I have not had time for an extensive Q&A, but this question deserves some ranting.

I would still be interested in your input regarding my earlier comment on your post on Quality Medical Care. Recent experiences of my own make me doubt that healthcare is even as rational as "rationed by ability to pay." I have excellent health insurance and the ability to pay out of pocket for what I need, but here in Boston it is virtually impossible to get a doctor's appointment with a GP or an obstetrician (forget about a specialist), even when I tell them I'm recovering from a pulmonary embolism that landed me in the hospital. Is there a doctor shortage? If so, money doesn't appear to move you to the front of the line. What is going on? No one seems to know, or at least want to discuss it.

Amazingly, I do think we have a doctor shortage. The shortage is subtle, but known to most practicing physicians. It differs among specialties.

I am often asked to help someone find a physician. Despite working in a major academic medical center, I find this a difficult task. Access seems no better in the private sector.

We need more first contact physicians - internists, family physicians, and obstetricians. Obstetricians are leaving practice secondary to malpractice costs. Internists and family physicians are leaving for the reasons that I state almost weekly. Overhead continues to increase while reimbursement is either flat or decreasing.

From the physician viewpoint, medical care does not work as a free market. Our patients get first preference of our time. Eventually you fill your practice and no longer take new patients.

I know that this does not make sense. It seems counterintuitive to me. We have often little incentive to accept an additional patient. Patient care is suffering - and ability to pay (while a factor) does not necessarily help one find a physician.

I expect some excellent comments from my physician readers.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(3) Make the practice of medicine less risky.

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

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

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

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

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

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

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

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

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

Time for some excellent questions and comments.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Late Sunday, time to clean out my comments and emails. Sorry for the delay.

I feel that ephedra is not forced upon the general public, by the companies that produce it. It is forced upon us by the media. I never knew what in the world ephedra was until the news took all of the dirt it could dig up on the herb and force fed it to me. Ephedra is no more dangerous than alchol. I have never heard of an ephedra user killing any innocent victims, I want the FDA to pretend like the people that are of age, to decide the future of our country, are capable of watching there weight or increasing energy what ever LEGAL way they want!

This comment on ephedra misses the point. Ephedra is a drug, not a food. I have several problems with the current way supplements are sold in general. Ephedra makes the point well.

We have no quality assurance mandated for supplements. Thus, the dose you take has much more randomness than the dose of any prescription (or even non-prescription) drug. When you think you are taking a specific dose of ephedra, you may or may not be taking that dose.

My other major problem with ephedra is the lack of appropriate warnings and caveats. It is possible that one could use ephedra responsibly with little danger (note that I say it is possible - that hypothesis would require testing). However, as currently marketed people take this drug without sufficient medical supervision. It can cause sudden death. Ephedra is dangerous, and therefore it should have the same regulations as any drug you might buy.

"If we had no efficacy requirement, drug companies would have the ability to assert claims without supporting data. The evidence based physician would not have the data necessary to make good decisions about drugs."

There is a difference between an unelected bureaucracy requiring some particular standard for an efficacy claim, and longstanding law forbidding fraud. You seem to have no faith in the latter.

If a pharm supplier made false claims of efficacy, they would be criminally liable for fraud, just as is anyone distributing anything that is not subject to FDA's particular requirements for efficacy.

I'd trust my physician's opinion on efficacy over a bureaucracy's any day. If I find my physician's opinions inaccurate, I can change physicians. If I find the FDA's pronouncements inaccurate, I can't change government bureaucracies.

I find this an interesting argument. As I consider it, I have two problems (and hope the writer will respond). First, proving liability for fraud would require that we engage our legal system. I do not believe that our legal system can answer these questions as well as scientists answer these questions. Second, as a physician, I do not trust my opinions on efficacy as much as I trust the FDA. I do not have the data, nor the time to analyze the data if I had it.

I believe that you do misunderstand the FDA. Their analyses include physicians and statisticians. These are not bureaucratic decisions, rather scientific decision (in my opinion). Thus, while I share your distrust of bureaucracy, in this specific case I believe we do have the right bureaucracy.

Would the patient have preferred the physician have not talked to him? Is the value of the visit only in the hands-on component? I agree that the case has to be made that the physician's time has value, whether it is spent listening, examining, performing procedures or talking. Lawyers, who do lots of talking, never seem to have to make this argument. Why is that? And for some reason--which does not seem to apply to our lawyer brethern--only the doctor's time spent with the patient is deemed to be compensable. Try telling a lawyer that you will only pay for the time spent is his presence. The patient needs to understand that listening and giving professional advice is a service. I think that retainer-based practice, which you have argued for here in the past, would help to fix this problem.

As usual C. Henry has made the point very well. This comment reinforces everything that I have stated about our current reimbursement system.

I agree in the importance of case taking and case taking skills. But good case taking isn't talking to the patient, it's listening to the patient. When people tell me that the doctor they saw was "no good", I ask why. The number one reason is, "He doesn't listen to what I have to say. The minute I give my complaint, out comes the prescription pad and he's writing the prescription."

Point well made!! If all we do is talk, then shame on us. We must listen and respond to the patient. Perhaps the key here is conversation rather than lecture.

Does anyone suffer from cancer of the stomach as a result of taking Proton Pump Inhibitors ?? I read that this is a known side effect to occur on trials of the drug on mice!

This theoretical consideration has no data to support it. We have many years of PPI use now, with no epidemiological evidence of a stomach cancer - PPI association.

I'm aware of the problem that lawyers sometimes make settlments in class action suits that enrich themeselves but provide little reward to the defendants. I would like to see the problem fixed as much as you do. However, to ignore the problem of adverse drug reactions, which is a leading cause of death and injury in America, and criticize lawyers pursing the issue on behalf of their clients is a perverse set of priorities. Why doesn't this issue get the attention it deserves from the medical profession?

Physicians worry about adverse drug reactions constantly. We are faced with a difficult situation. We must balance potential benefit against potential risk. Often patients can help with the decision making, however, many patients will not participate in the decision making process.

So we are damned if we do, and damned if we do not prescribe a specific medicine. Side effects occur. We do our best to minimize their impact, but sometimes we have an unavoidable risk.

How should we give this issue more attention? Who are you blaming - physicians, insurers, or the pharmaceutical industry?

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Thanks again for the comments and questions. I still have much to answer and comment. Hopefully I can find some time again tomorrow. Keep the comments coming, it certainly makes this blog a lot more interesting!!!

Back finally for a shortened version of Q&A. I have had too many trips recently, and Q&A needs quiet time at home. I will certainly get back to serious Q&A in 2 weeks.

How can I know in advance when a drug will be available as a generic? I saw a note at drugstore.com saying that Wellbutrin SR will be available as a generic soon but no date was given. I asked my pharmacist and she didn't know.

I have a love / hate relationship with the drug companies. I know they have a lot of costs to cover but if you look at the actual prices there's no way they're priced to market; they're priced to be sold to insurance companies. And the games they play with the patent system. It irritates me to no end.

The pharmacists are not much better. A couple of years ago I found out by chance -- in Time magazine of all places -- that an anxiety drug I was taking, Buspar, finally went generic after a bitter court battle. When I went for the refill she handed me the brand name and I asked for the generic. She was puzzled. There's only an $8 difference. I insisted she put the generic in and she gave in.

Several interesting concepts here. The first questions refers to how you know when a drug goes generic. I do not know a specific source for this information. Perhaps an astute reader does. I learn 'through the grapevine'.

Second, the reader comments on patent system games. He is correct. A down side of capitalism and government is that companies will always look for loopholes. They should from a pure financial viewpoint. But I can and should dislike their patent games.

What you don't mention is that pharmaceutical companies systematically manipulate how physicians practice medicine by:

1) not doing the studies that doctors would like performed.

2) publication bias - they don't report trials that are not favourable to selling their products.

3) many, many other ways.

The pharmaceutical companies have a goal - profits. Physicians generally (I will admit to some exceptions) have the joint goals of making money and helping their patients. Once one understands and accepts the pharmaceutical companies goals as a given, then one understands that they need not do studies unless they think those studies will result in a marketing edge. That is why I want a pharmaceutical tax which would fund the important studies.

Ok, I agree there are people in the drug industry who just want to do good.

But then there is.

The Journal of the American Medical Association on April 23 published the results of an incomplete clinical trial for a hypertension treatment developed by Pharmacia accompanied by a "scathing" editorial that criticizes the decision by the company to end the trial before its scheduled completion, the Los Angeles Times reports. In 1996, Pharmacia began to enroll participants in a clinical trial to compare the effectiveness of the hypertension treatment verapamil, marketed as Covera, to less-expensive diuretics and other treatments. About half the participants received Covera, and the other half received a diuretic or a short-term beta-blocker called atenolol. Pharmacia, which had spent about $50 million on the trial, decided to end the trial in 2000, two years early. Dr. Henry Black, dean of research at Rush-Presbyterian-St. Luke's Medical Center in Chicago and the lead researcher of the trial, said that Pharmacia officials decided to end the trial for "commercial reasons." Black said that Pharmacia ended the trial early because researchers could not determine the effectiveness of Covera compared to a diuretic (Maugh, Los Angeles Times, 4/23). According to the incomplete results of the trial, Covera proved no more effective than a diuretic in the prevention of heart attacks or stroke MacPherson, Newark Star-Ledger, 4/23).

This excellent comment needs no response. The sad thing about this episode is that no one is surprised.

I am schizophrenic with regards to the pharmaceutical industry as well. You're right, every rep tries to 'spin' the evidence so that their drug is the best, and your ACE inhibitor example is apt as every rep I talk to is now trying to echo the ALLHAT study (or whatever it was) that said that drug X prevented stroke better than other ACEs.

My favorite example pro-pharmaceutical companies is the vagotomy. As in, 'that surgery we used to do before H2 blockers and PPI's came along.' But when reps start pushing me to say their PPI is the best, I tell them, "You know, I like your drug, but I have to say I like all PPI's. I remember what it was like before we had these drugs and they're all miracle workers."

And I can't really play the outraged innocent, because I have been wined, dined and entertained at the expense of the industry many a time. That would actually make for a great rant. Do you accept such invitations, and what is your opinion of doctors who do?

Great comment, and I will respond to the last paragraph only. I have a $10 rule. I have decided that you cannot buy me for $10. Thus, I do eat drug company sponsored lunch at noon conference. I will not go to dinner a the drug companies expense. Nor will a play golf, or be a "consultant". I have done a few of these in the remote past, but as I thought through my peronal ethics I have decided on this personal costs. The pharmaceutical industry understands influence. They try to influence me, and I try very hard to use less biased sources of information.

Define healthy food.

Here's my problem, lowfat food almost always equal higher sugar food. If I switch my diet to a "healthy" diet I'll be taking more insulin and thus gain weight.

I'm a teacher and our cafeteria provides food that is very high in both fat and carbohydrate. Certainly not very healthy for the middle-aged adult.

We need to do some changes in food labeling. We need to call a serving of server. Look at your average sport bottle of Gatorade. (unhealthy drink for me) the nutrition label is misleading the serving size is in small case and is usually around 2 1/2 servings. Who drinks 2 1/2 servings of the sport bottle of Gatorade. They drink the sport bottle has one serving. Bet people would stay away from it if true servings were on the label.

Same thing goes for any other packaged food. Very few label's show true servings. And also would not hurt if restaurants started serving reasonable servings. Why is McDonald's selling two of things? And try to get them to give you one during those promotions.

I'll leave you with a funny... one of our assistant principals was eating candy, one of those large bags of cherry twists that are labeled a "no fat" food. It certainly wasn't a "no sugar" food.

Excellent comment! I will ask my daughter (who wrote the post referred to herein) for her response. I would say that the challenge of a food tax is arbitrating which foods deserve the tax, and which foods deserve the subsidy. Should we regulate taxes based on Atkins, or Walter Willett, or Dean Ornish? Each expert would probably stress a different list. While I like the proposal's concept, this comment does make us think about the potential problems.

That is it for this abbreviated Q&A. I hope everyone has a great week. Keep those comments coming - they certainly help focus my thinking and make this blog much better!!!

Here I am, back at the Q&A desk - sorting through the comments and questions. As always, the readers provide more material than I can use. Thanks to all who comment and question. Here are my highlights.

I enjoy your site, and noticed that you maintain a listing of "other medical blogs." I thought I'd point you towards my own site, the Ectopic Brain (http://pbrain.hypermart.net ), where I maintain a "What's New" page (http://pbrain.hypermart.net/blogger.html ) featuring news and information about the medical uses of Palm OS handhelds. Just FYI.

I had forgotten this email - but found it this morning. I have added the Ectopic Brain blog to the list on the left. For those who use Palm OS, this will be a valuable resource.

There is a reason why the real stuff will cost more and be more effective, there has been deep and serious research into it, using the best components to achieve the best possible results, generic medication may come from anywhere and the least expensive components will definetely be used. The molecules used in generic may vary just a little bit from the original, but the results will prove the difference between the two. Why pay less for your health? I'd rather buy something less this month and get what makes me feel great and healthy than saving a couple of dollars -or nothing at all -for something that makes me feel cheated and terrible. -Save in shoes, houses, etc, not in health.

This comment is wrong. Generic drugs have the same regulations from the FDA as trade drugs. The FDA maintains a site which provides information on generics - "http://www.fda.gov/cder/ob/default.htm">Electronic Orange Book. As one researches this issue one finds that often the same manufacturer makes both the generic and tradename preparation. I do not understand the disinformation concerning generics. They do work and they do save money.

Regarding your euthanasia position. Amen. But here's another place physicians should absolutely NOT be involved. Execution of the death penalty. How could any physician participate?

I do not think I could participate as a physician. The point is well made, and I believe that most physicians share this view.

I have read through the response from readers on omeprazole.  I find them interesting and strangely one-sided.  About 70% of omeprazole is being is dispensed as the generic, manufactured by Kremers Urban.  Given the millions of people switched to the generic (and many having been programmed to believe generics are of poor quality) I guess I shouldn't be surprised there are many who complain.

Having said that, I have two thoughts:

1) I have no respect for tactics used by the drug industry and wouldn't put it past them to have orchestrated some of these responses.  I worked for a state Medicaid agencies and frequently saw letters orchestrated by drug representatives (standard letter with different doc or patient name) opposing policy changes, and physician and patient letters complaining about generic failure.  Medicaid programs spend millions more for Clozaril (money desperately needed elsewhere), because prescribers demand the brand - all evidence to the contrary. This may sound paranoid, but with the $10+ billion involved in PPI sales, even those companies who hold patents will eventually see their market disappear to generic omeprazole.  PPIs represent a large share of many companies revenue.  Falling sales mean layoffs.  The drug industry is a master at controlling the message.  I have looked in chat rooms used by people with depression and seen drug industry reps pumping Lexapro as a wonder drug.  There must be a law against such action by a drug salesperson.

2) An aside, one of my colleagues complained when she switched to generic omeprazole, it didn't work as well as the Prilosec.  When I questioned her pattern of use, I discovered she took it with the breakfast meal.  When I told her to start taking the omeprazole 30 minutes before the morning meal, the problem resolved.  Many people don't know PPIs should be take 30 minutes or so before a meal.

3) If these are legitimate drug failures, prescribers should be encouraged to report them to the FDA.

Thanks for your rants on drugs like Nexium, Clarinex etc.  Many low income folks are duped by the drug industry and believe they must spend their limited discretionary income on these bogus drugs.   It appears all the ethics have gone out of the ethical drug industry.  Sad.

Often readers say things more elegantly than this ranter. This is such a case.

Well, I'd been dropping hints on my site for a week or so, and this week I made it official. I'm now one of Corante's tech bloggers - they needed someone to cover drug discovery and the like, and asked me if I'd like to come over. My site's been renamed from Lagniappe to "In the Pipeline," which at least gives folks some idea of what it's about.

The new URL is http://www.corante.com/pipeline. It looks a bit different from my old Blogspot site, but that's not necessarily a bad thing. Otherwise, nothing's changing - same topics and style as before. Same weird digressions, same lack of income, etc.

This commentary presented as a public service. I have changed the blogroll appropriately.

I have been switched to omeprazole 10 mg, but apart from slight mouth dryness I have had no other symptoms. On the contrary I am happy with the product; it has completely changed my life after the surgeon botched two hiatus hernia ops (and during the second one, accidentally tore my spleen!)

Anyway all my best wishes to fellow suffers - I know what its like!

By far the omeprazole rant has attracted the most attention of any single rant in this year of blogging. I included this positive comment, since it is in the minority.

I read your artical about patient autonomy. It was an excellent example of a physcian supporting the patient autonomy in the end stage of his life. Your approach to patient autonomy should be implemented as a routine practice.

We (medical school educators) generally are doing a much better job of teaching end of life issues. This education does include an understanding that our goal is to improve the patient's quality of life - as they define quality of life. I am personally impressed with how our students, interns and residents understand these concepts and apply them daily at the bedside.

Consider this: as these figures reflect declining compensation, our youngest graduates are entering the profession with the highest levels of educational debt in history, facing the highest prices for housing in many markets in a generation and have the greatest need to provide for their own retirements at a time of profound weakness in the investment markets. Practice costs have never been higher and the Medicare system is planning to cut reimbursements again next year, after a 5.4% gross cut last year. That 4.2% cut proposed cut will register against many doctors own incomes as double that amount given that other overhead will not be going down. Americans have blithely counted on the energy and durability of the private practice medical delivery system to see to the needs of our citizens. We don't have any real alternatives. Most patients really don't think of the effects of payment cuts except as it affects their copayments and deductibles. That luxury of ignorance may end abruptly and painfully.

This kind of information will travel quickly. College students trying to make decisions about going to medical school (vs. something else) won't ignore these reports, either. How can they? Finishing school with $200K of debt and without adequate compensation to repay the debt and to recover the opportunity costs of lengthy education and training isn't an option for anyone but the reckless and foolish. We want the best but don't want to pay for it, and will sue with abandon when we aren't satisfied. We are playing with fire with this. And we will very likely get burned.

I love C. Henry's rants. They are on target. We (society) are in trouble.

Hi, I was reading your Dec. 14, 2002 post about "Start Jogging" and you mentioned how you got shoes from a specialty shoe store. I haven't heard of any such stores around where I live, but how would you suggest I go about finding some? I've seen ads for a specialty shoe store that made custom inserts for shoes, but I'm looking for actual running shoes. Were your shoes custom made or did you just buy some popular brand like Adidas or Reebok?

We happen to have a specialty running store here in Birmingham. I friend at work suggested I go there. They sell regular brands, but helped me understand which type of shoe I needed. You might be able to figure that out yourself. This article from Runner's World should provide some valuable information - The Best Shoe for YOU! Let Runner's World help you find the right shoe for your running needs

What advice would you give to obese or overweight kids that try to diet or exercise but it never works?

Unfortunately, I am much better at identifying this problem than solving it. Exercise regimens do require self discipline. So does changing ones eating habits. Behavior changes challenge physicians so much that we start to avoid trying - because we get such a low success rate. The only advice that I can really give is to keep trying. Sometimes it takes multiple attempts until a change can really occur.

Was just switched over from Prilosec to the Generic Omeprazole and have been taking for 12 days now. I have had diarrhea and nausea for 10 of those days. Will be seeing the doctor about it soon! Does anyone know if the doctor has to say that the patient must have the Brand or the Generic version? This has been a bad experience!

While I doubt that the generic is the problem, I can answer your question about brand versus generic. Prescription pads give physicians the right to insist on brand name or allow substitution. If you want to pay for the brand name, it is your right to ask either the physician or the pharmacist.

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

This ends todays session. Try as I might, I just cannot avoid the Prilosec/omeprazole controversy. Without this blog I would not even know there was such a controversy!

Thanks again for the comments and questions. It is nice to know that my ranting induces comments and emails. That is wonderful confirmation that this blog has some worth. Thanks!!!
 

Thanks for the many comments and questions. I pick for Sunday based on my assessment of reader interest, or my own interest.

I am troubled by your answer to one of yesterday's Q&A questions and further troubled given your rant today regarding "When doctors sell out."

Yesterday you indicated the current medical system is flawed in that doctors who make correct diagnoses are not rewarded, but rather are punished when something might go wrong (punished perhaps by being dragged into court). I assume you mean the satisfaction of a healthy patient is not a reward in and of itself, but rather there should be some financial incentive for physicians who make the right diagnosis. That is, because doctors might be "punished" by a malpractice claim, they should be equally rewarded for doing their job correctly. Should the same system be in place for a police officer who stops a crime, an air traffic controller who succesffuly allows planes to land without an accident, for the same pilot landing the plane, or countless other professionals whose only reward is a job well-done and the satisfaction of knowing they did their job well?

Compounding my frustration, is your comment in today's rant about doctors selling supplements when you said "While money is not necessarily the root of all evil, it certainly can cloud one's judgement." Is this the same "cloud" that you propose as a financial incentive for doctor's who perform their job correctly???

I have thought carefully about how to answer this question from a long time reader. He raises some very interesting points, which I will do my best to answer.

I probably did not make my first point clearly enough. In medicine, even when we do everything properly, patients can still have bad outcomes. Unfortunately, sometimes patients (or families if the patient has died) view the bad outcome as the physician's fault. This tendency increases in our "blame someone" culture. Thus, we may have penalties for bad outcomes, regardless of our actions.

In most professions, and indeed in most jobs one receives rewards for a job well done. Promotions occur in law enforcement; higher fees result in law; more business results for a restaurant. Physicians have no such "upside". All generalists that I know already have too many patients. Fees are fixed by the insurance companies. Overhead keeps increasing.

I hope that I have explained the frustration and imbalance here. A job well done does give great satifaction - but only when the outcome is a positive one. We do not need great rewards, but we do need a better system to avoid penalties - and being named in a malpractice suit, regardless of the outcome of the suit - is a huge penalty.

The second question really compares apples and oranges. Supplement selling probably clouds physician judgment. Once once has a financial interest in something one sells, one will tend to sell that thing. Rewards for good work represent a different financial incentive. Here the incentives are aligned with the patient and physician's best interest - the health of the patient. Perhaps my wording was a bit imprecise. The problem I see is when physicians receive a financial reward not for providing medical care, but rather for something which the sell (using their MD as a sales advantage).

While I agree that advertising can have its pitfalls, as a psychiatrist I am pleased that patients come in for
treatment-with me or with anyone else. It has been my experience that very few patients request medications that they have heard about on TV. What they do request is treatment for the condition that they learned they were suffering from when educated by the advertisement.

Currently, only 50% if depressives in this country receive a diagnosis, half of those receive treatment and only 8 per 100 patients with depression are currently treated to remission (the currently accepted standard of treatment).

If residency programs do not train physicians adequately in the recognition of mental illness, and as long as some doctors still refuse to diagnose or treat it, then the most effective way to assure treatment will be consumer-driven. I applaud those companies that continue to advertise antidepressants on TV and would also like to note that these companies are amazingly philanthropic in their willingness to provide free medication for the indigent. We also rely heavily on them to continue to put money back into research to further decrease the mental illness burden for future generations.

I posted this comment just for the alternate viewpoint! Psychiatry may represent the main area of benefit for these ads! As a generalist, I do not want to argue about Nexium or Celexa. I do understand this psychiatrists point - and it is well stated - but I do not find it generalizable to most medical conditions.

"it is our right and who is to decide you have to live in pain "

This comment refers to a post on euthanasia from last May! I personally cannot accept active euthanasia as an option. Passive euthanasia is perfectly acceptable. Let me try to clarify.

I care for terminally ill patients regularly in the VA hosptial. When we have such a patient, we make a complete assessment of their quality of life issues. We can do a good job of treating pain and other symptoms.

I would never give a patient a narcotic dose with the purpose of ending his/her life. However, I will give a patient enough narcotics so that they do not have pain, even if that dose could possible stop respirations. This line, in my mind, is very clear. It has to do with intent. I will allow a patient to die in peace; I will not purposely cause a patient to die.

I find the latter a slippery slope. Once we (physicians) cross the point so that we help patients die, we will always have difficulty defining acceptable criteria. How does one develop criteria to prevent physicians from using euthanasia too "loosely"?

Thus, I remain on the side of aggressive palliation - for those interested read this rant from last October - More on palliation .

Re: Statins and muscle pain

Should endurance athletes ( say a triathlete anticipating a 6-6.5 hour maximal effort in a half ironman race ) stop their statin prior to the race? If so, then for how long? Incidently, races of this length and longer can cause elevated CPKs and in some cases mild elevations in cardiac CPK levels. This data makes no mention about pre-race statin ingestion.

I wish I knew the answer to this question. Someone should perform a study, perhaps at first during a 10K. I suspect (having no data, just hypotheses) that most patients would have no problems. But I really do not know the answer.

Well, anecdotally (is there such a word?) speaking, I probably still won't volunteer. I get one mild cold once a year, and "walking pneumonia" about every fourth, but the worst was the last time I took the vaccine. I prefer the pneumonia.

Probably idiosyncratic, I do not discourage others from taking it.

This comment represents the problem physicians have in promoting prevention. Patients (and sometimes physicians) rely on anecdotes rather than data. This process is known as the availability heuristic . You can read more about the heuristic - Availability heuristic

Definition: A heuristic or "rule of thumb" strategy biased for estimating probabilities (of past or future events), based on how easily the related instances of that event come to mind.

Example: Although diseases kill many more people than accidents, it has been shown that people will judge accidents and diseases to be equally fatal. This is because accidents are more dramatic and are often written up in the paper or seen on the news on t.v., and are more available in memory than diseases.

Background: People use heuristics to solve problems or reduce the range of possible answers to questions. Although at times it can result in the correct solution, the availability heuristic can also result in erroneous solutions to problems/questions. In using this rule of thumb, people judge frequency based on a quick count of examples. The use of this strategy is very widespread, and is used in making both trivial and important judgements. People tend to overestimate the frequency of certain rare events if they are dramatic and sensational and underestimate those that are more frequent but occur in private, ordinary situations. This appears to be because the rare, dramatic and sensational events are more easily available in memory.

The reader is wrong. We have many studies which show clearly that flu vaccines do not cause illness. But I doubt that I can convince him.

SARS is a respiratory ailment. If a person is very fit, doing a lot of cardio to strengthen the heart and lungs, are they less likely to succumb to such a virus?

First, we really do not know enough epidemiology to fully answer this question. In general, with any viral infection, host factors have great importance. I suspect that being fit improves ones odds, but this virus does act very aggressively in a small percentage of patients.

As an RN who just recently recieved her MSN in nursing education and would like to go into teaching other nurses the profession, it is really hard to leave the bedside knowing that I will make less money. THere needs to be more incentive to get that higher degree. As far as replacing the number of nurses we need through enrollment, that will be a long process, but the problem took a long time to evolve, it may take a long time to solve also. The problem is going to get worse, and the more qualified nurses we do produce, the better care for patients and the society we live in. 

AMEN!!!

I am a Human Resources Staffing Specialist who also happens to be a college student. I'm doing a research project on the 80-hour workweek and I'm trying to get some additional information. Do you happen to know where I might find how hospitals are going to comply with this rule? At my hospital, a large academic medical center in Philadelphia, we are planning on utilizing nurse practitioners and physician's assistants to make up the difference. My project is going to focus on how hospitals are planning to make up the hours lost by the residents as well as a cost analysis. Obviously, this rule will have a major financial impact on hospitals, large and small.

Tip O'Neill (from Speaker of the House) once said - "All politics is local". I suspect that you will find a wide variety of solutions to the 80 hour workweek problem. You will find variations within the same hospital. Let me try to clarify a bit.

Most medicine and pediatric programs will make minor modifications, being fairly close to the 80 hour work week already. Radiology, anesthesiology and pathology should have no problems. Surgery programs will have the greatest problem, as they are currently the most frequent offender. I suspect that many programs have not really determined how they will address the new rules. And some will try to ignore these rules (see last week's Q&A for example). Good luck in your project!

Final comments

Thanks again for the many comments and questions this week. You, the readers, make me think, keep me honest, and make this blog much better. As usual I apologize for not answering all questions or highlighting all comments. I have decided to avoid the omeprazole controversy as I have nothing else to add at this time.

Now it looks like a beautful morning in Alabama - off to the golf course (I know that is a cliche for a physician - but I really do love golf)!

Sitting here, back at the Q&A desk. Today I will share both questions and comments. Receiving these comments provides a great reward - it tells me that some readers really care about my rants. And that is a wonderful feeling!

Reframe the discussion how ever you feel is convenient. The bottom line is state medical boards do a pretty lousy job of patrolling the profession for substandard care, based in large part on failure of professionals and health service organizations to self-report problem physicians, and budget and staffing support received from state legislatures. And responsibility for budget and staffing support limits, as well as limited grounds upon which to trigger an investigation or disciplinary action, can be placed at the feet of the provider interest groups.

This represents one of my excellent comments from the Bloviator (you should read his page regularly - just look over to the Medical Blog list). He forwards an interesting viewpoint on self-policing. I hope he is reading this rant - do lawyers do a good job of self-policing?

He points out that State Medical Boards do not receive adequate funding. Thus, they have difficulty becoming proactive in searching for "problem physicians". He has served as counsel to a State Board - so I would not dare challenge him on that point.

However, I believe this issue is indeed a side issue. Our problem stems from how our society defines and pays for malpractice. The entire concept of punitive damages is quite problematic. How can anyone adequately define those?

As I (and many readers) have said repeatedly, the problem with malpractice settlements should concern everyone. If malpractice premiums and rewards continue to rise, then no rationalization for the high rewards will matter. If physicians cannot afford to practice, then patients will really suffer. In some ways we are considering the penalties for errors of commission, and as a society ignoring the costs of paying those penalities.

I empathize with true malpractice victims. However, our current system works more like a lottery than a true check and balance.

Trial lawyers are the problem here. We need an alternate system for judging and paying for real malpractice. Our health care system really does an excellent job of caring for most patients. But we never get extra rewards for great care. When we make an important diagnosis or help a patient through a crisis, we receive the same fees as when we care for a more straightforward, simple diagnosis. If the patient has a bad outcome (even if we really did everything right), we just might get sued. That cannot make sense to anyone. Our system of judging malpractice is broken. The penalties for malpractice are broken. As a result, medical care actually suffers. The current malpractice system discourages improvements in health care.

I am a second year general surgery resident at a busy metropolitan academic center.  I enjoy reading your medrants whenever I can find the time.  Major kudos is due to you and your site.

You have written often about the 80-hour workweek issue.  I agree with most of what you have written.  I can tell you though, from my own experience and from talking to friends that I have in other surgical residencies around the country, that compliance by surgery programs will be very poor.  My program director has hatched a plan of pseudocompliance.  "You can go home 6 hours after you finish call if you want to, but everyone else is staying.  By the way, if you stay to work extra, its on your own time and you can't count it on your timesheets."

 This comment does not surprise me. I suspect many surgery programs will try such tactics, and some will get caught. Such programs will probably penalize residents who do not play their game. But if they fire those residents, the residents will likely sing.

Surgery programs have attitude (yes I know this is a generalization - but many colleagues around the country confirm that generalization). They truly believe they understand training better than any outside group. Some programs will comply; some programs will have the above attitude. We will have to follow the changes in July to see which specialities adapt well and which struggle.

An endoscopy the other day revealed "very mild" gastritis (probably from taking Advil on an empty stomach), also "very mild" esophogial irritation from a bout with heartburn that I had during a particularly stressful period several months ago. The doc, who is does a great job with the endoscopy, does not do such a good job with followup and simply gave my husband on the way out a script for Nexium, with little direction. I have so many questions! First of all, I have lowish platelets, around 100,000. Does Nexium, like Tagamet, interfere with platelet counts. Secondly, is this drug really necessary??? If both problems are "mild," and if I really don't even feel heartburn anymore, can't I a)change my behaviors and cure the gastritis and b)assume that the esophagial damage is from an old problem and that the esophagus will heal itself, given time? By the way, I am a 47-year-old woman who takes no scripts, who hates taking pharmaceuticals and likes to believe she can heal herself holistically -- until something life-threatening comes along, at which point I will be grateful for life-saving drugs. I don't see this situation as a life-threatening one. Thanks for listening and for whatever advice you can offer.

Thanks for the question. Giving advice on medical issues without actually talking with a patient and examining them and their medical record is a bad idea. Thus, I will couch my answer in generalities.

I am not aware of proton pump inhibitors (the class which includes Nexium) causing problems with thrombocytopenia. A quick search did not find any such problems. Tagamet is a histamine-2 blocker - a different drug class.

Not knowing your history of gastritis and esophagitis, I can make no comments on treatment. If you truly have endoscopic evidence of esophagitis, then I doubt holistic treatments will work. In general weight loss does help esophagitis.

If your gastroenterologist does not discuss your diagnosis well, you might try going back to your internist or family physicians. They should be able to sit down and discuss your management strategy. If you do not have a generalist, you need one (as I rant about regularly).

"We teach residents to consider a complete differential, but to concentrate on the four most common diagnoses - undiagnosed asthma, ACE inhibitor cough, post-nasal drainage, and gastroesophageal reflux disease (GERD)."

How about chronic bronchitis?

This comment came from a rant about cryptic cough. I did not make clear that I was talking about cryptic cough. Chronic bronchitis, in my experience, is rarely (if ever) cryptic). These patients have a productive cough and fit into a classic syndrome. If we take all cough presenstation, then chronic bronchitis is an important consideration.

I knew one attending whose favorite retort to the "natural" argument was to snap, "Well, poison ivy's natural
too!"

Well stated.

and what about the "natural course of an illness?" We all know that over 90% of common maladies like Otitis Media, Sinusitis, and Pharyngitis will resolve with NO intervention. Try saying THAT to the next patient with a runny nose who asks for a "natural cure."

While I do think we should prescribe antibiotics for bacterial otitis, sinusitis and pharyngitis, I agree that we are too quick to give patients antibiotics for viral infections. Why do we do this? It saves time and the patient expects it. I have always tried to avoid this behavior. Unfortunately, I see too many colleagues, residents and even students who start "a Z-pak" whenever they get a cold. We need to do a better job here!

A pre=emptive apology for this rant.

This is old news to the average otolaryngologist. OVERHWELMINGLY, patients who I see for chronic cough have underlying GERD. I'd guess that 80% have GERD, 10% have chronic sinusistis, and then there are about 10% "other." Most are not difficult to diagnose on history alone (not to sound facetious- most are easy to diagnose my simply LOOKING at them). Chronic sinusitis is easy to rule out- order a CT scan. The only problem you'll run into in that regard is that our radiology colleagues have a penchant for overreading these scans. (I would LOVE to see a blinded study of sinus CT scan interpretations by radiologists. I would wager that you'll get a substantially different interpretation by 5 out of 10 readers.)

I have a pet peeve: I IMPLORE my generalist colleagues (and others) to stop using the term "post-nasal drainage" so flippantly. I peer into pharynges every day of my working life (X 20 years) and I can tell you that it is RARE to actually spot any kind of discharge trailing down the posterior oropharyngeal wall. The only other time one sees this is as a subtle finding on endoscopic exam- a modality that is not available to the average generalist. I'm constantly astounded at how many patients come in telling me that their Primary care doctor "spotted drainage down my throat." Don't you find it odd that everyone and his cousin talks about "post-nasal" drainage" and yet this is not a term that is loosely used by the one specialist in human medicine who ought to know the most about it?

Sadly, most of my day is spent UNDIAGNOSING "sinusitis." These patients are almost always complaining of facial pain (shockingly, predominantly female, often depressed; usually with a background history of headache and other pain syndromes) i.e. "another sinus infection" and/or "post-nasal drainage" i.e. almost always symptoms of GERD. Is it any surprise that they don't get better with antibiotics? And the ones that do are often responding to a placebo effect.

There has been, and continues to be, a lot of gold to be minded treating "chronic sinusitis" surgically. Please spare your patients needless antibiotics and surgery. Concentrate on SYMPTOMS, not preconceived diagnoses. If you do, you'll almost always come upon the right assessment the first time.

Sometimes readers have better rants than DB. This is a great example. Thanks to Dr. Kranky for this post!

Do you know of a medical study on use of Singulair for people with chronic sinusitis? I do not have asthma but have had injections for years, had 2 sinus surgeries and suffered 10 years of infections every 3 months (average). I've slightly improved via acupuncture, but still need help. (It does not help living in the humid Washington, DC area) 

First, read the comment about. Second, do you have chronic sinusitis or allergic rhinitis, or both. If you have allergic rhinitis, then Singulair can help (but is not better than nasal steroids). You might benefit from a fresh look at your symptoms and treatment. Again, not talking with you and having access to all your records, I cannot completely answer your question.

One way to calculate the benefit is to measure the number of specialty referrals generated in a "shared" practice vs. the model that most of us feel is more beneficial- per given condition (or tentative diagnosis). AND factor in the number of visits to each primary care model BEFORE the referral was made.

It's been my experience as a consultant that too many conditions were turned into "chronic" or "complicated" this or that, simply because there were 3, 4 different primary care physicians (sometimes PA's of NP's) on the given patient's care.

Another excellent comment which complements (in my opinion) the point I tried to make. Continuity certainly has important benefits on satisfaction (for both patients and physicians). It also often leads to better care. I agree with the comment, although I do not know of a good study to confirm this observation.

...

Once again, thanks for the comments and questions.  
When there is no continuity in the thought process on a given patient's situation, is it any surprise that delay
and anxiety result?

How am I suppose to chose? Am I prepared to die on the operating table, NO. Do I want to die slowly by staying 362lbs, NO. So now what? I know most people think obese people should be able to just stop eating and the weight will come off, but it doesn't work that way for everyone. Me being one of those people. I have a 12 yr old son that I want to live for. I want this surgery but how can I say, as I'm being wheeling into surgery "see you soon" knowing that he may never see me again..all because I want to be healthy. I'm so confused!

This eloquent paragraph defines the problem of obesity. You know that your weight is a major problem, yet cannot succeed with conventional methods.

Most physicians and readers do have difficulty understanding your situation. Peronally, I have succeed in modifying my diet and enhancing my exercise program. That must not work for you.

So what are you to do? No one can make this difficult decision for you. When does one risk everything (albeit a low probability) to gain everything? I can tell you that on average having surgery will benefit you. But averages work for populations, not for individuals. Talk to some surgeons who specialize in this surgery. Interview them, and they might help you with your decision making. Good luck - we all hope you make the right decision for yourself.

I'm not a doctor... my wife has Atrial Flutter. She feels much better in Sinus Rhythm. So isn't it a good idea to have "rhythm" control just from a quality of life point of view?

And if she is in sinus, are the data clear that she should still be on warfarin? How about going back to warfarin if she should go into AF, but otherwise don't take it. She's been in sinus for several months now.

Thanks for this interesting question. Let me first describe the difference between atrial fibrillation and atrial flutter. Heart rhythm normal starts with the atria (the 2 smaller chambers) contracting, and very soon thereafter the ventricles (the larger chambers) contract. In normal hearts these contractions synchronize to maximize blood flow through the heart and out to the body.

Atrial fibrillation occurs when the atria no longer have coordinated contractions, rather they fibrillate (fibrillate refers to the act of fibrillation - muscular twitching involving individual muscle fibers acting without coordination). Thus, the atria "quiver" but do not send coordinated impulses to the ventricles. The ventricles receive irregular signals to contract. Thus, the rhythm becomes irregularly irregular.

One danger of atrial fibrillation comes from the "quivering" in the atria. Since they do not contract properly, the blood tends to pool, allowing coagulation to occur. (oops another medical term - coagulation means that clots can form). The clots are the problem. They can grow to a large enough size that they cause problems when they "break loose" from the atria. Thus, the risk of stroke in untreated atrial fibrillation.

Atrial flutter is a different rhythm. In this rhythm the atria do have coordinated contractions - usually at a very fast rate (think around 300 times per minute). This atrial rapid rate is usually modified by the electrical connection to the ventricles (what we call the AV node). The AV node handles the electrical impulses from the atria - passing on a signal to the ventricles to contract. A rate of 300 is too fast to pass on to the ventricles. Usually every other or every third signal gets through.

Because atrial flutter usually causes symptoms immediately, most patients receive treatment to restore sinus rhythm. The unusual patient with chronic atrial flutter does have some risk for thrombi and emboli (blood clot terms - thrombi when they form - emboli when they break off and flow elsewhere and cause problems).

When atrial flutter is succesfully treated, anticoagulation is generally not needed. If it became intermittent one might anticoagulate (especially if the patient alternated between atrial flutter and atrial fibrillation).

I hope this complex answer helps.

I just started taking Zetia after a muscle bout with Lipitor. What side effects will I have with Zetia? Hope to hear from you.

Having not yet treated any patients with Zetia, I have to look this one up. The FDA says stomach pain and tiredness can occur. FDA information on Zetia. I hope that helps.

Will the vaccine prevent other hpv like common warts and also when will it be available?

Great question, which I cannot answer! I suspect that the vaccine will prevent some warts - but will probably only work against a small subset of HPV strains (those which most commonly cause cervical cancer). I have no idea on the timetable for this vaccine.

Well, maybe. Services are services. But what about the consumer? I am facing 4 or 5 hours of work to sort out insurance problems caused either by the insurance company or by the doc's office. I've got a dentist who has filed 4 times for the same services (and was paid fully), and an internal medicine practice that just billed the insurance co. for services 8 months ago. Straightening this out will cost me 3 or 4 hours of weekend time. And no reimbursement! :) I have to go through this two or three times a year.

First, thanks for the comment, and I do understand your frustration. The object of your frustration is the insurance companies not the health care professionals. Why should we charge you for filling out forms? Because we are running a business and time is money! The forms that I imply are extra forms. Another comment states it well -

I am all for it. (Speaking as an MD.) Doctors spend huge amounts of time filling out these forms. I'm sure I don't have to convince *you*, but here is a partial list:
- Disability forms
- Jury duty forms
- health clearances for school, work, prospective adoptive parents
- Life insurance forms (death claims)
- Letters to health clubs allowing patients to get out of their memberships
 
It's unbelievable. It adds a significant amount of time to the time spent in the office. I think it's time to start charging.

And that is the point of the rant.

And is use of hormones also a placebo for those of us who have had hysterectomies with oophorectomies, or those twenty-somethings in premature menopause? Since we are lumped in with all other women and all conceivable forms of hormones are now too dangerous to use (and goodness knows there are no side effects or risks in the antidepressants, bone-density enhancers, statins, antihypertensives, false teeth, dried-up-eyeballs, and, let me not forget, copious helpings of KY to "treat" that vag atrophy that we'll be switching to), I can only guess not.

Gee, if hormones are that evil, maybe women should ALL have oophorectomies before menarche. Think of all the problems that would prevent!

Premature menopause and oophorectomies represent a totally different situation than the studies address. One difficulty in medicine is the balance between belief and data. I prefer data. We must criticize studies carefully, but then understand what they tell us. I would prescribe hormonal therapy to patients with oophorectomy or premature menopause until around 50 years.

With specific reference to vaginal atrophy, I understand that vaginal estrogen does help a great deal. Also, continued sexual activity seems to retard atrophy.

...

Thanks for the many excellent comments and questions. I hope some of these answers are helpful. And thanks for reading!!
 

First, let me apologize that this will be an abbreviated Q&A. I have many good questions sitting on my home computer. But, I am visiting friends in Richmond, Virginia, so I only have access to questions since Thursday. I will address a few questions today - and hopefully start catching up later this week.

hi, my husband cannot take statins of any kind due to the severe muscle symptoms, and the elevation of liver enzymes during a course, what are Zetia's side effects if this drug is taken alone. His cholesterol is 9.9. and has the inherited gene.

This is a very fair question. I did not know the answer to this question, but through the genius of Google I can provide a good reference. Zetia Side Effects

For what? These are grown men. They clearly know the risk. Their own friends and colleagues have died from this supplement, and yet they continue to take it. If we were to ban ephedra somehow, they'd just find something else to take, rather than perhaps cutting down the number of pancakes they have at breakfast. I'm all for education, but when your buddy dies from a drug that you yourself are taking, don't you think that'd be education enough?

This comment raises an interesting point. How far should we go to protect consumers? While I understand the reasoning behind her argument, I believe it to be an oversimplification.

We have many potential users of supplements. Athletes will find performance aids, legally or illegally - as Ron Dibble explains - On Steve Bechler's death . While one would think that athletes are "grown men", I doubt that they often act like them - but many would argue grown men may be an oxymoron. Can they really make informed decisions about supplements? I read where a baseball star argued against banning ephedra because "it is legally and OTC".

Even if I grant you that they should be able to take the risk, what about college athletes, or high school athletes, or just anyone trying to lose weight. And what other supplements are putting us at risk. We should all know about ephedra now, but I doubt that we do. The information on bottles is imprecise and uninformative.

So, I will stand by my previous rant. We need to revisit the dietary and supplement act of 1994. We should not allow marketting of dangerous ineffective supplements.

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Well that is it for the abbreviated Q&A. I owe the readers more answers. I will catch up. I will catch up. I will catch up.

After travelling all day (LA to Birmingham), I finally sit down to a large number of excellent questions and comments. I may have to do a second Q&A later this week. Here are some highlights.

While this is an easy proposal to attempt to marginalize as impractical or unfavorable (or socialist), fortunately, this is not the only universal coverage proposal being discussed right now. Howard Dean and Dick Gephardt both offer universal coverage planks in their presidential platforms. To pull a quote from a Los Angeles Times article appearing today, "To me, what's exciting is that the universal coverage debate is back on the national agenda. That in itself is huge."

I respectfully disagree. I really do not think that universal coverage is really back on the national agenda. Yes, our health care system needs a boost, but this debate will not provide a constructive contribution (in my opinion).

Perhaps this type of thing must be allowed, but if the case is not proven to the satisfaction of both judge and jury some penalty should be exacted.

Alas, someone will eventually "win" a case on an emotional basis. If not against McD or other fast-food outlet, then against their suppliers or the ranchers and farmers.

The reader makes a powerful suggestion. What if these suits carried a penalty for losing? A losing suit does create costs to society and to the entity sued. Should there be a penalty for losing suits? Perhaps our friend the Bloviator can rant back on that one.

I appreciate your opportunistic jabs at the pharmaceutical industry--they are big business and thus an easy target. Historically speaking, any industry (US Steel, Microsoft, Standard Oil, etc. etc.) which turns a profit at greater rates than other businesses is made to feel that it is doing something wrong, either by the media, the government, or consumers that support it. It would prove to your readers that you truly are against the extravagances of the industry if you printed those stocks in your own 401K minus the dollar amounts) --I personally would be interested to see if pharma stock is absent or for that matter, any health care stock (particularly managed care stock). If you are like most doctors, most all of you benefit via retirement plans, annuities, ROTH's, etc from the profitabilty of an industry that you love to hang in effigy each and everyday. Most of you take great pride in claiming that you don't support the gifts, company incentives, and marketing ploys; however the purchase of stock in these companies makes your rage against them comical and nothing short of hypocritical. I have yet to meet a doctor who doesn't know what is going on with Pfizer, Merck or J&J stock. Why is that?

This is a fair critique. In the interest of full disclosure, I have no idea what stocks are in my 403(b) (working for a medical school I have a 403(b) rather than a 401(k)). My money goes into TIAA-CREF as mutual funds and bond funds. I do not know what stocks they buy. I have never bought a pharmaceutical stock, and believe that to do so would be personally unethical.

I was on Prilosec; harmacy gave me the generic - yep- Omeprazole! I had stomach aches for a week, and then had an "episode" with acid-the pain was so gut-wrenching, I was doubled over and in tears. To top it off, I gave the pills to my husband (who is on Prilosec too), and after one pill, he had a stomach ache three hours later! Who listens to these stories? How do we know the "right" people are hearing this AND can do something about it? I also want my money back!

As I have previously said, we do need a study of this issue. Knowing the chemical and the FDA rating, I remain skeptical. However, I continue to get many comments on this issue. I will remain vigilant for any news concerning generic omeprazole (brand name Prilosec).

Boxing is only dangerous when not played by professionals

Wrong! Boxing has as a goal creating brain damage (for that is what a knockout is). Amateur boxing is much safer than professional boxing. Nontheless, both should be banned (if I were the king of sports).

Did it ever occur to anyone that maybe the insurance companies should have a cap on their costs? Why should a patient who loses an arm, a leg, or worse have a cap put on the damages that they can collect? Oh, yes, I know, if we penalize the insurance industry it will jepordize our free enterprise system. Oh, heavens!! Far better to limint the awards those "little" people might collect for an incompetant doctor.

I do understand the desire to penalize the "incompetent doctor". Several problems exist in this response. The first is the assumption one makes of incompetence. Can a jury really judge medical competence? Sometimes yes, but not always. The next problem relates to the impact of large judgements. As a society we must balance the individual good with the societal good. Large malpractice awards penalize the innocent physicians and therefore their patients. The money must come from somewhere, and it is not coming from the physicians, even if he/she did commit malpractice.

The large damage awards and resulting high insurance costs may partially repay the public for the huge amount of time the doctors force us to waste. The money is just not distributed correctly.

Go into any doctor's waiting room and you find numbers of patients waiting, wasting time. A 2:00 o'clock appointment usually keeps you sitting for an hour or two in the waiting room, then half an hour or so in a small, sterile treatment room, finally about ten minutes with his eminence. This costs you a half days work. No wonder juries go against doctors. The jury members have been mistreated in this way too many times.

This comment uses gross generalizations and comes to illogical conclusions. First, most juries find in favor of the physician. Second, the reader is partially right - ideally we would rather not keep you waiting. Sometimes the exigencies of practice do cause these delays. Most physicians would like to see you on schedule, but we must "squeeze in" other sick patients, or have patients who need more time than we scheduled. I do understand you angst and hope you can find a physician more suited to your schedule.

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More at a later date!

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

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

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

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

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

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

Blaming the insurance companies is a smokescreen.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I've lost count of how many times the pulmonologist has ordered or dc'd antibiotics without telling the I.D. MD, who then comes in at 8pm and rants at the nurses for not notifying them of the change. I'm not sure what a good solution would be. We need both generalists and specialists, but the missing link is communication... and common
sense