I often rant about the dilemma of pain control. We (physicians) often receive criticism for inadequate pain control. We clearly have risk for overprescribing narcotics. This article discusses hospitalized patients and pain control - Pain Common and Often Undertreated in Hospitalized Patients

Altogether, 18% of patients with pain reported inadequate pain control while in the hospital, even though the hospital's pain management program met JCAHO criteria for accreditation, Dr. Whelan said. "All patients need to be thought of as high risk for pain," because caregivers may be more likely to miss pain "when they're not suspecting it as much."

"Pretty consistently, age, race gender seem to play role in how perceive and report pain," he added. "Patient characteristics that seem to be consistently associated with differential reports of pain probably are important to think about as we go forward in treating and researching pain."

I find this difficult research to interpret. As an inpatient attending, I often ask patients about pain on rounds. The problem that we have is interpreting their answers and deciding how to treat. Treating pain requires some art. One never really knows how much pain a patient is suffering.

This survey methodology obtains subjective data. Patient's recall of their hospital stay gives us some clues, however, we really need prospective data.

Nonetheless, the message the we who care for hospitalized patients should attend to pain issues is an important one. Even more difficult is deciding on discharge pain meds.

Our favorite surgeon - Bard Parker (A chance to cut is a chance to cure) - blogs on this subject (unfortunately his links do not take you right to the story - therefore, scroll down to Thursday, Jan 29 and read - Those that can, do). Here is the question - Do academicians get paid for sitting around and contemplating their navels? Ok, that was sarcastic, let's quote Bard Parker's original post from January 24 (actually talking about Dr. Dean and his wife)

... The difference between Dr. Steinburg and the academic is that the academic's salary is paid by the university. If he chooses to practice part time, he doesn't have to worry about covering the cost of over-head, the university will. A doctor in private practice has to keep earning the money to pay for her rent, malpractice, staff, utilities, etc. The profit margin in medicine is very small. Cutting down by one or two days a week can erase a doctor's income. It also means two days when you're not available to your patients. And that means that a certain percentage of patients will leave and go to someone who is more accessible.

Sorry Bard you obviously do not understand how academic medical centers work. As a division chief, I am responsible for the budget for approximately 20 physicians. One can imagine the division as a medium sized business. Like any business, the moneys in must equal the moneys out.

We have multiple sources of income, only one of which is "the university". According to a formula developed in our department, we receive a sum of money calculated from our teaching activities (fortunately we are paid for teaching - not true at all medical schools). We get moneys for clinical activites (after paying an exorbitant overhead). We pay our own malpractice (just like all physicians) and get no allowance for practicing less than full time. We get moneys from research grants - some of which pay faculty salaries. Some of faculty have paid administrative positions; some work part-time at the VA (which lowers their university and practice plan salaries).

When you add up all of our sources of income they must equal or exceed the expenses. We pay the secretaries salaries. All the supplies, copy machines and computers come from our budget.

Academic salaries are competitive only if the moneys are earned (and our faculty certainly earn their salaries).

I find it interesting that you would publish some surgeon's salaries. Faculty salaries are (unfortunately) public record - regardless of how the money is earned. I have never seen private physician's salaries published.

The university does not pay the salaries. The salaries are earned. Often academic physicians (especially surgeons) can operate more for two reasons - specialty referrals and housestaff who help care for the increased patient load.

So I find the common perception of academic salaries from many practicing physicians inaccurate. We are paid just like all others. We earn money, pay overhead, and then distribute the "profits" as salary. We are not very different from private practice, except we have more diverse income sources. We still must meet a bottom line.

Long time readers know that I favor legalizing drugs, especially marijuana. As penalties for marijuana decrease in GB, they are having a heated debate about the wisdom of that policy. Is cannabis a risk to health?

Professor John Henry, a toxicologist at St Mary's Hospital in Paddington, grabbed headlines last year when he warned about the risks of smoking cannabis.

Addressing a conference in London, he said he was convinced the drug can cause mental illness.

"Regular cannabis smokers develop mental illness. There's a four-fold increase in schizophrenia and a four-fold increase in major depression," he said.

However, others have yet to be convinced. Frank Warburton, acting chief executive of DrugScope, supports the decision to downgrade cannabis.

"Cannabis is not as harmful as other Class B drugs," he says.

"While we agree that there may be link between cannabis and mental illness, we would argue against the simple assumption that cannabis causes mental illness.

"If someone had a pre-existing condition, then cannabis may exacerbate it. That is not the same as saying cannabis causes mental illness."

Mark, who first used cannabis when he was 12, said he backed the decision to downgrade cannabis.

"Cannabis is nothing. It doesn't cause any problems. It doesn't cause any violence.

Cannabis is not benign. Nor is alcohol, nor are cigarettes.

We must change the tenor of this debate. The question which I believe should drive our decision making is: Do our current laws benefit society and individuals?

I believe that they do not. They criminalize a drug which many enjoy. By making marijuana illegal with (at times) several penalties, we might well cause a disrepect for the law. Many students develop a cognitive dissonance between what the see and what the law says.

It would be difficult to make the argument that alcohol is less dangerous than marijuana - in fact I could easily make the counter argument.

By having marijuana illegal, we make its use part of a "drug culture" that may well lead many to try other drugs.

I feel strongly that we must rethink our approach. We must understand the risks and benefits of making marijuana illegal. Primum non nocere.

I might love this diet. Can a high-carb diet help you lose weight?

American Dietetic Association spokeswoman Cindy Moore agreed and said with low-carb diets hogging the spotlight, “it may be a reminder that we can lose weight in a variety of different ways.”

Foods on the successful diets included high-fiber cereal, vegetarian chili, whole-wheat spaghetti, many fruits and vegetables, and skim milk. Daily calories totaled about 2,400, similar to participants’ usual consumption.

The control group also received prepared meals with similar calories, but the foods included sausage, scrambled eggs, macaroni and cheese, French fries, whole milk and fewer fruits and vegetables.

The successful diet was not tested against Atkins and other low-carb regimens, which contain more fat and fewer carbs than the control group diet.

There is more than one way to skin a cat, and more than one way to lose weight. This way looks interesting to me. I hope we read more about this new diet.

About 15 years ago, I first heard that we would focus CHF treatment on the neurohormonal response. The first time I heard this concept, I had a paradigm shift which has continued to this day. We improve quantity and quality of life now that we understand how decreased ejection fractions lead to progressive heart failure (it is not simply hemodynamics).

A similar paradigm shift is occurring in coronary artery disease. Multiple studies point to the inflammatory response as a major risk factor in which patients with strutural disease have the dynamic problem of intimal rupture, release of platelet activation, and clots leading to myocardial infarctions.

While we have focused primarily on C reactive protein, several studies have pointed to other inflammatory proteins as potential markers. Today's JAMA has an important study concerning another such protein. Here are two links about that article - Study Links Heart Attacks, Protein and Placental Growth Factor Helps Determine Prognosis in Acute Coronary Syndromes. This article adds to a growing literature which focuses on both predicting the risk of MI and on understanding the pathophysiology involved.

How do we put this article into perspective?

The study ``is an important step forward'' but also raises questions, including whether the protein would be useful in assessing risk in the general population, said Dr. Robert Bonow, a Northwestern University cardiologist and former president of the American Heart Association.

The German research will probably help lead to a whole new minimally invasive way of testing patients with chest pain, said Dr. Eric Topol, the Cleveland Clinic's cardiology chief.

``No one would ever have thought that through a few proteins you could know what's going on in the artery walls,'' Topol said.

He predicted that in the next few years chest-pain patients will routinely be given blood tests for an array of inflammatory proteins.

``This is where we're headed,'' Topol said.

The article's authors speculate further:

"Measuring PlGF levels may extend the predictive and prognostic information gained from traditional inflammatory markers in patients with ACS," the authors write. "Since the proinflammatory effects of PlGF can be specifically inhibited by blocking its receptor,... these findings may also provide a rationale for a novel anti-inflammatory therapeutic target in patients with coronary artery disease."

This study adds to a growing body of knowledge. While these studies do not yet effect therapy (and some of our current therapies probably work to decrease the inflammatory triggers), I suspect that we will have new exciting treatment avenues over the next 5-10 years. We should watch this story unfold.

True panic attacks are hard for us to understand. I found this description on a web site:

A panic attack is a sudden surge of overwhelming fear that that comes without warning and without any obvious reason. It is far more intense than the feeling of being 'stressed out' that most people experience. One out of every 75 people will experience a panic attack at one time in their lives.

Having made this diagnosis several times - with excellent treatment success each time - I have taken an interest in learning more about the disorder. Today's NY Times has an interesting article about panic attacks - Panic Spells Are Traced to Chemical in the Brain

People with panic disorder, according to scientists at the National Institutes of Health, have drastic reductions of a type of serotonin receptor, called 5-HT1A, in three areas of the brain. The findings, reported last week in The Journal of Neuroscience, lend credence to the suspicion that serotonin dysfunction plays a role in the disorder.

"This provides evidence for what we've been telling patients all along," said Dr. Dennis S. Charney, chief of the mood and anxiety disorders research program at the institutes and an author of the paper. "Panic disorder is due to a specific abnormality in the brain, not a weakness in character."

About 2.4 million Americans have the disease, which can leave its victims living in constant fear of attacks that might plunge them into outbursts of worry and thoughts of impending death. Experts have compared it to being stalked by a lion. The episodes, often resembling a heart attack and known to strike at any time, can be so terrifying that some associate them with the place that they occurred — the subway or the grocery store, for example — and will refuse to go there again.

Rangel wrote about panic attacks recently, with reference to another blogger who criticized Dean for having a history of panic attacks. Read Rangel's assessment - Howard Dean has suffered from anxiety attacks and remember that we are considering a disease not a human frailty.

I preach this, but until this review I did not have a great reference. Now I do - The Differences Between ACE Inhibitor-Treated and Calcium Channel Blocker-Treated Hypertensive Patients

Abstract

Large-scale outcome trials have demonstrated that blood pressure reduction with angiotensin-converting enzyme (ACE) inhibitors or calcium channel blockers (CCBs) is associated with reduced cardiovascular complications in hypertension. Comparative trials against conventional drugs and between ACE inhibitors and CCBs have failed to reveal conclusive differences in cause-specific outcomes. Studies in high-risk patients suggest that ACE inhibitors are superior to CCBs and other drugs in protection against cardiovascular events and renal disease. Very long-term prospectively collected observational data from the Glasgow Blood Pressure Clinic and the UK General Practice Research Database strongly support an advantage of ACE inhibitors over CCBs for cardiovascular morbidity and mortality. Considering all the available information, it can be concluded that the use of CCBs in the routine therapy of hypertension cannot be recommended while wider use of ACE inhibitors, along with low-dose diuretics and ß blockers, appears justified.

Tennessee doctors to get paid for "doing the right thing"

Health care quality improvement advocates believe that following evidenced-based guidelines, spending more time with patients and making better use of electronic medical databases will lead to better patient outcomes and lower costs.

A new study led by Vanderbilt University in Nashville, Tenn., and BlueCross BlueShield of Tennessee will put this theory to the test.

According to Tennessee Blues' Chief Medical Officer Steve Coulter, MD, doctors will be paid "for doing the right thing" and researchers will measure whether this improves outcomes without significantly adding to costs.

Physicians will be measured and compensated based on how well they adhere to evidence-based guidelines for treating congestive heart failure, diabetes and hypertension and for follow-up calls and e-mails to patients.

"The current system contains some perverse incentives: It rewards volume and procedural complexity; it doesn't reward low-intensity activities like phone calls and e-mails and following evidence-based guidelines," Dr. Coulter said.

What a great project! I certainly hope that they can do the study properly, and that the results fit our preconceived notions of what we should do. Hopefully more groups will take this challenge. Positive results could fundamentally change how we practice. And that would help everyone.

Generation gripe: Young doctors less dedicated, hardworking?

In a survey of physicians ages 50 to 65, 64% said doctors trained today are "less dedicated and hardworking" than physicians who entered medicine 20 to 30 years ago.

But younger doctors say that's not true. They say lifestyle considerations are shaping how they approach their practices and creating a healthier profession that strives to balance professional and personal lives.

One thing is sure: Older norms of practicing medicine are giving way to newer approaches, but not without some friction.

"There's kind of a loss of what it means to be part of the profession. Being a family physician has responsibility that sometimes extends beyond 9-to-5 and we have to be accountable to patients at other times," said San Antonio family physician James Martin, MD, board chair of the American Academy of Family Physicians.

Can we have our cake and eat it too? Can we function as excellent physicians and yet still have time for a full and rich personal life?

The younger generation has, in my opinion, a more complete perspective. Too many physicians have worked so hard, that their personal life and personal growth have suffered. Medicine is a great profession, but it need not devour ones entire life.

Being a physician did and does require great dedication. However, if one functions in that role 24/7 then he/she will likely burn out at some point. The burn out is evident in broken marriages, drug addiction and depression. Most physicians my age have doubts about their career choice.

The survey of physicians ages 50 to 65 also asked:

If you were starting out today,
would you choose medicine
as your career?
No 52%
Yes 48%

Would you encourage your children
or other young people to choose
medicine as a career today?
No 64%
Yes 36%

These answers tell me that the old ways no longer make sense. We can take great care of our patients and balance that with a full and rich personal life. Our patient care will benefit. Our families will benefit. And we will benefit.

Fixing American health care requires a basic shift in approach in the system of justice. What's needed is fundamental: deliberate standards that everyone can rely upon -- standards governing not just the amount of damages but what is good care and what is not. A growing consensus among patient safety advocates and other credible health care experts holds that a new system of medical justice is needed, including a special health court or administrative compensation scheme that could deliver deliberate, binding rulings on standards of care.

Defenders of the current system argue for juries because they are "democracy in action." But that is exactly what's wrong. Justice is supposed to be rendered by the rule of law, not a kind of running plebiscite.

William Sage, a health care expert at Columbia Law School, recently observed that it would be a shame to waste the current crisis. American health care finds itself in a "perfect storm" of needless errors, unaffordable cost increases, declining access, inadequate accountability and fearful and frustrated professionals. Millions of people are being hurt. Instead of frittering away the moment in an effort to solve one part of the problem, we should seize the crisis to do what's needed.

Now go read the entire Op-Ed from the Washington Post - Heal the Law, Then Health Care.

This Op-Ed lays out the problem and the solution beautifully. They echo my opinions.

And here is another editorial about the topic - not as complete - but the point is made - Ending legal maltreatment Posted by at 06:24 AM | Comments (6) | TrackBack (1)

My frequent commentor, Fakeo Nameo, writes:

Seems like HSAs are trying to get around the inflation caused by third party payers,
which is a good thing. But who actually comparison shops for medical care? "Hey Doc, how much for a liver transplant at your hospital? Do I get a discount if I talk my brother-in-law into getting one too?" Ok, some folks might shop around for checkups, and routine care but if the condition is serious they usually buy whatever the clinician recommends. The agency problem, of clinicians benefiting from advising more expensive care also drives up cost, and HSAs won't really help that.

Fakeo develops a strawman which stands tangential to the main issue. HSAs would encourage you to consider Prilosec OTC rather than insist on Nexium. They would encourage you to ask your physician to develop a lower cost regimen for your antihypertensives. They may even discourage your insistence on having a CT scan when none is indicated. They will not effect big ticket expenses - nor should they.

Rangel has continued his discussion - A small example of how HSAs might work with a nice relevant discussion.

Robert Goldberg in the Washington Times pens this heartfelt opinion - When family matters most

It is painfully apparent to me as well that the more we move toward greater government involvement in health care financing and cost containment, the more intense is the desire to both control and ultimately attack the very source of hope and better health that is at the heart of modern medicine. The insurance companies and government programs with their formularies, technology review committees and prior authorizations would have summarily delayed and denied my daughter access to the medicines that are making her well. They are drugs being used in a novel fashion, they are new and they are expensive. They are, therefore, hated and hunted by the bureaucrats, the politicians and the candidates. And they and their proposals for universal care that would control costs by limiting access or imposing price controls have nothing but dire news for Sara and others in the Princeton eating disorders program.

But President Bush has a better and more compassionate way. If his bill passes, low-income people will have the opportunity and choice to buy insurance, save for health care and deduct the full cost of insurance premiums. I will be able to invest directly in keeping my daughter alive, and millions of other families will be able to accumulate billions that will ultimately force insurers to deal directly with our doctors and us in providing more compassionate and cost-effective care for people with eating disorders.

HSAs will increase patient autonomy and make the costs involved in quality health care more explicit. I do not understand how that can be anything but a major improvement.

Bush's Health Proposals

The chief new proposal in the president's speech was a tax benefit to encourage people to set up health savings accounts, as authorized in the recent Medicare legislation. Under that measure, individuals who take out a high-deductible insurance policy to cover very large medical bills can invest money in a tax-free savings account to pay for routine medical expenses. The accounts will get unusually generous tax treatment. Now Mr. Bush proposes to allow participants to deduct the full cost of the premiums for the high-deductible coverage as well. The accounts are intended to make people more cost-conscious in deciding what care is really necessary, a worthy goal, but they have the potential to interest mostly those who are healthy and relatively well off.

I believe that this benefit will help the middle class a great deal. Higher deductible insurance should save money. Putting money into a tax-free savings account makes sense to prudent people of many economic strata. Their accusations sound like economic class warfare to me. This editorial takes a cheap shot at Bush. I would expect more from the Times. Time out. Maybe I should not expect more.

Study: Taxes Pay for Most Obesity Costs

Taxpayers foot the doctor's bill for more than half of obesity-related medical costs, which reached a total of $75 billion in 2003, according to a new study.

The public pays about $39 billion a year - or about $175 per person - for obesity through Medicare and Medicaid programs, which cover sicknesses caused by obesity including type 2 diabetes, cardiovascular disease, several types of cancer and gallbladder disease.

The study, to be published Friday in the journal Obesity Research, evaluates state-by-state expenditures related to weight problems. The research was done by the nonprofit group RTI International and the Centers for Disease Control and Prevention.

"Obesity has become a crucial health problem for our nation, and these findings show that the medical costs alone reflect the significance of the challenge," said Tommy Thompson, secretary for the Department of Health and Human Services. "Of course, the ultimate cost to Americans is measured in chronic disease and early death."

States spend about one-twentieth of their medical costs on obesity - from a low of 4 percent in Arizona to a high of 6.7 percent in Alaska.

Obesity is everyones problem. Obese patients cause health care costs to increase (in a disproportionate fashion). Therefore the increasing obesity burden raises my insurance costs. And the obese raise our Medicare expenditures.

That we must as a society address obesity is not a new thought. Placing this battle into an economic perspective makes sense. I still believe that the obese should have to pay higher insurance premiums. You should be rewarded for a healthy lifestyle. A move to HSAs would place the burden of obesity on the obese. Maybe that would change behaviors.

Medpundit has a different take on this issue - Wages of Sin:

As usual, Rangel is all over this issue with a long, well considered post - Democratic candidate John Edwards and how he got rich

He virtually defines the problem of malpractice lawyers - Edwards' persuasive powers and Junk Science Warrior.

Edwards' is smooth, ruthless and apparently unconcerned with data. He scares me. The Mr. Nice Guy routine does not ring true after reading these two entries.

You probably saw this on TV or read this in the newspapers. The Post-Atkins Low Carb Diet

The level of saturated fat that is permitted in the Atkins diet is still more than in other low-carbohydrate diets, and 60 percent of calories are still supposed to come from fat, although trans fats are not permitted. But setting a limit brings the diet more in line with others, like the South Beach Diet.

The diet industry is still riven by arguments over the best way to lose weight, but many mainstream researchers say that if low-carb diets have moved people away from refined carbohydrates like sugar and white flour, they have accomplished something important. And some acknowledge that a low-carb diet fills many people better than a low-fat diet, helping to keep them on the diet.

Rangel is doing a great job! He started discussing HSAs recently and continues with this outstanding piece - Health Savings Accounts (HSAs); The most important legislation of 2003!

Please read his entire rant, but if you would rather just read my excerpts, here goes:

Having such high cost insurance for healthy individuals or families in order to cover every possible medical expense does not make a lot of sense from an insurance standpoint. People get insurance to protect themselves, their assets, and their property from sudden loss, accidental damage, or unexpected massive expenses. We do not purchase auto insurance so that it will pay most of the costs of gas, cleaning, and routine maintenance from normal use. We don't get home owners insurance so that most of the relatively low expenses for routine cleaning, maintenance, and repairs will be covered! If we did, then home and auto insurance rates would be massive . . just like health insurance. Yet we expect most expensive health insurance to pay for everything from routine office visits and low cost tests to prescription medications.

==========

The reason why health insurance costs are so high is because health care itself is so expensive. And the reason why health care is so expensive is that most consumers of health care treat it as an entitlement rather then as a consumer product or service like any other product or service in a free market system. I have commented on this before.

When you have a situation where health care consumers blindly purchase health care products and use health care services without any idea of the actual costs involved then there are no incentives to control spending or usage or to treat the health care system in any way like the free market system that it is. When we spend perverse amounts of money on health care we can only expect ever increasing costs. This is basic economics. The more money you put into a system the higher the costs are going to be.

The economic underpinnings of HSAs makes so much sense that I cannot understand why the Democrats oppose them so much. I have had an old fashioned Medical Savings Account for several years. The tax savings has made this worthwhile. I no longer buy dental insurance, because I figured out that I saved money using MSA moneys for all my dental care.

Rangel has nailed the insurance industry. We should always understand our expected gain (or loss) prior to choosing a plan. If you are healthy, the gamble (albeit a relatively small one) on high deductible health insurance is a smart one. But then you will not hear this in New Hampshire this week.

Read Rangel and his link to the NY Times article - More ideas on HSAs

His article and the NY Times article lays out the debate over whether HSAs will decrease health care costs. This interesting perspective from the NEJM (subscription required) - "Me-Too" Products — Friend or Foe? - addresses this issue, albeit indirectly.

The reason that this strategy of maintaining high prices for first-in-class products works is that we have not actually had a true market in health care — at least so far. The physicians who write the prescriptions or choose the devices and the patients who receive them have not been saddled with much or any of the cost. As a result, some me-too products have made money for their manufacturers mostly because of clever marketing, without improving outcomes or lowering costs. The lesson: for market forces to really work, physicians have to choose products as if costs matter. As patients bear more of their health care costs, we can expect that they will pressure their physicians to do so.

While the article discusses much more, that one paragraph cogently summarizes one of the major financial problems of our health care system. HSAs could address this issue.

I have no comment as I have commented excessively on this issue. But read it anyway - The Widening of America, or How Size 4 Became a Size 0

Drug Companies Get Too Close for Med School's Comfort

Studies indicate that most physicians meet with pharmaceutical representatives four times a month.

Studies also reveal that most physicians erroneously believe the representatives do not influence prescribing habits.

When doctors and trainees meet with reps, they change their prescribing habits and are far more likely to prescribe the drugs described, even when they are more expensive or have no benefit over alternatives. They are also more willing to request illogical changes to hospital guidelines that govern which drugs can be prescribed.

Estimates suggest that roughly $1 billion was spent advertising antidepressants to health professionals in 2000.

More than 400 psychiatrists were asked by Dr. Timothy Peterson and his colleagues at Harvard to describe their beliefs about antidepressants. More than half said they believed that newer agents were more effective than older antidepressants known as tricyclic antidepressants and that newer antidepressants, called selective serotonin reuptake inhibitors, or S.S.R.I.'s, had fewer side effects than generic S.S.R.I.'s.

But studies conducted at Oxford, Duke, the University of Manchester and the Canadian Coordinating Office for Health Technology that used a statistical strategy called meta-analysis to combine the results of hundreds of independent studies found that S.S.R.I.'s were as effective as tricyclic antidepressants or slightly less effective. They also revealed that S.S.R.I.'s were tolerated by slightly more patients but had as many side effects.

As usual I have mixed feelings when it comes to the pharmaceutical companies. While I personally work hard to distance myself from drug reps, I do understand the importance of the industry. This article presents a biased opinion against the pharmaceutical industry. But much of the content is accurate.

I appreciate the many comments on my two previous posts. One struck me

The outward display of emotion is not a reliable guage of one's compassion. This is because doctors must compartmentalize intellect and emotion in order to be competent. Some physycians, stone cold on the surface, are the ones who go the extra mile for the patient. I've seen others, outwardly compassionate and "touchy feely" who never seem to be around when needed. Some doctors put on a better show than others, but such appearances can be deceiving.

This is a very interesting and cogent point, however, this is tangential to the point of the rant.

My concern is in how we as physicians talk to each other. If my words are accurate then as a teaching attending I convey important meanings to my trainees. We strive to teach professionalism in training (it is actually explicit in Internal Medicine training these days). One method for teaching professionalism is role modeling professionalism. To me that was the point of the resident's post which started the entire discussion. When we forget to respect patients such as the one which started this discussion, then we have lost part of our professionalism (in my opinion). How we act at the bedside is an entirely different discussion which we may have another time.

Well that post got some attention. I wrote the post from the perspective of a teaching attending. Words are important. I pride myself in semantics. We should say exactly what we mean. Our words in medicine should convey our meaning explicitly.

As a teaching attending, I have a responsibility to be a role model (Unlike Charles Barkley). My words must convey meanings and feelings.

Thus I disagree with a couple of commenters. I should remind the students and houseofficers that we are taking care of people, not diseases. Each time I uttered the words sad case, I reemphasize that point. Each time we use the term great case in a matter other than I proposed, we are forgetting the patients.

We need some emotional detachment - just not too much. We need to learn to compartmentalize our feelings and not take our work home too often. Nonetheless, if we lose our empathy than we start to lose our humanity.

Medicine is based on science, but it requires art. When we focus excessively on the science, our patients eventually suffer. And, I believe, we do also.

So I will stick with my strict definition of great case. Students, interns and residents have complemented me when I make that explicit distinction on rounds. And I feel better about myself.

Rangel has blogged eloquently about this subject - The humanistic paradox of the study of medicine. In this rant he cites A Great Case.

I will not repeat these excellent posts, but will offer my personal definition of how I encourage the use of these phrases.

• Great case - an interesting diagnosis (either an unusual disease or an unusual presentation of a common disease) and making the diagnosis leads to a cure. For example, we had a patient several years ago who had cryptococcus growing from his blood and bone marrow. This infection was secondary to hairy cell leukemia. We successfully treated his fungal infection and then hematology/oncology cured his leukemia. That is a great case .
• Interesting case - the diagnosis makes one think. The presentation is dramatic. An interesting case can become a great case, if the patient is cured.
• A sad case occurs when a patient has major morbidity or mortality and he/she has done nothing wrong. I rarely classify alcoholic cirrhosis as a sad case. The case that Dr. Van Hee cites is both an interesting case and a sad case.

I submit that all medical educators, housestaff and students should adopt this classification system. The meanings are clear and convey the right messages.

As physicians we can find a patient's illness intellectually stimulating and yet unfortunate. That circumstand is not a contradiction. However, we should reserve great case for those patients who stimulate our intellectual needs and that we help dramatically. I (and all physicians) long for the truly great cases!

One of the problems that I have with our current malpractice system is the artificiality of the process. Malpractice lawyers use a bag of tricks to make a complex decision seem like a straightforward one. One cannot easily convey the context of the decision either on paper or in testimony.

This essay from the LA Times does convey many features of the complexity and number of decisions that one physician is making with just one patient. A doctor's daily round of judgment calls

All of medicine is probability. If 80% of people with ordinary pneumonia get better on erythromycin and Mr. Miah turns out not to be one of them, does it mean that my decision was wrong? If I call Mr. Miah and he feels fine, would my decision, then, have been the right thing?

I wonder, though, if the outcome is truly relevant. Obviously in cases of utter negligence or gross error it is important, but what about in the gray areas of everyday medicine? Could a decision about whether I made good or bad judgments in this case be rendered in the absence of knowing the outcome? Can a judgment call stand on its own legs, irrespective of the consequences?

I recommend the entire article. It reminds us the medicine is practiced much more easily through the retrospectoscope than in real time.

We all second guess our decisions at times. All bad outcomes lead to introspection. What could we have done differently? What clue did we miss? Should I have gotten a different consultant?

Medicine is a challenging and wonderful profession. I love the intellectual stimulation. I thrive on the complexity.

If my patient has a bad outcome, when is it inevitable, and when is it my fault? And who should judge?

Vaccine Is Said to Fail to Protect Against Flu Strain

Medpundit addressed this issue yesterday - Defending Dean. Today Maureen Dowd attacks Dean's wife because she continues to practice rather than campaign with her husband. The Doctor Is Out

The NY Times (who ran an article yesterday and the op-ed today) and their ilk apparently do not understand. Medicine is an important profession. Many who choose medicine feel that what we do transends politics. Dean's wife - Dr. Judith Steinberg Dean - practices medicine. She is apparently dedicated to her chosen profession.

Why would anyone expect her to sublimate her career for her husband's? Working with many medical couples in training, I see separate physicians, each working on their chosen avocation.

Why should his aspirations impact her career? What do I not understand?

Bravo to Dr. Judith Steinberg Dean! She likes seeing patients - so that is what she will continue to do. The heck with this political stuff.

BTW, this does not change my opinion of Dean. Nor should it.

I try to write clear paragraphs. Please read this one carefully.

So I was conflicted prior to adoption, and I remain conflicted. On the whole we have a better training program. I am greatly in favor of the 4 days off each month (and sometimes have been able to give housestaff an extra day during the month). The 80 hour rule is important. The 24 + 6 rule still gives my angst.

Note that I have not attacked the 80 hour rule. In fact, we try to get our residents at 70 hours or less. My only angst is the 24 + 6 rule.

Let me reiterate the problem. An intern comes to work at 7 a.m. to preround. She admits all day (maximum of 5 patients). She likely gets a few hours sleep. This next morning we make rounds from 7-10 a.m. Under the rules she has 3 hours left to get all her work done.

Several patients have diagnostic studies done. She would like to see the imaging studies and discuss them with the radiologist. She would like to go to noon conference (it is on a topic that she is very interested in).

But the ACGME insists that she leaves by 1 p.m. She hardly has time to check out her patients. Perhaps she has the next day off. By the time she returns in 2 days, her chance to review the imaging studies loses its urgency. She looks at the films, but the educational impact is decreased.

I am not saying that she should . Rather I am saying that she should have the option of staying.

A reader sent in this link. It is a good one. Foregone conclusions

The public is being regularly deceived by the drug trials funded by pharmaceutical companies, loaded to generate the results they need

Weight loss surgery has a major "upside". Morbidly obese patients who have major weight loss have wonderful health and social benefits. Despite the danger, for many patients the risk is clearly worthwhile.

We must always remember the risk though - Mass. Panel to Probe Obesity Surgery

Massachusetts health officials announced plans Tuesday to assemble a panel of experts to examine the dangers of obesity surgery, less than a week after the state's third death in a year linked to weight loss operations.

The death rate is significant. Patients need complete disclosure of the risks. But the benefits are great enough to make the risks worthwhile for many patients.

I ranted on this subject in November 2002 - Screening for h.pylori. A recent study adds more support to empirically treating patients who are h pylori positive - Antibiotics May Help Stop Stomach Cancer

This study is not definitive. Given the lower rate of h pylori positivity in the US, we will not yet advocate general screening. However, the data and concept should continue to receive attention.

Our favorite surgeon - Bard Parker - first alerted me to this story. His post - More 80 hour work week stuff - does a nice job of outlining the problem.

Rangel has a relevant post also - Apparently some residency programs are still overworking their residents.

Long time readers will remember that I have ranted often about this issue (just use the handy dandy search function to find my previous rantings). I will start with my conclusion, then share my angst. Generally the new rules are working. They have improved the quality of life of many houseofficers. I still worry about patient care. I still worry about education.

Most programs have made significant modifications to meet the ACGME requirements. I have written in the past about our adjustments. These adjustments give us houseofficers who are better rested. When they are available they are easier to teach (because they are awake!).

You do have to work harder to insure continuity of care. Pass offs are difficult. In our system care becomes a team phenomenon - we (the attending, resident and both interns) must really know all the patients. Someone (other than the attending) is gone most days, thus we are consistently picking up "the slack".

My angst relates to the interns. Internship is an important stressful year. During that year you learn the fundamentals of patient care. Hopefully you learn the difference between sick and very sick. You hone your clinical instincts.

The great majority of interns with whom I work are very dedicated to their patients. They do not want to leave the hospital because it is time to punch their time card (we do not yet have a time card system - but I believe other programs do). Sometimes in medicine you should stay.

This is why the main objection that I have to the new regulations is the 24+6 rule. Interns have the most angst post call. They want to get everything done right. Sometimes that takes 8 hours rather than 6 hours.

Many residents have concerns about patient care related to the new system. Residency is a time to develop an ethic about patient care. Do these new rules send the right message?

So I was conflicted prior to adoption, and I remain conflicted. On the whole we have a better training program. I am greatly in favor of the 4 days off each month (and sometimes have been able to give housestaff an extra day during the month). The 80 hour rule is important. The 24 + 6 rule still gives my angst.

Rangel has a link to the book - House of God. Hopefully all medical students and residents do read this book. Then I hope that they put the book into perspective.

Students and houseofficers, unlike their age matched education match peers, deal daily with death, self-induced morbidity and the horrors of illness. We all need some humor to deal with these stresses. The House of God uses exaggeration to make those points. Unfortunately, I disagree with the protagonist's final decision. Many of us lived that book, and matured into caring dedicated physicians.

I wish the ACGME was less draconian in their regulations. Since I resent all bureaucracies, I find this particular one no better than others. We need some common sense in interpreting these rules. Else, our next generation of physicians just may not learn the "right stuff".

This story explains the problem of choosing the right strains of influenza to develop a vaccine against. For Health Officials, Flu Shot Is an Annual Gamble

This article explains our portion control problem very well - Want to stay slim? Get a handle on America's out-of-control food portions

A scary story - The Beast in the Bathhouse

For now, researchers say, crystal meth use in the city is largely confined to gay white men in Manhattan, although they fear its eventual spread to the wider gay population and beyond.

There are no numbers, however, to show what health care workers say is the growing role that crystal meth is playing in transmitting H.I.V. Although the evidence is anecdotal, health officials say that crystal, which erases inhibitions and spurs sex marathons with multiple partners, is helping to spread the virus.

According to the city's largest private clinic for lesbians and gay men, Callen-Lorde Community Health Center, two-thirds of those testing positive for H.I.V. since June acknowledged that crystal meth was a factor in their infection.

Dr. Howard Grossman, one of the city's best-known AIDS specialists, said more than half the men who test positive in his private practice blamed methamphetamine. "This drug is destroying our community," he said. "It just seems to be getting worse and worse, and no one is doing anything about it."

This really has nothing to do with medicine, but I found it drop dead funny. But then, I guess I am a geek. When the universe is expanding it can make you late for work - By Woody Allen And it is great to see that Woody Allen still is capable of creating funny pieces.

Patient-centered model offered as road to reform

From Seattle, the call went out for proposals: Come up with an idea to fix the U.S. health care system and win $10,000. Contest judges cast their votes, selecting Vaughan Glover, DDS, a dentist in Arnprior, Ontario, as the winner.

Judges didn't think it strange that they picked a Canadian's idea to cure what's plaguing America's health system. They liked his patient-centered model, believing it uses the best of the American and Canadian systems.

So what did the winner propose:

Across the border came Dr. Glover's idea, which he has been working on for years and is the focus of a book he wants to publish. His patient-centered model promotes giving the patient information to foster good health over a lifetime.

The patient would have a primary coach, such as a doctor or nurse, to help guide care. Personal savings accounts for health would provide a financial support system.

Hmm, we would pay for a primary care physician (I have reinterpreted coach to physician). We would have a personal savings account (sounds a lot like a health savings account).

I wish the article had more details on the winning plan. I am glad to see it was not universal health!

If you do not read Rangel regularly then you should start. He absolutely nails this topic - Health care costs continue to increase (and I think I know why)

But the real reasons for such continuing increases in health care costs are simple enough. Americans have become very used to such expensive health care. The problem with these expensive expectations is that most Americans do not pay out of pocket for their care hence they are not aware of the actual costs of their care. This is unlike almost any other economic system where prices are controlled by supply and demand but this is not to say that the same economic forces are not at work here. What we are seeing with health care costs is what happens to any economic free market system when you add huge amounts of money combined with an ever increasing demand that is not responsive to the actual costs of the product or service.

Rangel bolded that last sentence. He is correct.

medmusings gets most of this right - The Online Doctor Visit Will Become Common When Patients Insist on it

I would only suggest that some reasonable modification of retainer medicine will speed up acceptance of online medicine. Our billing systems, i.e., having to bill for each separate portion of care, really make no sense. We could either bill for time spent (but this would be a record keeping nightmare) or go to a flat monthly (yearly) fee. This would cover telephone access, internet access, filling out forms, office visits and hospital visits. The idea is really not that outrageous once you consider it carefully. Afterall, surgeons get paid for the operation and not the visits before and after - they get one all inclusive fee.

You could make this more complex by charging different fees for different diseases (or more for several diseases).

My main point - our reimbursement system is the biggest problem we have in providing the proper care for our patients. The incentives are malaligned for the physician to provide the most reasonable and complete care for patients. Patients should complain about our insurance system. It is the reason they have a difficult time finding a good doctor - one who will spend adequate time with them; one who will answer their telephone calls; and one who will gladly communicate with them by email. And patients would benefit!!!

I rant incessantly on this topic - on December 31st I ranked time as the number 1 story of 2003 (for this blog). I said:

1. The time pressures on outpatient generalist practice - this is my number one story because I consider myself an advocate for generalist physicians. We ask our generalists to do more each year, and then structure a reimbursement system that pays them a fixed amount for a visit - regardless of the time necessary. It takes time to follow guidelines for prevention. It takes time to explain disease and management to patients. We must fix this problem to provide better quality care.

Many non-physicians think we can fix this with midlevel providers. To that I say "balderdash"! As we learn better how to care for patients the complexities of patient care increase exponentially. It does take a physician to do it right - and a physician with enough time. Not solving this problem will continue to have a major impact on overall patient care. This is our true health care crisis.

Family Medicine Notes says it better - Rectal Exams

My nurse complained to my wife yesterday that I take too much time with my patients. She's right that I do. But shouldn't I explain things? She asks "what in the world are you doing in there for so long?"

I'm mostly listening - but sometimes I'm explaining.

And patients appreciate it. And patients expect it. Yet no one really pays for it.

I remain upset over the malpractice case which the Bloviator pointed out to me yesterday. It seems like thoughts of the malpractice problem have caused an obsession this week.

What obscenity has 11 letter?

According to Miriam Webster:

1 : a dereliction of professional duty or a failure to exercise an accepted degree of professional skill or learning by one (as a physician) rendering professional services which results in injury, loss, or damage

2 : an injurious, negligent, or improper practice : MALFEASANCE

We all abhor malpractice. We all want to improve the quality of care that patients receive.

Unfortunately, our current tort system acts against improving care.

The current system has many losers - patients, physicians, and access to care amongst others. Patient care does not improve because malpractice claims are random, unsystematic and only someimtes related to true malpractice. Even if we commit malpractice (and I will assert that this designation is a hazy one), we are unlikely to be charged, and if charged we are still likely to win our cae.

Several problems exist with our current system. The first is in defining malpractice. I see malpractice as a very complicated label. To prove that someone has committed malpractice should require an extremely high standard. The default should be innocence.

Medical care is complex. It takes 4 years of medical school and 3-6 years of residency before one is ready to start practice. We continue to learn throughout our careers.

Judging another physicians care as malpractice requires a thorough understanding of the alleged activity, taken in the context of the interaction. I have written before, and still believe, that a random jury in this country cannot (and should not) be expected to understand the medical issues involved.

We must develop a system of accountability that helps patients and fairly evaluates medical care. Such a system would require a trained panel, probably including both health care professionals and other judges (here I use the generic meaning for judge rather than the legal meaning).

True malpractice has such great complexity that we need a separate and specific system for evaluating such cases. The system should have two functions - redressing patient and improving future care.

We have neither today. The case we discussed yesterday proves the flaws in our system.

Quality care has too much importance for us to ignore. A fair impartial system, one not prone to sophistry, obfuscation and hyperbole, rather one which dispassionately examines the facts and determines fair remedies, would advance our goal of having the best possible health care system.

Our current system wastes resources and makes lawyers unncessarily wealthy. Our legal system cannot have intended to treat medical care in this way. The current process has too much potential for financial reward (for the lawyer, rarely the patient). Finally, our current system negatively impacts access to care and quality of care.

The current tort reform goals of capping penalties for pain and suffering would only represent a short term financial bandaid. Until we transform our conceptualization of malpractice we will never make progress on providing the highest quality care possible.

I cannot stop thinking about this article and my rant (see just below). We must make this story a cause celebre. Any suggestions on what we can do?

Ross the Bloviator has a post which will make anyone shudder - Medical Malpractice: Evidence of An Imperfect System

The plaintiff's attorney, in essence, wants to reward those physicians who are behind the curve of adopting widely-accepted principles, and punish those who follow the latest literature. In his closing argument, the attorney makes what can only be described as outrageous claims:

During closing arguments the plaintiff's lawyer put evidence-based medicine on trial. He threw EBM around like a dirty word....He defined EBM as a cost-saving method and stated his belief that the few lives saved were not worth the money. He urged the jury to return a verdict to teach residencies not to send any more residents on the street believing in EBM.

I'm flabbergasted by this argument. Granted, it is an effective argument for its ability to tap into the current zeitgeist about the health care system -- average folks losing their health care coverage, managed care companies taking away benefits to make more profits, and our system's tendency (Don Johnson's going to love hearing me say this) to "give the people what they want" irrespective of what the science says is appropriate. In other words, no one should stop you, members of the jury, from having Cadillac care for Hyundai prices.

On the other hand, this flys completely in the face of two central tenets of our health care system -- a desire for an informed, autonomous patient who is able to effectively manage and participate in their own care, and a desire to have our health system adopt the latest medical evidence and, by doing so, improve patient safety.

At this point (and please read Ross' entire rant), I am just as flabbergasted as he. I have argued that the current jury system cannot fairly judge most malpractice cases. This case stands as testimony to my viewpoint.

Here a jury was obviously swayed by the hyperbole, obfuscation and sophistry of an attorney. There is no verdict here based on facts.

We must fix our system. Otherwise we cannot improve medical care. This case proves (as much as any one case can prove anything) that our legal system can impede quality improvement. The medical resident and the residency practiced excellent medicine. They followed guidelines.

These cases (albeit anecdotes) have a tremendous effect on our thinking. This case is wrong, but not as wrong as the legal system which allows it!

This trend started when I was in medical school. It has increased as the percentage of female medical students has increased. Young Doctors and Wish Lists: No Weekend Calls, No Beepers

For me the shame here is that the best and brightest no longer clamor for internal medicine slots. This rant comes from my heart as an academic internist. I apologize if I insult anyone.

Internal medicine is the cornerstone of adult medicine. We encompass a wide variety of complaints, and excel as diagnosticians. More recently, we have acquired the expertise to juggle the many medications that our sickest patients take.

Internal medicine is the common ground for all patients. We care for the complex with the aid of other specialists.

In medical schools, internal medicine generally represents the key rotation of the 3rd year. We win the teaching awards. We use physiology, pharmacology, biochemistry and anatomy daily.

In the old days, the best and brightest aspired to become internists. We all wanted to be Sir William Osler. But times have changed.

This notion of a "brain drain" to subspecialties from the bread and butter fields of medicine is not new. But in recent years it has come to be associated with a flight to more lucrative fields. What is new, say medical educators, is an emphasis on way of life. In some cases, it even means doctors are willing to take lower-paying jobs — say, in emergency room medicine — or work part time. In other fields, like dermatology and radiology, doctors can enjoy both more control over their time and a relatively hefty paycheck.

============

What young doctors say they want is that "when they finish their shift, they don't carry a beeper; they're done," said Dr. Gregory W. Rutecki, chairman of medical education at Evanston Northwestern Healthcare, a community hospital affiliated with the Feinberg School of Medicine at Northwestern University.

Lifestyle considerations accounted for 55 percent of a doctor's choice of specialty in 2002, according to a paper in the Journal of the American Medical Association in September by Dr. Rutecki and two co-authors. That factor far outweighs income, which accounted for only 9 percent of the weight prospective residents gave in selecting a specialty.

For me internal medicine represents the pinnacle of science and human interactions. I see too many students who like internal medicine but elect other specialties for "lifestyle" reasons.

I guess we need to fix the internal medicine lifestyle. But then I rant about that incessantly. Our payment system influences lifestyle.

As usual follow the money if you want to know the real issues. Lifestyle is chic to blame. But it requires excellent reimbursement to adequately control lifestyle.

Prescribing Patterns Respond to "Bad News" Findings of Clinical Trials

Physicians alter their prescribing patterns when clinical trial results suggest detrimental effects of the drug in question, two new reports in the Journal of the American Medical Association for January 7 suggest.

The intensity of media coverage appears to be a key feature in influencing physician and lay responses.

Now we just need to control the media!!!!! We can get our message out to all physicians if we just controlled the media. What a thought!

The above paragraph is meant to be sarcastic. I hope readers understand this meager attempt at humor.

I was rightly chastised for not explicating my position on malpractice in last night's post. When I found this link, I blogged in anger - a major mistake. This issue requires careful thought and a listing of all the problems. I made the mistake that a calculus professor might make, I went from equation A to equation F and skipped all the obvious steps in between.

The crux of Dwight Meredith's argument:

When discussing tort reform, and particularly medical malpractice reform, it is helpful to know the size of the problem. How much money is paid out each year in medical malpractice judgments and settlements? That would seem to be a basic fact that needs to be established at the beginning of a public policy debate. After all, if we do not know the size of a problem, how can we ever decide on a solution?

The tort reform lobby and the scare tactic media almost never report that basic fact. If you do not believe me, go to Google News or Google and try to find the answer.

In my post, I noted that medical malpractice payments total a little over $4.2 billion per year. As I have previously noted, the total of all sums paid out in medical malpractice settlements and judgments is approximately the same as Estee Lauder?s sales of makeup. The total of payments in 2002 would have paid interest on the national debt for about eight days.

This argument assumes that we can quantitate the cost of malpractice simply by counting pay outs. If the malpractice problem was just lost court cases and settlement, then Dwight would have a good argument.

The figure he cites greatly underestimates the costs of malpractice. As most physicians know, the vast majority of malpractice suits are won by the defendant (the physician or physicians involved). However, these cases still require significant financial resources (which the insurer pays). Even more cases are filed and withdrawn - still with significant legal costs.

Now I do not know the cost of defending a malpractice case, but these costs are not insignifcant.

The threat of malpractice permeates medical practice. It clearly influences physicians to order more expensive tests than are necessarily indicated. It can hamper the doctor patient relationship. Many physicians now fear malpractice so much that it has influenced their care.

Another issue that Dwight overlooks is the inability of physicians to pass on costs. If Chrysler loses a lawsuit, they can raise the price of cars. Physicians work in an artificial market. Our income is controlled by third party payors. We cannot successfully increase fees.

Malpractice insurance costs are rising. No one can dispute that. If it were a lucrative field, we would see more companies offering this insurance. The decrease in malpractice insurers speaks much louder than the hyperbolic quote above.

I am still angry over this issue. I hope this explication has done a better job of making my arguments. Tort reform is a complex issue. One figure of approximately $4 billion does not describe the issue. It reminds my of having a blind man describe an elephant from one touch.

One should always worry when someone uses hyperbole and obfuscation to make points. Scare Tactics Part II. The scary thing here is Dwight Meredith's post!

While cardiac prevention gets most of the publicity, increasingly we should become aware of preventing heart disease in chronic kidney disease patients. Nontraditional Cardiac Risk Factors Prevalent in Kidney Disease Patients

Print out this article as a handout for patients who have questions about CRP. Hunt for Heart Disease Tracks a New Suspect

Among patients known to have atherosclerotic heart disease, those with the highest levels of CRP were about four times more likely to experience symptoms of impaired blood flow to the heart during a treadmill test, indicating a direct relationship between inflammation and a heart attack, researchers at the University of California at San Francisco reported in Circulation last January.

"Our study supports the idea that heart disease is more of a systemic disease rather than just a plumbing problem," said Dr. Mary S. Beattie, the study's lead author. Based on such findings, some experts believe that levels of C-reactive protein are better than cholesterol levels at predicting future cardiac events. Patients can lower their CRP levels if they lose weight, quit smoking, change their diets and exercise more. Many drugs may also help, especially the cholesterol-lowering statins and the antidiabetic thiazolidinediones.

Should CRP Be Measured?

C-reactive protein can be measured by a simple, inexpensive blood test. The best results are obtained through two tests that are done at least two weeks apart with their results averaged.

In March 2002, experts from the Centers for Disease Control and Prevention and the American Heart Association concluded that patients deemed to be at "intermediate risk" of a heart attack, stroke or other cardiovascular event should be tested for C-reactive protein.

Intermediate risk is defined as those with a 10 percent to 20 percent chance of developing coronary heart disease within 10 years, based on age, total cholesterol level, smoking status, systolic blood pressure (the upper number) and blood level of protective H.D.L. cholesterol.

The experts recommended that those with C-reactive protein levels of 1 milligram per liter or more take aggressive action to reduce the level.

Certainly food for thought!

Despite New Law, the Fight Over Medicare Continues

Democrats, denouncing the arm-twisting tactics used to pass the bill in the House, vowed Monday to rewrite the law to reduce the role of private health plans, to increase drug benefits and to authorize the government to negotiate drug prices.

Unless we elect a Democratic majority in the House and Senate, I doubt that they will get their wish. I would like to see some slack in negotiating drug prices. It sure works for the VA system.

Many readers have a New Year's resolution to lose weight. You can lose weight just by dieting. However, increasing activity can help greatly. Need Exercise? Count on It

"You'll lose muscle mass, your metabolism will slow down," she says. "You gain a lot more things with exercise than just maintenance of weight. You get an increase in energy, an increase in metabolism; you decrease the chance of cardiovascular diseases; you get a reduction in blood pressure, things of that nature. If you don't work out, if you only consume as many calories as you burn, you're missing out on all that."

Rangel weighs in - What's Dean’s problem? . . He's a doctor!

Let me respond a bit to Rangel. I dislike Dean as a presidential candidate. He changes positions too often, and has too many misstatements for my comfort. I disagree with him strongly on foreign policy.

However, none of those criticisms has (or should have) anything to do with his medical training. My objections to his candidacy are based on his platform and his campaigning. But medicine has nothing to do with it.

I suspect that if Medpundit reconsiders her original post on this topic, she will withdraw some of the hyperbole she employed.

Medicare reform helps doctors and patients

Physicians will have a much happier new year thanks to the Medicare reform legislation signed into law last month. Instead of a 4.5% Medicare payment cut, doctors will get at least a 1.5% increase this year and next.

Not only that, but many physicians in rural and underserved areas will be eligible for 5% Medicare bonus payments. Lawmakers also took a step toward making payments in rural areas more equitable by eliminating for three years cuts that result from geographic adjustments to a portion of the payment formula.

---------------

The physician payment formula responsible for the now-averted cuts is still largely intact. The law makes some changes to the system in an attempt to prevent the seesaw increases and decreases that marked physician payment updates during the past several years. But those changes don't go far enough.

If Congress doesn't repair the flawed formula in the next two years, physicians will face steep payment reductions in 2006.

The root of the problem is the sustainable growth rate. The rate is actually a spending target, computed using a complex formula. If overall physician spending misses the target in any given year, payment is adjusted upward or downward in following years to compensate. The formula's goal is for physician payment updates to reflect the change in the gross domestic product.

Not surprisingly, the estimates on which the rate depends are often wrong, leaving physicians vulnerable to sharp payment hits. In addition, the formula doesn't account for factors that increase physician spending but are beyond their control, such as technological innovation and government coverage decisions that increase demand for services.

Punishing physicians for changes that benefit patients is unfair. And tying physician payment to the gross domestic product also makes no sense. As AMA President Donald J. Palmisano, MD, said recently, "The medical needs of our Medicare patients do not wane when the economy slows."

So the short run news is good. Could Congress possibly have the common sense to treat the disease rather than the symptoms? Even this Pollyanna remains a skeptic.

Pennsylvania tort crisis: Lawmakers fiddle, doctors burn

In order to attract younger physicians and keep older physicians from retiring early, physicians say Pennsylvania needs to pass a constitutional amendment that would allow noneconomic damage caps. And they say lawyer fees need to be curbed.

Not surprisingly, the Pennsylvania trial bar disagrees. Instead, it points to the cyclical nature of the insurance business, noting that insurance companies have gone through a spell during which they are receiving lower income on investments. Attorneys also say the state should focus on improving patient safety.

It's been an ongoing argument in Pennsylvania for several years now. And doctors say that as more of them leave the state, retire early or cut high-risk services, the state is growing ever closer to a meltdown.

Would you start a practice in Pennsylvania? Would you stay?

I must differ with Sydney Smith on this one - The Doctor Factor

Someone once described medical education as being akin to living the life of an abused child. And that's not too far from the truth. When we're medical students and residents, we get lambasted and yelled at for the simplest of mistakes or errors or lack of knowledge. We're ridiculed in front of our peers and our superiors at morning presentations, after sleepless nights spent doing work no one else wanted to do. Sometimes we're ridiculed in front of patients during morning rounds. At least, that's the way it was twenty years ago, and it's a good bet that's the way it was thirty years ago when Dr. Dean went through his training.

I either grew up in a time warp or my medical school and residency were just much more humane. I have no recollection of such treatment.

As a teaching attending I hope (and believe) that I have never treated students or residents like that.

Now I must admit that some doctors fit the description.

The man is a doctor. This is the least-examined chapter of his career. But suddenly it all makes sense: Where else but in medicine do you find men and women who never admit a mistake? Who talk more than they listen, and feel entitled to withhold crucial information? Whose lack of tact in matters of life and death might disqualify them for any other field?

I see less of this all the time. Such personality flaws are certainly not limited to medicine. Many lawyers fit this profile. Many businessmen (and businesswomen) fit this profile. Famous sports figures fit this profile.

While the original author backtracks a bit and admits using sarcasm, still I find the writing of this opinion piece, even if meant to be humor, as a personal insult. We should not attribute characteristics of a group to an individual, whether race, gender, location (Southerners), vocation or avocation.

I write in defense of physicians, who happen to span the breadth of human frailities and goodness. I see no truth in the essay, and cannot do anything but condemn such writing.

db steps gingerly off of his soapbox, somewhat angry but feeling better after venting!

My frequent commenter - Bernie - believes so strongly in "natural" remedies that he ignores the data. He uses a variety of strategies to make his points. A recent comment:

Why is it so unreasonable to place the burden of proof on the FDA? Historically the courts have been very deferential to the FDA when it has filed suit.

Today's exercise for the reader. Go to the corner drug store and head for the cold and allergy relief section. Read the list of ingredients and see how many products include ephedrine or pseudephedrine. Then write a letter to the editor of your local paper thanking the FDA for removing that "dangerous" ephedra from the market.

Another commenter responds accurately:

Bernie: The dangers of ephedra are that (1) the marketing material and packaging do not disclose the risks, and (2) many (most?) of the formulations are uncalibrated. Would you take ground foxglove leaves to "Improve cardiac output!"?

One of my greatest objections to the dietary and supplement law is the lack of information on what you are ingesting. These products do not have dosage standards. Ephedrine and pseudoephedrine (two of the active ingredients in ephedra) come in known precise dosing. We have carefully designed studies to define safe dosing.

We (the concerned medical community) are asking for the same standards on the dietary and supplement market. Patients (and their physicians) should know what they are taking. Supplements should pass safety standards (at least). We need precise information on risks.

And who can really argue that those desires are unreasonable?

A Doctor's Toxic Shock

After taking bupropion, I describe potential side effects to my patients in much greater detail. Even though I continue to prescribe it, I'm hypervigilant about any signs of distress. If a patient complains of symptoms similar to mine, I switch meds immediately. In the past, I would have encouraged the patient to stick it out, anticipating that most side effects would eventually pass. I wonder where I'd be now if I had followed my own advice.

This article tells an important story. As physicians we must understand side effects, explain them to patients, elicit them from patients, and document our discussions.

Hospitals sue over nurse law

California's hospitals sued Tuesday to challenge the state's strict interpretation of a first-in-the-nation law to establish nurse staffing levels, arguing that it will burden hospitals and threaten health care.

The California Healthcare Association, which filed the lawsuit in Sacramento County Superior Court, does not challenge the new law's overall rules, but said rules for covering nurses on breaks would be virtually impossible to satisfy and could backfire.

The law, which takes effect Thursday, requires one nurse for every six patients in general wards, and a 1-to-5 ratio a year later.

The rules require a hospital to provide a nurse to fill in whenever another nurse takes a break from patient care, so that the nurse-to-patient ratio is maintained at all times.

This is a good law and a good interpretation. As often seems to happen, the hospitals worry more about the cost than the outcome. Nursing staff ratios are important for patient care.

Researcher Links Obesity, Food Portions

The University of Illinois researcher has set up several food experiments that show the more people are given, the more they will eat -- regardless of whether they are full or think the food tastes good.

Hmm. I have ranted about this concept in the past. How many of you complain about small portion sizes at restaurants? How many of you choose a restaurant because they have "generous" portions?

I blogged on this story a few days ago. Our favorite blogging surgeon provides a more complete rant today - Practice Makes Perfect III

New Renin Inhibitor Curbs Essential Hypertension

A very interesting development that we need to follow.

Aliskiren, a new nonpeptide orally active renin inhibitor, appears safe and effective in treating essential hypertension, European researchers report. However, they also note that it remains to be seen whether this approach yields "protection against heart attack, stroke and nephropathy" comparable to "angiotensin-converting enzyme inhibition and angiotensin receptor blockade."

What Took So Long?

The answer to both those questions involves a truly terrible federal law, the 1994 Dietary Supplement Health and Education Act (DSHEA). The administration can be legitimately criticized for the unduly long time it took to get to yesterday's announcement, given the FDA's years-long effort to restrict ephedra. Even now, it will be months before the FDA's action takes effect. Mr. Thompson said he wanted to get the word out before dieters turned to ephedra to help fulfill their New Year's resolutions, but the new regulation won't be published for some weeks, and after that won't take effect for another 60 days -- and that's before the expected lawsuits from ephedra manufacturers.

But the fundamental fault lies with DSHEA. The law simultaneously makes it too easy to get dietary supplements on the market, and too hard to get them off. While manufacturers must show that ordinary drugs are safe and effective before they are allowed to sell them, dietary supplement makers face no such requirement before peddling their goods. If manufacturers develop information that calls into question their product's safety, they don't have to tell the FDA. And when there is an indication, as in the case of ephedra, that the product is dangerous, the law imposes a steep hurdle before the government can intervene: authorities must prove that the product presents a significant or unreasonable risk of injury.

I rant about this issue incessantly. I will continue to rant about this law. This is a huge public health issue.

Friends often ask me about the risk of mercury from eating certain fish. This commentary gives one answer - Fishy warning about mercury

My family will love this article, as these are foods we all love. And they seem healthy! Simple choices can boost nutrition in 2004

Less than 10% of the students in my entering class were women (1971). Even that was considered a major step forward. The profession is changing. For first time, more women apply to med school

Kirsten Mewaldt's sense of idealism prodded her to apply to medical school. She sees practicing medicine as a way to serve humanity.

But Mewaldt, like many other women, also sees a big practical benefit to becoming a physician: With the changes in the profession in recent years, it has increasingly become an attractive career for someone who wants to balance work with raising children.

"One of the things that's great about medicine is the flexibility," said Mewaldt, a second-year medical student at the University of Southern California, offering an opinion that defies the traditional reputation of a profession with little time for family life.

"I'm considering going into emergency medicine, and that has a wonderful lifestyle if you're considering having a family," she said. "You can do three 12-hour shifts a week, and then you're not on call. You're done. You can be home with your kids, pick them up from school, and actually be around."

This is great, but ...

We must reconsider all our projections on numbers of physicians needed in this country. Women (in general) have a better sense of balance and just will not work the ridiculous hours that many men worked in the past. This means that we will need more physicians for the same number of patients.

A reader posted this comment/question today:

Hi Medrants,

Your salary won't be increasing with the ridiculous cost of drugs. The notion that extremely expensive ACE-I are either no better or potentially less effective than thiazide diuretics represents a huge waste of ((LIMITED)) health care dollars. Please choose one of the following:
1) Stick with your current salary and prescribe whichever antihypertensive you like.

2) Prescribe thiazides first line and advocate some of the money previously wasted on ACE-Is goes to help providing comprehensive outpatient care.

1 or 2 ?

First, I learned many years ago that hypotheticals are dangerous. Lawyers love to pose them to make rhetorical points. They are tricky to answer.

This question has several flaws. First, ACE inhibitors are no longer ridiculously expensive. Second, for many patients they may even save costs (i.e., less CHF, less progression of CAD, less onset of diabetes mellitus). Thus, the question as framed lacks coherence.

Please refer to my many commentaries on ALLHAT. Diuretics rarely control BP alone. Most patients require two drugs for adequate control. In many subgoups the evidence supports ACE inhibitors plus a diuretic as the best combination.

My critiques of ALLHAT stem from designing a study which does reflect practice. If an ACE inhibitor alone does not control the BP, the next logical drug is a thiazide diuretic. Almost any class of antihypertensives benefits from adding a thiazide.

To me the importance of ALLHAT is that thiazides do work. However, when one adds all additional evidence, many subgroups - type II diabetes mellitus, proteinuric chronic kidney disease and known CAD in particular - have great benefit from an ACE inhibitor. I generally start with an ACE inhibitor, and quickly add a low dose of a diuretic if adequate pressure is not achieved with an ACE alone. ALLHAT does not provide the data for that treatment plan, because it was designed for a different less important question.