across its back last week, and now it's doing just what it's told. The pack will follow.

It's a Weighty Problem, But A Crisis? C'mon

There are those who want the obese to pay for their obesity, so as not to burden the rest of society. Some proposals under consideration -- extra taxes on fattening foods, for example -- would shift the economic costs to me, in part to discourage the behavior which has supposedly led to my body mass index and in part, I suspect, to punish.

Allow me to respond personally to those behind these ideas.

Let's make a deal. If you would like me to pay for my body mass index, I will come back to you and find something you owe me.

Do you overwork, and suffer from workplace stress? That's $30 billion a year, says the International Labor Organization. Hand it over.

Do you bike long distances or run marathons or lift weights or do Eskimo rolls in a kayak or go boating? Injuries from recreational activities cost $26 billion, says the American Academy of Orthopedic Surgeons. Pay up.

And don't get me started on occupational injuries, mental illness, bad driving, heavy drinking, body piercing and all the rest. All diseases and injuries -- and the behavior associated with them -- have economic costs.

Here's how it works practically. Most of us engage in risky behavior and are free to do so. When risky behavior becomes expensive behavior for society, our freedom shrinks. We get browbeaten. Or our behavior is made to seem antisocial through a campaign of negative publicity. Whatever makes our risky behavior possible -- say, fatty foods or fast cars or maybe someday skateboards -- gets taxed, possibly out of existence. It's not exactly Big Brother. Big Mother is more like it.

But how do we determine which costly behaviors are crises requiring institutional mobilization and intervention and which are not? Do we just start with the highest cost and work our way down?

This opinion piece does provide some food for thought. As a non-obese person, I will respond concerning the financial implications.

Obese persons consume more short term and long term health care costs than the non-obese. Thus, I am taxed to pay for your weight related disease. I would like to see adjustments made to health insurance premiums based on weight categories.

This proposal is not a tax proposal. I believe that it would encourage personal responsibility. You would receive a financial incentive to control your weight.

I believe this would represent a positive reinforcement for weight control. It also speaks of fairness to those who accept personal responsibility for their weight.