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.
See here for more discussion.

Tuesday, November 25, 2008


IRRELEVANT NOTE:  Did you notice a rise in some banks’ ATM fees recently?  --$3.00 is higher than I remember seeing here in Texas--  Recall that we had no ATM fees until the Savings and Loan debacle.  My conspiracy paranoia makes me wonder if this is how we pay for financial crises:  nobody raises your taxes, they just bump up the fees and hope you don’t make the connection.


Scientific panel concludes Gulf War syndrome is a legitimate illness.

NBC Nightly News (11/17, story 11, 0:40, Williams) reported, "A major federal study released" Monday "puts to rest the question of whether Gulf War real or not." The "450-page report concludes that exposure to toxic chemicals, including a drug meant to protect troops from nerve gas, sickened one in four of the almost 700,000 veterans in the 1990 to '91 conflict. Veterans' groups said today's report vindicates them after years of denial on the part of their government."


Doc D:  There are a lot of problems with this report, from a scientific standpoint.  A peripheral concern is that the report was politically motivated, but that’s a separate question.  Allegations of “years of denial on the part of their government” are just BS.  I was a part of the investigation:  we studied every one of these people up one side and down the other; accepted into the investigation anybody who thought they “might” have an illness related to the war; and tracked and monitored them with repeated annual and other periodic testing and evaluation.  They got more tests and exams than you would ever order for a real patient with an illness (even more than House, MD), repeated over many years, in order to cast a wide net over something we weren’t sure “was” something.  The problem is, people alleged that Gulf War Syndrome (GWS) caused everything from baldness, to chronic lung problems, rashes, and brain cancer.  How do you define an etiology when every symptom known to man is possible?  I observed one patient testify to Congress that GWS made his vomit fluorescent. 


So, I’ve read through the report, and it still lumps people together in this way.  For example, it compares GWS to other “symptom-defined” illness, like chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity.  Unfortunately the existence of these three as “illnesses” is still controversial.  For something to be a “disease”, it has to have an origin, cause, process, and defined effects.  To just throw together a bunch of symptoms that tend to occur after a common event (the war), is to commit the post hoc ergo propter hoc fallacy:  A precedes B, therefore A caused B.  Calling such bundles of symptoms a disease has occurred frequently throughout history (“railroad heart” for instance).  It may be that they are “socially constructed” syndromes, a phenomenon of a particular culture and place in time.  It could be a coincidence, but the rate of undiagnosable patients in this country is about the same as the rate of GWS---3%.  Or, with more knowledge of the symptoms, we may tease out a real illness in the future…admittedly our knowledge of many diseases started out this way.  Or finally, it may be just chronic effects of nerve agent exposure, which is not a war syndrome:  it’s a real complication of exposure to a toxic chemical.  I don’t know.  But for now, I don’t know of a single disease that can cause symptoms across every organ system.


Researchers hope gene therapy strategy will lead to AIDS treatment.

The Wall Street Journal (11/7, A13, Schoofs) reports that a new therapy preformed in Germany, in which a physician "deliberately replaced the patient's bone marrow cells with those from a donor who has a naturally occurring genetic mutation that renders his cells immune to almost all strains of HIV," has renewed hope that a gene therapy strategy against HIV could prove successful. "The mutation prevents a molecule called CCR5 from appearing on the surface of cells. CCR5 acts as a kind of door for the virus. Since most HIV strains must bind to CCR5 to enter cells, the mutation bars the virus from entering." The Journal notes, however, that "caveats are legion." For instance, "the transplant treatment itself, given only to late-stage cancer patients, kills up to 30 percent of patients. While scientists are drawing up research protocols to try this approach on other leukemia and lymphoma patients, they know it will never be widely used to treat AIDS because of the mortality risk."


Doc D:  if you just read the title of this news extract, go back and read the whole thing. Did you notice that this transplant “kills up to 30 percent of patients?” Not “hastens death,” not “causes fatal complications,” but “kills.”  That's three out of every 10 people. By contrast, Vioxx causes harm to one in ~20,000 people. You may be asking yourself, what is the utility of continuing to do research into something that “will never be widely used to treat AIDS?"  And, how likely is it that other immuno-compromised patients, with leukemia or lymphoma, will react differently?  The idea behind gene therapy is good, maybe eventually this will turn up something worthwhile.


The take-home lesson, however, is that the article didn’t really say what the title implied, did it?  I read somewhere that about a third of the people just read the headline.  Thanks again, American media…


Washington state voters approve measure allowing medically assisted suicide for terminally ill patients.

The AP (11/5, Woodward) reports, "Voters have approved a ballot measure making Washington the nation's second state to allow terminally ill people the option of medically assisted suicide." Under the measure, "a terminally ill person" can "be prescribed lethal medication, which would be self-administered."

 …The measure "protects doctors from being prosecuted under a state law forbidding anyone from aiding in a suicide attempt," and "specifies the patient's death certificate should list the underlying terminal disease as the cause of death," the Seattle Times (11/4, Tu) added. Still, "the Washington State Medical Association, which represents nearly 7,000 doctors, said it was opposed to" the initiative. Among the measure's backers were "national right-to-die organizations Compassion & Choices and Death with Dignity, along with former Washington Gov. Booth Gardner." Supporters stressed that "the measure includes many safeguards," and they contended that "terminally ill patients who are suffering great pain should have the choice to hasten their deaths in a 'humane and dignified' manner." Meanwhile, critics argued that "end-of-life care has advanced to the point where pain can be controlled."


Doc D:  I don’t have a problem with people controlling their own lives, and the ending of it.  There are other things that bother me about this:  Falsifying the death certificate is number one; I’ll bet that creates some legal wrangles.  Also, I suspect that a significant number of the ~350 cases in Oregon (the other state with such a law) had a treatable depression that they successfully concealed.  I also agree that our ability to control or eliminate pain in “end-of-life” care is now very good.  But the biggest thing for me is that I didn’t become a doctor to be the agent of death.  It’s possible that I’m out of touch…



Medical quote of the Day:

All doctors up to the present century seem to me to have failed, because in the cure of diseases they have given little thought, or none at all, to the specific nature of each disease, and considered only the external symptoms, which are no more concerned with their specific nature than the type and richness of the soil are with species of plants which may grow in it.—John Locke [1632-1704]



Doc D

Opinions are entirely my own.  Quotations from Kaiser Daily Health Policy Report ( © Kaiser Family Foundation), PND News Briefs – Texas Edition ( © 2008, Physician's News Digest, Inc.), AMA Morning Rounds (© U S News Custom Briefings), and other sources in the public domain.  As always, you may share this column, with appropriate attribution (here and in the text) included:  I just ask that you not forward my email address.  I don't care to argue with wacky strangers.



Friday, November 21, 2008


Research indicates many health screens may be ineffective.

Forbes (11/6, Farrell) reports, "A new battery of health screens promises to detect dreaded diseases early so patients can put up a decent fight. In fact, they stoke fear and invite risk." Typically, "screens differ from diagnostic tests in that screens are aimed at patients who are not at unusually high risk, and exhibit no particularly alarming symptoms." The problem is that "plenty of screens don't really work that well. Many yield lots of false-positive results, which lead to unnecessary (and risky) treatments; others work, though not in time for patients to act, leaving them to a life of endless dread." In addition, "these screens can cost thousands of dollars, and many aren't covered by insurance." That is why "the United States Preventive Services Task Force, a government-backed group of healthcare professionals," studies and evaluates health screens. To date, the group has rated "64 potential screenings, and recommends that patients and doctors consider only 30 of those."


Doc D:  For us preventive medicine guys, the US Preventive Services Task Force produces the accepted guide to what-who-when for prevention screening.  Their website is here:  If you want to read the whole guide, you can find it on this page.  BUT, even better, there is an electronic search where you can put in age, gender, tobacco usage and sexual activity (just “yes” or “no,” you can’t answer “too little” or “unsat”…sorry), and it will construct a table of screening you should accomplish.  A great tool, here:


On the other hand, some of the commercial advertising promotes testing that is potentially costly, and useless at best (harmful at worst).  Be sure to consult with your doctor first, before getting a genetic screen, or “environmental sensitivity” testing, etc.  Some of these are just rip-offs, some are quackery.  If you’ve already done one of these, well, it’s your life and your money.  Admittedly, some may be useful once proven—“virtual” colonoscopy, for example; this has a lot of appeal for people because they are squeamish about, or afraid of, the fiberoptic scope.  Here is the Task Force’s statement as of May 08:


“The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”


But, don’t delay, waiting for some new technology to prove itself.  You could regret it.  And, some of the older techniques are as good or better.


Study indicates testosterone patch may increase sexual enjoyment among women.

The Wall Street Journal (11/6, Winstein, Byron) reports, "A female testosterone patch," called Intrinsa, "showed promise at boosting older women's enjoyment of sex," according to a study published in the New England Journal of Medicine. The patch "is designed to treat 'hypoactive sexual desire disorder,' meaning a lack of interest in sexual activity that leads to unhappiness." It "delivers a steady stream of testosterone, a hormone associated with sex drive in men and women." For the study of the patch's effectiveness on the disorder, researchers recruited an estimated 264 women to wear "Intrinsa patches, to be placed near the belly button and changed twice a week, and 277" women to wear placebo patches. The investigators found that those who wore Intrinsa patches "reported 4.6 satisfying episodes in the previous four weeks," at the end of six months. Meanwhile, those wearing "a fake patch" reported 3.2 satisfying episodes.


Doc D:  At first, I didn’t want to touch this with a ten foot pole.  But, you know?  Who am I to underestimate that extra 1.2 “satisfying episodes” per month for “older” women?  (although they make it sound much like enjoying the taste of a Big Mac).  Plus, don’t you just love the names that pharmaceutical companies come up with:  “Intrinsa”  I’ll bet they spend millions in research to pick the name that promotes the “association” they want with their product.  I mean, feel the power of “Intrinsa”…I’m not even female, and I’m ready to use it.


One serious comment.  Pharmacists can compound testosterone in a cream base for one-twentieth of the cost of the patches.  It’s absorbed thru the skin just like the patches.


Researchers say women have more varieties of hand bacteria than men.

Following a story covered by the AP yesterday, UPI (11/5) reports, "Not only do human hands harbor far greater numbers of bacteria than previously believed," but women also "have a greater diversity of microbes," according to a study published online in the Proceedings of the National Academy of Sciences.

        Noah Fierer, of the University of Colorado at Boulder, and colleagues, "scrutinized the palms of 51 undergraduate students for bacteria, just after the students had finished their academic exams," HealthDay (11/4, Gardner) added. "On average, each hand was home to about 150 different species of bacteria," and "overall, more than 4,700 bacterial species were identified on all hands," although "only five of which were common among all volunteers." Notably, about "17 percent of bacteria types were shared between right and left palms, while volunteers shared just 13 percent of bacteria species with each other, probably due to 'environmental' conditions, such as oil production, skin dryness, and what surfaces the hand had previously touched."


Doc D:  If this was publicly funded, I’m writing my Congressman.  I’m all for basic science research that teaches us new things about the fundamental nature of the universe.  But, if it fails that test, then it needs to pass the test of being useful.  So, what advice did you garner from this study:  don’t shake hands with women?  Our left and right hands need to share more for us to be healthy?



Medical quote of the Day:


If you live to the age of a hundred, you’ve got it made because very few people die past the age of a hundred.—George Burns


Doc D

Opinions are entirely my own.  Quotations from Kaiser Daily Health Policy Report ( © Kaiser Family Foundation), PND News Briefs – Texas Edition ( © 2008, Physician's News Digest, Inc.), AMA Morning Rounds (© U S News Custom Briefings), and other sources in the public domain.  As always, you may share this column, with appropriate attribution (here and in the text) included:  I just ask that you not forward my email address.  I don't care to argue with wacky strangers.







Researchers say counties with higher rainfall may also have higher autism rates.

USA Today (11/4, Rubin) reports that, according to a study published in the Archives of Pediatric and Adolescent Medicine, "counties with higher precipitation levels" may "also have higher autism rates." Lead author Michael Waldman, Ph.D., a professor of economics at Cornell University, "says he decided to investigate a possible link between precipitation levels and autism rates because of findings from a 2003 U.S. Department of Education survey that collected state autism rates data. States with the lowest rates were New Mexico, Mississippi, Colorado, Oklahoma, and Tennessee, while those with the highest rates were the more northern states of Minnesota, Oregon, Indiana, Maine, and Massachusetts."


It was speculated that “these children may spend more time indoors, or because rain brings chemicals in the atmosphere to the ground, they might be exposed to environmental triggers that can trigger a genetic predisposition to autism”


Doc D:  People are desperate to come up with an environmental cause for autism.  It’s vaccines, it’s the air….This study may be a case of the Texas Sharpshooter fallacy.  The Texas sharpshooter takes his rifle out to the barn and fires repeatedly into the side of it.  Then he goes up and draws a circle around the bullet holes, and announces that he hit the bullseye with every shot.  In science, what one cannot do is use the same information to construct and test the same hypothesis — the question is, did the researcher see the pattern of rainfall in this limited group of states (as it appears above), and then go gather the data from those states?  I see this all the time in epidemiology:  most of the so-called cancer clusters are a result of this type of fallacy.  For example, a hypothetical cluster of brain cancer on one floor of an office building.  There’s not a “killer” chemical present on that floor of the building:  people have just drawn their bullseye (that floor) after the fact.  Remember, for unrelated events to be truly random they can’t be evenly spaced across the domain:  that’s not random, that’s an orderly arrangement.  In true randomness, there will be clumps here and there… randomly.


Ok, that’s enough on that.  My head’s spinning…



CMS says physicians could earn up to 5.1 percent in 2009 bonuses.

Modern Healthcare (11/1, Lubell) reported, "Physicians who successfully comply with various incentive programs could receive an overall payment boost of up to 5.1 percent in 2009, under a final rule issued by" the Centers for Medicare and Medicaid Services (CMS).

        MedPage Today (10/31, Fiore) added that the CMS also "suggested a physician 'could receive up to a 5.1 percent pay boost for 2009.' But, earning that much will require extra initiative" on the physician's part. This "new rule also adopts changes to quality reporting initiative, including the addition of 52 new quality measures, for a total of 153, in areas including osteoarthritis, rheumatoid arthritis, back pain, coronary artery bypass graft, chronic kidney disease, melanoma, oncology, coronary artery disease, hepatitis, and HIV/AIDS."


Doc D:  Right…free money.  Guess how much time is needed to accomplish the paperwork to submit for the payment. This “boon” probably won’t be enough to hire the person you need to accomplish the workload required.  No…wait…that’s it!  This is a jobs program.



Survey indicates nearly half of primary care physicians would consider leaving medicine soon.

CNN (11/18, Willingham) reports that almost "half the respondents in a survey of U.S. primary care physicians said that they would seriously consider getting out of the medical business within the next three years if they had an alternative." After sending "questionnaires to more than 150,000 doctors nationwide," of which 12,000 responded, the Physicians' Foundation also discovered that "many said they are overwhelmed with their practices, not because they have too many patients, but because there's too much red tape generated from insurance companies and government agencies.”


Doc D; the administrative burden is high now, but you aint seen nothing yet.  If we partially nationalize the healthcare system you can expect to see more administrative workload, and the government will need to hire another 50,000 people to handle it.  Failure to address underlying cost increases and reduced access from a physician shortage will make being covered by insurance of little value.



Medical quote of the Day:


So long as the body is affected through the mind, no audacious device, even of the most manifestly dishonest character, can fail of producing occasional good to those who yield it an implicit or even a partial faith. –Oliver Wendell Holmes [1809-1894]


Doc D

Opinions are entirely my own.  Quotations from Kaiser Daily Health Policy Report ( © Kaiser Family Foundation), PND News Briefs – Texas Edition ( © 2008, Physician's News Digest, Inc.), AMA Morning Rounds (© U S News Custom Briefings), and other sources in the public domain.  As always, you may share this column, with appropriate attribution (here and in the text) included:  I just ask that you not forward my email address.  I don't care to argue with wacky strangers.





Friday, November 14, 2008


Children who are obese, have high cholesterol may show early warning signs of heart disease, study indicates.

The New York Times (11/12, A16, Belluck) reported that a new study, presented Tuesday at the American Heart Association conference, "finds striking evidence that children who are obese or have high cholesterol show early warning signs of heart disease." The researchers "found that the thickness of artery walls of children and teenagers who are obese or have high cholesterol resembled the thickness of artery walls of an average 45-year-old."

Doc D:  Why the doom and gloom?  “Turn a frown upside down…”   This means that the average 45-year-old has the arteries of a child.  I’m feeling younger just thinking about it.

Seriously, remember the President’s Fitness Test when us older…er, more mature…folks were in grade school?  I still have my scorecard from 7th grade.  We need to bring serious fitness back into the school curriculum.  If we need some New Age justification for it, let’s called it “physical socialization.”  One day when I was still on active duty, a young airman filled out his annual physical form with the words “video games” under the question about current physical fitness activities.  When I told him we were looking for things he did that strengthened his muscles and increased his endurance, he just looked at me, uncomprehending.  Very sad for his generation, and will make the Baby Boom population’s healthcare requirements look trivial.

Research suggests listening to music may expand blood vessels, increase blood flow.

ABC World News (11/11, story 11, :20, Gibson) reported that "researchers at the American Heart Association meeting released a study showing when people listen to music that makes them happy, blood flow, a key measure of heart health, improves."

        The Los Angeles Times (11/11, Roan) Booster Shots blog adds that "ten healthy volunteers were asked to listen to music they enjoyed after avoiding the music for a minimum of two weeks before the study." Participants "were also asked to listen to music that made them feel anxious, and to audiotapes designed to promote relaxation, and to watch videos designed to induce laughter."

        Investigators "found that the diameter of the average upper arm blood vessel increased 26 percent after listening to joyful music, and listening to music that caused anxiety narrowed blood vessels by six percent," AFP (11/12) reports.

        HealthDay (11/11, Gardner) added that "blood flow also increased 19 percent during the laughter...phase and 11 percent during relaxation."


Doc D:  Does this work if I find Mettalica relaxing and Chopin anxiety-producing?  Actually there’s no correlation between episodic, temporary changes in arterial diameter and the development of cardiovascular disease.  This is one of those “findings” that, if you exercise a little commonsense thinking, you realize it’s useless.  Note that watching videos inducing laughter was not associated with changes:  I guess that means laughter doesn’t help, right?  What a waste of research funds.


Your Tax Dollars at Work rating:  Better used as kindling.


Nurses association says members are facing more aggressive patients in EDs.

The Boston Globe (11/11, Lazar) reported that with more patients and increased waiting times at emergency departments (EDs), the Massachusetts Nurses Association "says its members are fending off an increasing number of aggressive patients, as well as their frustrated family members."


Doc D:  Why include this excerpt?  Hint:  Massachusetts is the state that passed a near-universal coverage law, without considering the other three elements of healthcare reform:  quality, cost, and ACCESS. 


Supplement to previous newletter:

  1. The journal Health Affairs is the “New England Journal” of healthcare policy.  They published an analysis, prior to the election, of the incoming administration’s healthcare plan.  I tried to figure a way to attach a copy, but the journal won’t allow free distribution by subscribers.  It’s pretty technical anyway.  But I can show you an excerpt:

“The health reform plan put forth by Sen. Barack Obama (D-IL) during the 2008 presidential campaign focuses on expanding insurance coverage, providing a variety of subsidies to individuals and small businesses, and expanding eligibility for Medicaid and the State Children’s Health Insurance Program (SCHIP). It greatly increases federal regulation of private insurance, including what benefits must be offered by all insurance plans, but it does not address core economic incentives that drive health care spending. The plan does not promise universal coverage, and it does not include a mandate on everyone to purchase insurance, which was central to Sen. Hillary Clinton’s (D-NY) plan during the Democratic primary….  The following analysis reflects the authors’ concern that Senator Obama’s failure to address the perverse incentives in the U.S. health system will exacerbate the cost problem he has argued must be solved if we are to achieve anything close to universal coverage. Tax subsidies that promote first-dollar coverage have led consumers, health care providers, and suppliers to act as if any service that might yield some value, no matter how small, should be covered. Subsidized third-party payment has helped drive up health spending and, as demonstrated by the Dartmouth Atlas, sometimes has even led to poorer health outcomes. Realistic expectations about cost, value, and the outcomes that health care is likely to provide must be better understood by all parties. Senator Obama promises business as usual, albeit with greater regulation intended to impose behavioral changes from the top down. In our view, such a strategy will fail to limit spending growth, will impede useful innovation, and will require more sacrifices in the years ahead.….(main body of text)…

The savings estimates and the resulting impact on federal outlays from the Obama plan are controversial. Savings proposals include familiar ideas, many of which are embraced by both candidates: greater use of information technology (IT), improved disease management and care coordination, clinical effectiveness research, and better payment methods. Although many policymakers and experts agree that such policies would improve health system performance, there is little evidence that they can be implemented quickly or effectively and little proof that implementing the policies would yield net reductions in health spending.  The Congressional Budget Office (CBO), for example, has analyzed the likely savings from the adoption of health IT and found that “the adoption of more health IT is generally not sufficient to produce significant cost savings.” In another report, the CBO noted that “initial results from disease management programs and other efforts indicate the difficulty of reducing the use of care.” In a letter to Rep. Pete Stark (D-CA), the CBO reported that total health spending might be reduced by $6 billion over the next decade through the use of comparative effectiveness research, of which $1.3 billion would accrue as reduced federal outlays. Over that period, national health expenditures are projected to total $32.5 trillion.”--“The Obama Plan:  More Regulation, Unsustainable Spending” by Joseph Antos, Gail Wilensky, and Hanns Kuttner, [Health Affairs 27, no. 6 (2008): w462–w471 (published online 16 September 2008; 10.1377/hlthaff.27.6.w462)]

  1. Speaking of the New England Journal of Medicine, the current issue this week has a series of free articles on reforming Primary Care.  This concerns the Access part of reform.  A short quote:

U.S. primary care is in crisis. Primary care physicians must care for more and more patients, with more and more chronic conditions, in less and less time, for which they are compensated far less than subspecialists. They must absorb increasing volumes of medical information and complete more paperwork than ever, as they try to function in a poorly coordinated health care system. As a result, their ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields. In a roundtable discussion …four experts in primary care and related policy…explore the crisis, as well as possible solutions for training, practice, compensation, and systemic change.”

See the articles here:  The Future of Primary Care,


Medical quote of the Day

Science, of course, is necessary; it has its justified place and each year it becomes more important to the proper practice of medicine.  But neither tests nor science can fully replace the art of medicine and that is fast disappearing, though occasionally one sees shy, frightened bits peering cautiously out at the man who is ill through the maze of millimols and hydrogen ions and tests for histoplasmosis, which mean precisely nothing.—Henry Jackson, Jr.  New England Journal of Medicine, 1956.


Doc D

Opinions are entirely my own.  Quotations from Kaiser Daily Health Policy Report ( © Kaiser Family Foundation), PND News Briefs – Texas Edition ( © 2008, Physician's News Digest, Inc.), and AMA Morning Rounds (© U S News Custom Briefings), and other sources in the public domain.  As always, you may share this column, with appropriate attribution (above) included:  I just ask that you not forward my email address.  I don't care to argue with wacky strangers.


Posted By Doc D to NOSTRUMS --Dissecting the Medical Doc D at 11/14/2008 09:40:00 AM

Wednesday, November 12, 2008



No jokes in this one…well, maybe a little irony…and only one topic.  If you’re not up for some serious thinking on a complex issue, give it a miss.  Next issue I’ve got a couple of doozies for your entertainment.


U.S. Rep. Henry Cuellar expects Barack Obama to pass legislation within the early months of his presidency that will ensure that an extra four million children receive health insurance.

Cuellar said that, of the four million extra kids that will receive coverage under CHIP, about 500,000 live in Texas and many of those are from the border, reported the Rio Grande Guardian. Cuellar said CHIP was important to him because he authored the legislation - HB 997 - that set up a pilot program in Laredo back in 1997, when he was a state representative. The pilot program was so successful that it became a model for the whole state, the Guardian noted. The 110th Congress tried to expand CHIP but fell about 13 votes short of overriding President Bush's veto. Cuellar said the bill was postponed until next March, and that he was confident the new president "will be willing to work with us," the Guardian added.
Rio Grande
Guardian, November 6, 2008

AMA, other physician groups hopeful President-elect Obama will make healthcare reform a major priority.


Modern Healthcare (11/6, Lubell) reports, "Physician organizations appear confident that President-elect Barack Obama (D) will make healthcare reform a major priority, although his interests in resolving Medicare payment issues are less clear." According to AMA president Nancy Nielsen, M.D., Ph.D., "Obama 'has proposed a serious framework for health system reform in 2009, and made it a central issue in his campaign." Dr. Nielsen added that "the AMA shared Obama's focus on expanding health insurance coverage and choice through income-related federal subsidies," and the group looks "forward to continuing to work with him and the new Congress toward reform." She also noted that "bipartisan efforts will be an essential building block for comprehensive healthcare reform."


Doc D:  Healthcare reform proposals need some close scrutiny.  The Republican party proposals focused on market competition along with tax measures to increase affordability, allowing more people to be able to buy healthcare coverage.  This is more of the free market same-old-same-old.  The best that can be said is that it would give “some” of the uninsured a chance to be covered, and that costs, while continuing to rise, would rise a little slower.  Ultimately, it would only delay the worsening crisis. 

The Democratic platform, on the other hand, concentrated on the “Pie in the Sky” approach (see here, or  the emphasis was on coverage for the uninsured, the most clear of which was that for all children.  Costs were dealt with by “cutting taxes” and reduced administrative overhead, primarily from the adoption of electronic health records (EHR).  Actually, the reduced taxes would be in the form of a rebate, like we got this year (what insanity was that, with a big budget deficit already?), and NOBODY I know except Obama advisers thinks that EHR’s are going to save much money: it will take many years even to adopt a universal standard for health records. Right now there are a hundred software systems, none of which can talk to each other.  So, will the administration and Congress plan to nationalize another chunk of the healthcare market, with no realistic way to pay for it?  Does this sound familiar?

Let me recap some things I’ve shown in previous letters:

  1. 75% of the federal budget is “transfer payments:” This part of the budget is unalterable.  The Big Three that account for most of this spending are:  Medicare, Social Security, and Welfare.  With current revenues, all three will be bankrupt eventually.  Where’s the money going to come from to pay for the Big “Four”, with the addition of another healthcare benefit?
  2. The “47 million uninsured” figure everybody tossed around didn’t stand up to scrutiny.  It included 20% who were below the poverty line, and were already potentially covered, and it included everybody who made enough not to need coverage.  See the data here.  The most recent update (2007) says that the no. of uninsured has fallen by 1.5M.  Still a problem we need to fix, but not as advertised.
  3. The Clinton administration balanced the budget.  Hoo-ray.  But, most people don’t know that $160B of the $200B deficit reduction came out of Defense: reduced manpower, cancelled equipment replacement, and the like.  Those tanks and planes are wearing out, and there’s nothing in the pipeline to replace them.  You need at least a decade of lead time to develop and procure things like this.  ANOTHER big bill that will be forthcoming, and will cause a lot of finger-pointing.
  4. Employers say that their biggest cost is Labor, and the fastest growing part of that is healthcare.  Tax increases on businesses, and increased employer healthcare requirements (as proposed), will reduce capital for (1) growth, (2) hiring, and (3) salary increases.  In a time when we expect layoffs due to the financial crisis, this could aggravate rising unemployment.
  5. The federal deficit had been falling in the last three years and until the mortgage brouhaha, was projected to be about $100B.  Now it’s projected to double from the current $200B (even before the financial bailout).  The President-elect’s often repeated claim about the war costing “$10B a month” sounds like a lot of money to you and me, but doesn’t even raise a blip on the GNP graph, and wouldn’t pay for a single domestic program, if recouped.  All of Defense spending is only 3.5% of the federal budget (30% in the 50’s).
  6. Massachusetts, which passed a near-universal coverage law last year, is seeing acceleration in healthcare costs and increasing waiting times.  While the advocates still continue to make happy talk about bringing in the unfortunates who were not covered before, the dirty little secret is that they plumped a whole bunch of people into the system without any way to pay for it, and without considering whether there were enough doctors and clinics to absorb the increase.  This is what happens when you concentrate on Coverage, and disregard Cost, Access, and Quality.
  7. The proposal to expand CHIP included those children in some states who were in families at 300% of the poverty line.  Covering children is a good thing, but this was a transparent effort at national child healthcare.  It would cover all the families except those who are wealthy.  Why couldn’t they just say so?
  8. Fewer applicants to medical school, more doctors retiring early, and very low percentages of medical students who want to go into Primary Care…all spell a big problem on the horizon.  What good does it do you to have healthcare coverage, when nobody is there to take care of you when you need it?


So, what are we facing?  The biggest danger, as I see it, is that we will adopt a major overhaul in healthcare without consideration for ALL the major elements that need to be addressed:  Coverage, Cost, Quality, Access…a four-legged stool.  The administration will likely pursue the traditional Democratic line:  a nationalized program on the European model.   First, get everybody inside the tent with coverage, then introduce the “sacrifice” the President-elect has talked about:  either we raise revenues or we ration care.  Revenue will come from us, the citizens, either through the businesses that provide us with our livelihood or directly through taxes, or fees, or surcharges…or even a VAT like Europe has.  Rationing is the major road that Europe took:  philosophically, they said that ALL the citizenry will share in reduced availability of care, so that it evens out across the board.  If the radiation therapy unit you are using to get your cancer treatment goes on the fritz, you wait until it’s fixed (a real case from a patient I know).  To be fair, some people will disagree with me on this, and say that these are just temporary imbalances in the resourcing of their system…but the data says that everybody waits.

If I’m right, this is a MAJOR change to how we view well-being.  Traditionally, we have valued the individual highly, as against valuing the group (the European model).  We just need to be sure that’s the change we want.

In closing, my guess is that the incoming administration will do one of two things:

  1. They will do a “Hilary”.  There will be an early, big push to get a major healthcare overhaul pushed through, because they know that the clock is ticking on the traditional six-month honeymoon period.  The danger is that it will be just a push to “cover” people, and not reform of the system.  Beyond the honeymoon peeriod, people will begin to say “wait a minute…we wanted change, but this is not the change we thought we were getting.”  Sadly, some new faces will be in town, but it’s the same old political process.
  2. They will be so encumbered with the financial crisis that they will back off on major healthcare reform for one-to-several years, incurring the risk that down the road there will be less punching power to effect change.  At some point, disenchantment sets in, and Congress may flow back toward the Republicans, as has frequently occurred in the past.  The most that can be accomplished in the short term is some improvement in CHIP or the like.

Option 2 is more likely.  There’s some evidence that this could unfold this way.  If you looked at the election results closely, the country voted for a liberal president, but on the ballot resolutions voted conservatively:  one gay-marriage ban didn’t pass and one state did adopt assisted suicide, but elsewhere most proposed gay-marriage bans, affirmative action restriction/elimination, and the like passed.  To me, this means that the election WAS about change, just not a specific change.  The voters are progressive on economics, but conservative on social issues.  Where “Change” bumps up against this polarity, the fur will fly.

Doc D

Opinions are entirely my own.  Quotations from Kaiser Daily Health Policy Report ( © Kaiser Family Foundation), PND News Briefs – Texas Edition ( © 2008, Physician's News Digest, Inc.), and AMA Morning Rounds (© U S News Custom Briefings).  As always, you may share this column, with appropriate attribution (above) included:  I just ask that you not forward my email address.  I don’t care to argue with wacky strangers.




Monday, November 10, 2008

Hibiscus tea...NOT; pay for performance; and Where Did All the Doctors Go?

Herbal tea containing hibiscus may lower blood pressure in prehypertensive, mildly hypertensive patients, study suggests. HealthDay (11/9, Gardner) reported that "drinking three cups a day of hibiscus tea (found in most commercial tea blends in the United States) lowered blood pressure over a six-week period, most significantly among those with the highest blood pressure to begin with," based on the results of a trial presented by Diane McKay, assistant professor at Tufts University, and colleagues at the American Heart Association meeting. Doc D: Wait a second. You’ll not be surprised to hear that there were only 65 experimental subjects, and the study lasted only 6 weeks. Plus, don’t you want the health benefits of lowered pressure, rather than just a good number? Secondly, the data was significant for systolic pressure (the first number; i.e., if you’re 120/70, then 120 is the systolic pressure), but not so for the diastolic pressure. While both measurements are potentially significant, it’s the diastolic that traditionally shows the minimum that your pressure drops to. Thirdly, the ‘commercial tea blends” may not have enough, or in the right form. Lastly, does anybody know what’s IN hibiscus tea? Like most herbals, probably about 200 compounds, some of which may have undesirable effects. So, this is an interesting nature note, and they’ll probably write a grant for more of your tax money to look into it, but it ain’t time to prescribe tincture of hibiscus every 6 hours. Health advice utility rating: Disregard. Physician discusses flaws in P4P program. In an essay published in the New York Times (9/9, F5), Sandeep Jauhar, M.D., writes that these days, patients often receive "antibiotics without solid evidence of an infection. And, part of the blame lies with a program meant to improve patient care." This "program is called pay for performance, P4P for short," and "employers and insurers, including Medicare, have started about 100 such initiatives across the country." It is intended "to reward doctors for providing better care." For instance, physicians "receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure." Dr. Jauhar argues that this may seem like a sound idea, but "in a survey [conducted] in New York State, 63 percent of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery." In addition, while Medicare requires that "antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital," physicians "often cannot diagnose pneumonia that quickly." Dr. Jauhar concludes that the program's "deep flaws must be addressed before patient care is compromised in unexpected ways." Doc D: I’m conflicted about Pay for Performance programs. Do we really want a program in place that will influence doctors to cherry-pick their patients? The insurance industry started the cherry-picking process many years ago, and it resulted in more regulations to keep them from doing it. I’m a great believer in incentives, but I would prefer ones that are strictly positive. I also think that some of the criteria that are being adopted by administrators don’t make good sense. The decision by Medicare to not pay for bladder catheter infections in hospitalized patients is a good example: while a lot of these infections are avoidable, you can do all the right things, and your patient will still get an infection, especially patients with a lot of medical problems. So, guess what message doctors and hospitals take from this? Study indicates fewer medical students intend to become primary-care physicians. NBC Nightly News (9/9, story 10, 0:30, Williams) reported that a new study shows that few medical school students plan to become primary-care physicians. Most "are going into specialized fields instead." USA Today (9/10, Rubin) reports that "medical students are shying away from careers in general internal medicine, which could exacerbate the U.S. doctor shortage expected by the time the youngest baby boomers head into their senior years," according to a study published in the Sept. 10 issue of the Journal of the American Medical Association. In fact, "only two percent of graduating medical students say they" were considering practicing as primary-care physicians, the AP (9/10, Johnson) adds. By comparison, a similar survey conducted in 1990 showed that nine percent of medical students were interested in primary care. The data showed that "paperwork, the demands of the chronically sick, and the need to bring work home are among the factors pushing young doctors away from careers in primary care." Salaries in primary care dissuade medical students from the field. The Columbus Dispatch (9/10, Hoholik) reports that "fewer U.S. medical students are choosing careers in family medicine because of long work hours and low pay," according to a research letter published in the Sept. 10 issue of the Journal of the American Medical Association. Doc D: I see this as a crisis in the making. Some people say that the primary care mission is evolving, that we will see routine family medicine move to retail clinics and practices that are staffed by nurse practitioners and physician assistants. These non-physician providers do great work in the context of what they are trained and allowed to do. However, by law, these folks have to be supervised by a physician. So, do we cut these folks loose from physician oversight? Does 1-2 years of clinical education make someone safe to treat independently? Or are we back to square one, with a need for family practice physicians? I don’t know how all this will come out, but as you might imagine, universal healthcare coverage will stretch the capacity of the system: it doesn’t help to have coverage, but not be able to get an appointment. For those of you who have been driven to our country’s emergency rooms, and waited hours, what will it be like when waiting periods increase further? Doc D Opinions are entirely my own. Quotations excerpted from AMA Morning Rounds (© U S News Custom Briefings)


What I'm Reading - Updated 3 May