nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Thursday, November 29, 2007


This email is a personal message to friends and family. It represents my opinion on healthcare issues, for the entertainment (if not benefit) of those I know and care about. I do not represent any interest or organization, and I try not to impugn named individuals or organizations—we do too much scapegoating already. My concern is with poor processes and system defects. I am aware that some of you forward these things on. While that was not my intent, it’s OK, and I stand by what I say…but, please don’t forward my email address with it. I don’t have the time or interest to engage in a dialogue with a stranger who has something on their mind, or a decided opinion to argue. We live in a strange world. Thanks.

New York state lawmakers to enact physician-ranking legislation.

In continuing coverage from previous briefings, the AP (11/27, Matthews) reports, "Acting on concerns about possible 'physician profiling,' state lawmakers said Monday they would pass a law to force health insurers that rank doctors to put patient care first, instead of using cost as the sole measure." The lawmakers "joined state Attorney General Andrew Cuomo (D) to announce the proposed law, which is based on a so-called model code for doctor ranking that Cuomo has persuaded top insurers to adopt." In recent years, physician-ranking programs have become "a rapidly growing practice within the healthcare industry," and "Cuomo said major insurers nationwide either operate or are in the process of developing these programs." Reacting to the announcement, Nancy Nielsen, M.D., Ph.D., president-elect of the AMA, stated, "Attorney General Cuomo is to be credited for persuading many of the nation's largest health insurers to acknowledge the risks of physician profiling."

Doc D: Getting “cut rate” care (ie., efficiency) is one issue with physician ranking. The companies that are promoting this are in the business of making money, and the govt is trying to control rising costs. While modern medical practice has to efficient, I’m not sure I want to be taken care of by the cheapest doc around. Maybe, like the old used car salesman joke, he/she “makes it up in volume.” But, there’s another problem: the doctors with the best quality results may not be the doctors you want to see. In the medical community we knew those docs who would take on the hard cases, and those who wouldn’t. We also knew which ones were the best at the hard cases, and their mortality results were not as good as the others…but I would trust my life to them. In my opinion, there’s no substitute for your own personal knowledge: find somebody who deals with you in a straightforward manner, and whose opinions make sense. IF they don’t, ask for an explanation. Develop a sense of trust or find somebody else. These quality and efficiency indicators can’t substitute for that.

Rhode Island hospital fined for wrong-site surgeries.

The AP (11/27) reports, "A Rhode Island Hospital was fined $50,000 and reprimanded by the state department of health Monday after its third instance this year of a doctor performing brain surgery in the wrong side of a patient's head." According to the health department, much like a similar incident four months earlier, the 82-year-old woman suffered no long-term ill effects. Still, "in August, a patient died a few weeks after a third doctor performed brain surgery on the wrong side of his head."

Doc D: I cannot understand how this stupidity happens. The article goes on to say that they are considering developing a pre-operative checklist. Duh. That’s been standard of practice for a long time. In hospitals where I’ve worked, there is not only a checklist, but the ENTIRE surgical team (incl. doc) meets outside the door and runs through the whole process…anybody can ask a question, from the gas passer to the orderly. This process is repeated inside the room, as everything is checked off that is needed, armbands checked and re-checked, the patient asked to state their name and what they are having done, etc, etc. And finally, as the first cut is about to be made, there’s a final “have we thought of everything?” At any time during the operation, anyone can call a “time-out.”

I know one surgeon who signs his name to where he’s going to operate (directly on the skin) on the day before. A lot of surgeons do this, but this guy tells the patient “don’t wash it off, because if my name aint on you tomorrow, I’m not operating.”

Study indicates non-white women with metastatic breast cancer experience more pain than white women.

The UPI (11/27) reports, "Whites with metastatic breast cancer have less pain," and the pain occurs later during the course of the disease compared to nonwhites, according to a study published in the Jan. 1 issue of Cancer.

Doc D: They were all taking the same medicines, and in the same amounts. But, in my opinion, this is trash science. According to this article, the researchers offer no hypothesis and their only recommendation was to consider treating non-whites’ pain earlier. Wouldn’t it be better to just ask the patient if they’re having pain and treat it then, white or not? Duh, again. Perception of pain is a complex phenomenon, and individual assessment is the only guide. This study may represent your tax dollars at work. Let’s hope not.

Doc D

Opinions solely my own

Tuesday, November 20, 2007


Parents of unvaccinated children capitulate under Maryland county threat of jail, fines.

In continuing coverage from a previous briefing, the New York Times (11/18, A36, Abruzzese) reported, "Hundreds of parents, who had been warned that they might face fines and jail time unless they had their children immunized, brought their children to a courthouse" in Prince George's County in Maryland "Saturday for the vaccinations." The parents and their children were summoned to appear before "Judge C. Philip Nichols Jr. of Prince George's County Circuit Court, who is in charge of juvenile issues." Earlier in the week, the judge mailed letters to "more than 800 households with children in public schools, strongly recommending that the children be immunized Saturday at the courthouse, where health department workers had set up tables to process paperwork and give shots, or that parents prove that the children had already been immunized in accordance with state law." On Nov. 1, "Prince George's County state's attorney, Glenn F. Ivey," sent a similar letter to the same households "informing parents that their children would be withdrawn from school until the school received proof of vaccination," and that if the children remained without the proper immunizations, the parents could "be subject to criminal charges with a maximum penalty of 10 days in jail and a fine of $50 per day of absence." After Saturday's vaccine drive, the number of children that officials say still need vaccines is "939, with 101 children receiving shots and 71 having their records updated."

Doc D: On most things, I think people should have the freedom to decide what they will and won’t do. Immunization is not one of them. Vaccination is the #2 all-time, most effective tool in human history against the morbidity and mortality of infectious disease (#1 is the sanitation movement; #3 is antibiotics). Parents should not have the freedom to expose their children to serious illness. In this country, people still die of pertussis, measles and…yes…chickenpox. There are about 150 deaths a year from chickenpox. But, even more important, people don’t have the right to increase the vulnerable pool of unvaccinated that leads to increased transmission of the disease…to others, especially the young, old, and chronically ill who are more susceptible. By the way, these parents had multiple notices, letters, announcements, and home visits to inform them of the requirement…months ago. And it’s not clear that anyone was threatened with jail, at least at this point.

I’ve had patients and parents say to me, “what difference does one person make? If everybody else takes their shot, then I’ll be safe without it?” This is despicable and immoral…and I tell them so. If one can get away with it, others will want to, and then we are not safe: it’s happened before. We almost eradicated measles in this country 30 years ago, then people stopped getting their kids immunized, and ten years later we had outbreaks in colleges (several hundred deaths).

So, bottom line is that some people have to be compelled to be responsible adults.

Report indicates U.N. overestimated number of HIV/AIDS infections.

In a front-page article, the Washington Post (11/20, A1, Timberg) reports, "The United Nations' (U.N.) top AIDS scientists plan to acknowledge this week that they have long overestimated both the size and the course of the epidemic, which they now believe has been slowing for nearly a decade," according to documents prepared by the U.N. But, according to the newest estimates, "the number of annual new HIV infections [is] 2.5 million, a cut of more than 40 percent from last year's estimate." Furthermore, the total number of people worldwide who have HIV will now "be reported as 33 million," rather than last year's estimate of almost "40 million and rising." Critics have previously questioned the agency's "portrayal of an ever-expanding global epidemic," and have even maintained that the U.N. has over-exaggerated "the extent of the epidemic to help gather political and financial support for combating AIDS."

On its front page, the New York Times (11/20, A1, McNeil Jr.) reports that these new figures mean "that new infections with the deadly virus have been dropping each year since they peaked in the late 1990s," rather than steadily increasing as had been portrayed.

Doc D: This is fascinating. I remember one interview around 1990 where the person said, “it’s not a matter of IF we will get AIDS, it’s a matter of WHEN.” (scaring ourselves to death, again) Now the UN is scrambling to do damage control for overestimating, PLUS telling us falsely that the disease was rising when it was falling. The UN is trying to put the onus on the countries who reported the numbers, but the UN tacitly agreed to the flawed methodologies in India and Sub-Saharan Africa. This is not to say that HIV is not a major global problem; but it’s just a fifth of the problem that malaria, or schistosomiasis, are (~100-200 million each). Another blow to UN credibility.

Simple Recipe Turns Human Skin Cells Into Embryonic Stem Cell-like Cells

ScienceDaily (Nov. 20, 2007) — A simple recipe--including just four ingredients--can transform adult human skin cells into cells that resemble embryonic stem cells, researchers report in the journal Cell. The converted cells have many of the physical, growth and genetic features typically found in embryonic stem cells and can differentiate to produce other tissue types, including neurons and heart tissue, according to the researchers.

Doc D: Most of what I write is skeptical, but this is good news. There were two studies published describing methods of doing this. This technique avoids using human embryo tissue, which I have ethical concerns about (not over the use of them, but over what the need for them can tempt people to do). It’s worth noting though, that these converted stem cells show a “similarity” to stem cells, but don’t act identically. So, it’s a step forward, side-steps the ethical issue, and gives much more material to work with…a win-win. Note that when the stem cell controversy was at its height, the President urged scientists to find a way to do exactly this, and for these reasons…two years later, lo and behold.

Sorry for the long message, I just got especially worked up this time.



Opinions solely mine.


Monday, November 12, 2007


Merck agrees to settle thousands of Vioxx cases.

In continuing coverage from previous briefings, ABC World News (11/9, lead story, 2:55, Vargas) reported, "For years, the drug, Vioxx (rofecoxib), relieved the pain of arthritis and other conditions," and had "a strong following among doctors and patients alike." Suddenly, "researchers discovered it could be fatal by raising the risk of heart disease and stroke. A flood of lawsuits followed."

The CBS Evening News (11/9, story 3, 2:00, Couric) added that in "one of the largest legal settlements in U.S. history," Merck "agreed to pay nearly $5 billion to settle thousands of lawsuits filed by those who claimed the painkiller Vioxx caused heart attacks and strokes."

On its front page, the New York Times (11/10, A1, Berenson) noted that Merck's settlement agreement "may not seem like a corporate victory. But it is, according to lawyers and drug industry analysts who have followed the Vioxx litigation since Merck stopped selling the drug in September 2004, after a clinical trial showed it raised the risk of strokes and heart attacks." In 2005, "some analysts estimated that Merck would have to pay as much as $25 billion to settle Vioxx claims." However, per this agreement, Merck will pay $4.85 billion, a mere fraction of previous estimates.

Doc D: You could write several books on this fascinating case history, so I wanted to offer a couple of thoughts.

First, the reports don’t really tell you how information on risk emerges, or describe the uncertainty there was when some studies emerged of increased risk, but others said there wasn’t. Studies take time, and have limitations on what you can say they prove. The righteous indignation you heard from some investigators was disingenuous. As a matter of policy, should we pull everything that shows a hint that there may be a problem, even before we confirm it? Remember the study that showed an increased risk of leukemia in children who lived closer to power lines? That turned out to be bogus, but created a media sensation, and took several years to refute. Do we all move away from the wires in the meantime?

Second, they don’t tell you what the risk really is. To say that something increases a risk five-fold isn’t enough. For instance, say that the risk of something is one in ten million. A five-fold increase is five in ten million. In the context of other risks, this is trivial. There’s some of this confusion in the Vioxx story. The data(*) shows that “current” use of Vioxx by a person over 65 would cause one extra first MI in every 700 people (I say “current” because there’s no increased risk in having taken it in the past.) Now, if you are that one person, “one” is a lot. But, overall this is not a “kiss of death” for the population. By comparison, consider Motrin…everybody takes that. Under the same conditions (current use, over 65) motrin causes one extra first MI in every 1000. Different, but not harmless, eh? Where’s the hue and cry about Motrin? Are we scaring ourselves to death?

Third, Merck has been winning almost all the lawsuits because they are able to show that coronary artery disease (CAD) is something that occurs gradually over decades and it’s hard to show that a person with CAD didn’t have an MI because they already had a problem. They want to settle because fighting all these cases, even winning them all, will cost more. So, what we have is a legal system that allows for blackmail to obtain unproven compensation, and Merck has no choice. Remember the silicone breast implant settlement? At the time, $5B was the largest in history….but years later the Institute of Medicine issued a final report that included new data, and re-evaluation of all the old studies, that said that there was no credible evidence that silicone implants were implicated in ANY chronic disease (which is what people alleged). Too late for Dupont to do anything about it, but a lot of people got some free cash.

Fourth, there’s a psychological thing at work here. Most diseases occur due to imperfections in a person’s makeup, whether it’s genes, immunity, whatever. External causes of illness (like exposure to benzene causing leukemia) are rare. However, it’s too threatening to the ego to admit that our weakness is internal to us. The most tragic situations I’ve experienced are those where parents have a child who gets a potentially fatal cancer: they absolutely refuse to admit that it could be anything other than some evil outside influence that caused it, because otherwise they have to admit to themselves that they contributed to the makeup of a child that has to suffer this horrible life. I’ll admit that there are people who think if we eradicate all exposure risks, then many diseases will disappear. I can’t agree: our bodies just can’t go on forever, they fail.

This may sound very harsh, but we can’t compensate everybody who has something bad happen to them. A couple of years ago, people started suing one of the first companies to manufacture mechanical heart valves back in the 60’s, because the valves were starting to break. Well, that’s not good…but they lasted 20-30 years, and before the valve was invented, these people just…died. I don’t know of any other mechanical items that last that long (cars, refrigerators, etc). Something’s not right here.

So, bottom line: if Vioxx was still on the market, and there weren’t better choices, I would take it. Here are some drugs that cause just as many, if not more, bad things to happen to people: diuretics, thyroid hormone, digitalis, all high blood pressure medicines, seizure medicines, penicillin… I could go on forever. Pharmacologically, there aint no free lunch.



Opinions solely my own, etc.

* BMJ 2005;330:1366 (11 June)

Friday, November 9, 2007

For the MRSA-minded

CDC says good hygiene may reduce staph infections.

In continuing coverage from previous briefings, the AP (11/8, Neergaard) reported, "Drug-resistant staph infections that have made headlines in recent weeks come from what the nation's top doctor calls 'the cockroach of bacteria' -- a bad germ that can lurk in lots of places, but not one that should trigger panic." According to Julie Gerberding, M.D., head of the Centers for Disease Control and Prevention (CDC), "It takes close contact -- things like sharing towels and razors, or rolling on the wrestling mat or football field with open scrapes, or not bandaging cuts -- to become infected with...MRSA outside of a hospital." She testified at a hearing of the House Committee on Oversight and Government Reform that "[s]oap and water is the cheapest intervention we have, and it's one of the most effective." Therefore, MRSA can be prevented if people practice "common-sense hygiene."

Doc D: It always takes a while for common sense to emerge. I love the term “cockroach of bacteria.”

Doc D;

Opinions are entirely my own

Monday, November 5, 2007


Poll finds most Americans favor birth control in public schools.

In continuing coverage from previous briefings, the AP (11/3) reported, "People decisively favor letting their public schools provide birth control to students," according to an AP-Ipsos poll. "The survey was conducted in late October after a school board in Portland, Maine, voted to let a middle school health center provide students with full contraceptive services." Investigators found that "67 percent [of respondents] support giving contraceptives to students." Among these, "37 percent...would limit it to those whose parents have consented, and 30 percent [would provide birth control] to all who ask." In addition, "62 percent said they believe providing birth control reduces the number of teenage pregnancies." Notably, "[m]inorities, older and lower-earning people were likeliest to prefer requiring parental consent, while those favoring no restriction tended to be younger and from cities or suburbs." Those "who wanted schools to provide no birth control at all were likelier to be white and higher-income earners." The AP pointed out that "nearly half of teens aged 15 to 19 report having had sex at least once, and almost 750,000 of them a year become pregnant."

Doc D: I try to stay away from politically charged issues in medicine, but I’m dubious about the validity of this poll (they’re all this way). There’s too little information on how the questions were asked, which is the most critical element determining the answer you get. (1) If the question was just a generic one about giving contraceptive to “students”, then there’s too little discrimination for people to define their answer: middle school students? High school? College? (2) Also, ask yourself, if 37 percent want parental consent and 30% don’t, what do the other third want…”I don’t know?” “I’m not sure?” “I don’t care?” Way too big a group not to comment on. (3) “62 percent…believe…reduces the number of teenage pregnancies” ? In most studies the pregnancy rate is off by the extent of how available abortions are: these figures are less likely to get included as pregnancies. For instance, California has a lower teen birth rate than Texas. Tx uses abstinence, Ca uses contraceptives. Does this mean that contraceptives reduce pregnancies? Maybe not: in Ca it’s very easy to get a teenage abortion, in Tx it’s not. (4) finally, “half of teens 15 to 19” had sex at least once, implies that this is another reason to use contraceptives. Did I miss something here? This discussion started with a school board authorizing contraceptives for “middle” school. It’s been a long time, but aren’t the 15-19 year olds in “high” school? I’ll stop here, but I have about twenty other questions…all unanswered.

All of this is not to say for sure that the poll and people’s beliefs are not correct. But, one thing is certainly true…it’s pitiful reporting.

North Carolina project to improve care for heart attack patients shows promise. The AP (11/5, Marchione) reports that the "nation's most ambitious statewide project to redo how serious heart attacks are handled" is taking place in North Carolina, according to findings presented at the American Heart Association meeting. The program includes "55 small hospitals [which] agreed to send appropriate patients to 10 larger ones for angioplasty, even though it meant giving up thousands of dollars of revenue." When researchers "compared the care of more than 2,000 patients before and after the project," they found that more patients received angioplasty, "and the portion of eligible patients not receiving artery-opening procedures dropped." They also found that "[m]ore patients got care at top-tier heart hospitals, and more quickly than similar patients did before the project began. Helicopter transfers rose, and more paramedics diagnosed heart attacks from EKGs done in ambulances." In addition, the "average time it took a small hospital to evaluate and refer patients to a larger one dropped from two hours to 71 minutes."

Doc D: A couple of other studies you might like to know about. I’m sorry if I’m fuzzy on the details but I can find the references if need be.

  1. At one time not so long ago, heart attack patients in one country (I think it was Scotland, but I’m not sure) were sent home without hospitalization if they had no complicating findings. The data showed that survival rates between using that approach and using a Coronary Care Unit in those circumstances were about the same. Hunh?
  2. I can’t remember the exact dates, but, say the 70’s. Researchers in Rhode Island did a study of survival of everyone brought to the ER who had arrested outside the hospital and were resuscitated in, or before arriving at, the ER. All patients so defined were then admitted to Intensive Care. They also wanted to know what it cost to save a life in this way. They accumulated some ~350 cases over a period of time and looked at how many were still alive 30 days after the event. First the cost: on average somewhere between 50 and 100 thousand dollars. The survival at 30 days? Zero. (Yes, none survived.)

Caveat: these are ambiguously related to results about angioplasty. The point is a general one only. When I hear about results that show “improved care” I always ask myself “against what standard?” It’s great to get treated by the best, with the best, and quickly. The assumption is that if you get that, then you’re in great shape…but that’s not the end result we want: we want RECOVERY.

As with most of these emails, which I enjoy writing, the message is to criticize what you’re told. Every information source is biased and advocating something (even me). I’m thinking of putting together a list of Medical Myths, like…(1) All doctors are rich (avg income is 132K, hasn’t change in 10 years), (2) all drug companies are rich (a few are, but more go out of business), (3) universal healthcare will solve the healthcare cost crisis (anybody who thinks the govt does anything cheaper, hasn’t been paying attention—and guess where they get their money?), etc….

Opinions are my own…and that of few others, unfortunately.



Thursday, November 1, 2007


Senators suggest creating federal agency to fight MRSA.

ABC World News (10/31, story 10, 2:45, Gibson) reported, "On Capitol Hill today, senators proposed creating a federal office to battle" MRSA. "There's been alarm across the nation since health officials announced two weeks ago that more people were dying from MRSA than from AIDS." During a Congressional hearing, Sen. Orrin Hatch (R-Utah) said that MRSA is "[a] public health issue that should scare everyone, each one of us in this country."

Doc D: this is very interesting. I agree that drug-resistant infections are a problem that requires attention, but remember the original article that said 19K people died of “all” drug resistant infections (not just MRSA)? Let’s assume that there is under-reporting of these infections and deaths, as some media have suggested, and adjust the figures upward by 50%. So now we have 27.5K deaths. This is still a very low number. By comparison there were 60K deaths from influenza in the most recent year for which there are data, and death rates from drug-resistant infections don’t even appear on the list of significant causes of death. But we’ve got a nationwide panic going on, with everything from schools, private gyms, restaurants, and other gathering places being shut down to be scrubbed. Bacteria, some pathogenic, are ever-present in everything we touch or come into contact with…but there has to be a source: and that source is a person. So, I say scrub away…the first student carrier will re-populate the school’s bacterial fauna within days. If we put this much effort into more fruitful endeavors like ensuring universal immunization, we would save about ten times as many lives.

If you want to do something useful, teach your kids to wash their hands, especially after coming into contact with “public” surfaces, or before eating. And practice what you preach. This interrupts the chain of transmission, and reduces the spread. And, remember that hospitals are where the sick people are, and where the bad germs get concentrated.

Oh, and the “more than AIDS” comment. Remember when predictions were that most of country would get AIDS? Actually, our treatment of the disease has improved so much that most people don’t die like they did in the early years. Survival rates of 10-20 years are becoming common., and there’s actually a sub-population of AIDS victims, who are under intense study, whose disease never seems to progress.

Like the “bomb” in the fifties, we appear to need a deep-seated fear of the unknown to target our anxieties. There’s a fascinating psychological element to this whole story.

Physicians less likely to accept responsibility for errors if liability threats loom.

In the Wall Street Journal's (10/31) Health Blog, Jacob Goldstein wrote, "The 21st century doctor is supposed to be all about transparency, but legal liability, that seemingly eternal bugbear, continues to weigh on the profession." Recently, there has been much discussion about the benefits of physicians admitting their errors and apologizing to patients. Patients feel validated, and typically accept much smaller settlements as part of the process. Currently, Massachusetts is considering legislation which states that "if a doctor apologizes to a patient and admits making a mistake, the statements couldn't be used in court." Other states have already adopted similar legislation. However, "not everybody's on board, especially the lawyers," notes the Journal. They argue that physicians "should be held responsible" if they "cause harm." While many advocate "full disclosure," Massachusetts physicians maintain that "if the threat of liability remains," most healthcare providers will not admit to errors.

Doc D: I’ve always had mixed feelings about this. I’ve had patients that I developed a trust with, and who trusted me, that I wouldn’t hesitate to say I had made a mistake. There are others who brought an attitude to the doctor-patient relationship that made me wary of them: some were resentful of the “power” over them they thought I had, or didn’t like needing to seek help, or had had bad experiences in the past (real or imagined). Sometimes it was just a personal thing: mutual dislike (although we get trained to disregard personal feelings, you can’t totally ignore a gut reaction). This latter group I was very careful with, not to give them an opening they could take advantage of. It’s a shame that medicine has to be practiced so defensively…when people complain that their doctor doesn’t engage with them, or is impersonal, it’s my guess that this is what’s going on.

My advice is, find a doctor you can work with, develop mutual trust. If a diagnosis or treatment doesn’t make sense, be forthright with needing an explanation. But be wary of any doctor who always just does what you want them to: they won’t stand up to you when you’re wrong.

As always, opinions are my own.



What I'm Reading - Updated 3 May