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.

Sunday, March 22, 2009


I do my best to resist the temptation to talk about strictly political stuff.  All of it is so outrageous; the only therapeutic thing to do is just grind my teeth.  But, I ran across this quotation and thought it interesting.  So, I apologize in advance for my lack of discipline.

The excerpt is from a speech to Congressional Democrats by Henry Morgenthau, who was Treasury Secretary for FDR.  The time is 1939, ten years into the Great Depression:

We have tried spending money. We are spending more than we have ever spent before and it does not work. And I have just one interest, and if I am wrong ... somebody else can have my job. I want to see this country prosperous. I want to see people get a job. I want to see people get enough to eat. We have never made good on our promises ... I say after eight years of this Administration we have just as much unemployment as when we started ... And an enormous debt to boot!".”  (from Burton Folsom, Jr., New Deal or Raw Deal? (New York: Simon & Schuster, 2008), p2).

Maybe we’ve figured out how to spend in the interim, but …I don’t know.  And unfortunately, we don’t yet (sarcasm) have a Second World War to fix the debt problem.


Research suggests maggots may be no more effective than standard ulcer treatments.

A 14th century treatment, typically employed by military doctors, has made its way into modern laboratories, according to the AP (3/20, Cheng). Until the 1930s, "maggots were commonly used" to treat wounds, but the practice "fell out of favor when antibiotics and surgery became widely available after World War II." Still, those "in a remote place," or communities that "don't have access to a surgeon or good medical care" might still choose such an option today.

       …in theory, maggots can "'clean out' dead tissue -- a process called debridement -- stimulating healing and getting rid of bugs such as MRSA in the process."

        Aiming to validate or debunk those assertions, the Canadian Press (3/19, Ubelacker) reported that researchers at the University of York conducted a study, published Mar. 19 in the BMJ, in which … the "maggot therapy was significantly faster at debriding...from wounds than hydrogel, (but) there was no significant difference in the time for the ulcer to heal."


Doc D:  This may be a little too gross for you.  There’s more to the story.  Medicines don’t help remove the dead tissue from a wound.  When I was in training we would put moistened dressings onto the wound and allow them to dry.  Returning later in the day we would peel off the dressing, to which the dead tissue had adhered.  This worked “fairly” well, but when you looked at the patient it was clear from their pale and sweaty face that having a dried dressing yanked off an open wound was like ripping duct tape off a hairy chest.  Also, some of the dying tissue wouldn’t come free, so you had to keep doing this procedure daily until all the bad stuff was gone.  Maggots can only eat dead and dying tissue so they have the advantage of being selective, and it’s uncomfortable only in the beginning.   BUT, remember what I said above:  antibiotics don’t remove the non-viable tissue and that’s what keeps the infection going:  a culture medium for germs.  So you need both debridement and antibiotics.



Nine percent of family medicine slots went unfilled this Match Day.


 In the Wall Street Journal (3/19) Health Blog, Jacob Goldstein wrote that while Match Day "offers plenty of human drama," its "process also offers a window into the collective desires of the newest crop of doctors." For example, about "nine percent of the" family medicine "slots went unfilled." Family medicine, a specialty in which physicians often "work unpredictable hours," offers "median compensation" of "around $180,000 a year, according to a 2008 report from the Medical Group Management Association (MGMA)." By comparison, "anesthesiology, which often offers regular working hours," offers "median compensation of about $400,000." Notably, approximately "one percent of" anesthesiology "slots went unfilled," possibly indicating that "medical students, who often have more than $100,000 in debt, respond to market forces."


Doc D:  Another tidbit of evidence that suggests we are headed in the wrong direction with healthcare.  Dis-incentivizing primary care will lead to access problems.  If there are few doctors trained in primary care, who will take care of people?  There are only two answers:  non-doctors (with much less medical training) or doctors who didn’t train in primary care.  Good luck with being treated for your pneumonia by a dermatologist.


And by the way, I never made $180,000 in my life, despite being a general, and receiving flying pay and hazardous duty pay for parachuting in addition.  My military pay was about a third of what my old partners were making in the ER group I left to join the Air Force.  In fact, my pay went DOWN when I made general because the government thinks that your position and authority are compensation enough (they stopped my medical pay).  Not so for other types of federal employment.


Children born to older fathers may score lower on cognitive tests, study indicates.

The New York Times (3/10, A12, Rabin) reports that "the children of older fathers scored lower than the offspring of younger fathers on I.Q. tests and a range of other cognitive measures at eight months old, four years old and seven years old, according to a study " published in the online journal PLoS Medicine. For the study, researchers "reanalyzed data from the federally sponsored Collaborative Perinatal Project, which gathered information from more than 50,000 pregnant women seen at 12 university clinics in the United States from 1959 to 1965." The investigators "analyzed the scores of 33,437 children who, as part of the project, had been tested at regular intervals in a variety of cognitive skills, including thinking and reasoning, concentration, memory, understanding, speaking and reading, as well as motor skills. Fathers in the study were age 14 to 66, while mothers were 12 to 48."

        Bloomberg News (3/10, Lauerman) reports that, according to the researchers, "average IQ among children dropped steadily on a number of tests as their fathers' ages rose." For instance, "children born to fathers who were age 20 scored an average of two points higher on an IQ test than children born to 50-year- old fathers."

        HealthDay (3/9, Reinberg) reported that the researchers also "found that the older the mother, the higher the kids' scores on the cognitive tests. WebMD (3/9, Doheny) also covered the story.


Doc D:  What the…?  This is one of those useless studies that waste our money and tell us nothing.  No knowledge of basic science and nothing that makes life better.  Are we saying that young men and old women need to “get together” and procreate in order to get the most intelligent children?  And what causes this ambiguous result?  Decadent sperm? Decaying skills in parenting?  Gray hair and balding?  Andropause?  Lastly, how significant is two IQ points…unless it’s the final seconds of a basketball game?


I want my money back.



Medical quote of the Day:

Entry in The Devil’s Dictionary, by Ambrose Bierce [1842-1914?]:

MIND, n.  A mysterious form of matter secreted by the brain.  Its chief activity consists in the endeavor to ascertain its own nature, the futility of the attempt being due to the fact that it has nothing but itself to know itself with.



Nature Note:    Media Portrayals of Suicide.  You may have seen recent testimony to Congress on an increase in suicides among military personnel.  I was involved in a couple of these episodes:  there were several during my 28 years of service.  The suicide rate goes up and down over time, and interest peaks when there is a rise.  The DoD has published data on this for a long time.  The first thing to note is that suicides are always a grave concern, but the rate in the military has always been lower than that of the general population, even during war.  Each military service has an elaborate program to detect, prevent, and treat signs of stress and mental illness among military personnel.  They take it very seriously; as a commander I disciplined supervisors who were slow to recognize when someone’s life was going off the rails. 


An interesting issue, though, is what is the effect of the media’s portrayal of suicides?  Do they precipitate more suicides?  The available evidence, which some psychiatrists argue is epidemiologically weak suggests that media portrayals are more likely to be associated with suicidal behavior when they are prominent on the page (e.g., large headlines, photos of the body), appear in multiple places (e.g., several TV networks and newspapers), report celebrity deaths, and are based on real rather than fictional (e.g., TV soap opera) suicides.  Two particular studies are often cited as evidence for a copycat effect.  A series of highly publicized media reports of subway suicides in Vienna, Austria was linked to a rise in subway suicides, and the suicide of a famous Canadian journalist, GaĆ«tan Girouard, was also associated with a rise in the suicide rate.

The media have always claimed that the impact of bringing to light these events is of greater benefit than harm.  A family destroyed by the exposure of the media is less important than that the public hear innuendo or unsubstantiated attacks on a family member.  For those who don’t buy that argument it’s always been hard to quantify the harmful effect.  Now there is data to make that comparison, and this is encouraging for those like me who think the media attack dogs need to do their job from principle rather than profit.


Recommended Reading (yes,  I read them):


--The Myth of the Rational Voter:  Why Democracies Choose Bad Policies, by Bryan Caplan.  This book is a little more academic than most, but it rewards the effort.  H. L. Mencken, the early 20th Century journalist and satirist, said that “democracy is a pathetic belief in the collective wisdom of individual ignorance.”  When six times as many adults know the name of the current American Idol winner as know the name of the Speaker of the House, the informed citizenry necessary for democracy to perform well is…absent.  But, it’s always been that way, according to Caplan.  Taken all together, only a few percent of the population know platforms, candidate’s records, or have a formed opinion of public policy.  This is a problem for those who think that democracy works to make good policy.  However, says Caplan, democracies don’t operate out of ignorance, an evident state of affairs, rather they operate irrationally.  The greatest obstacle to sound economic policy is the popular misconceptions, irrational beliefs, and personal biases held by almost all ordinary voters.  Voters vote for what they want rather than for what they should.  There’s a lot in this book that brings you up short; it will test your belief in our system of governance, and provide an antidote to any belief that everybody should like us because we’re “special.”

--Kluge:  The Haphazard Construction of the Human Mind, by Gary Marcus.  Evolution is frequently given great credit for the marvelous machinery of nature, including the human body and mind.  But, the author argues, that’s not the way it works.  In fact, whatever gives the organism an edge wins out, whether it’s the best solution, or just enough better to make the difference.  “Adequacy” is the goal of natural selection, not the fittest or best.  Further, Marcus says, our minds are not a wonderful and complex web of infinite capacity and creativity.  The mechanisms by which our minds work are patched together with baling wire, spit, duct tape, and glue.  The result is extremely un-pretty, but gets the job done.  He goes on to offer ways to side-step the kluge in our thinking.  Fun reading, with lots of examples of cognitive folly.


Doc D


The above are my opinions, and they are entirely my own.  If you don’t like mine, form your 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 that are in the public domain.  As always, you may share this column, with appropriate attribution (here, and in the text) included.



Thursday, March 19, 2009


Obama backs away from plan to bill veterans' private insurance.

In continuing coverage, NBC Nightly News (3/18, story 7, 2:05, Gregory) broadcast, "A White House plan" to bill veterans' private insurance for war or service-related injuries "came under intense fire" Wednesday "in Washington and in American Legion halls across the country." Veteran "sources tell NBC News even the new head" of the Department of Veterans Affairs, General Eric Shinseki, "was strongly opposed. And late today, faced with another political firestorm, the White House put out this statement, saying the President had retreated and dropped the proposal."

        …veterans' groups "complained that the proposal would reverse government policy of taking responsibility for caring for the war wounded and said it could cause difficulties for veterans in getting future insurance or even jobs. Members of Congress leapt in to join the criticism."


Doc D:  This is a disgrace.  As the American Legion leader said in an interview, the President deflected every question about the moral commitment to care for our wounded, and re-directed the conversation to how much money could be saved:


“It became apparent during our discussion today that the President intends to move forward with this unreasonable plan, …He says he is looking to generate $540-million by this method, but refused to hear arguments about the moral and government-avowed obligations that would be compromised by it.”


At first, I hoped that this proposal was the product of some White House staff, politico, bean-counter…but apparently not.  The president saw no problem with it.  At the least, this is incredibly stupid, and out of touch.  He can sign legislation on swine odor, but war wounded need to find their own coverage.  As the American Legion wrote, sarcastically, on their website:


"If you were injured in Iraq or Afghanistan and you have not paid your co-pay, please press 1. If you were injured during military training and you have not yet reached your deductible, please press 2. If your family has reached its maximum insurance benefit, please call back after you have purchased additional coverage. Thank you for your service."


The response to this proposal was the first sign of bi-partisanship I’ve seen this year.


Clearly, this is a hot button with me.


Obama defends budget, healthcare provisions against Republican criticism.

The New York Times (3/18, A16, Cooper, Hulse) reports the White House "has begun a full frontal assault to get President Obama's first budget through Congress.  During an appearance on Tuesday at the Eisenhower Executive Office Building, Mr. Obama took a swipe at Republican critics of his $3.6 trillion budget and its agenda for healthcare."  Obama asked that "members of Congress who object to specific policies and ready and willing to propose constructive, alternative solutions.”


Doc D:  Unfortunately, this is a hollow challenge.  As we’ve seen, House and Senate majorities are of sufficient magnitude to make sure that no other alternatives see the light of day.  However, a plan is being hammered out by the so-called Gang of Nine, which is a bipartisan group of Senators, in concert with the administration.  I believe that there is widespread support for reform.  We don’t have any details of the Gang’s plan, so “what kind” of reform remains to be seen. 


Two problems I see:  first, the Gang of Nine met in secrecy for the last nine months.  This was fatal to the Clinton healthcare plan…where is the “transparency” that was talked about in the campaign.  Second, the President’s campaign mix of government and private insurance choice is not sustainable.  We saw this with the military’s TRICARE plan:  it allowed people to choose between several plans, but dis-incentivized all but the government-controlled, managed care option.  NOBODY has the deep pockets that the government has, and any private insurer that hopes to compete for business may be doomed to failure.   The government can, and does, take a loss wherever it feels the need to:  private insurers can’t.  I believe that it is likely that such a mixed system will inevitably move to a single-payer government system.  Americans have traditionally placed “choice” among their priorities, and I don’t think they will see this coming.


Over and above all this, my previous objections still stand:  nobody has come up with a way, short of rationing and controlling the types of care that can be offered, that will significantly control costs.  Even those nations with these mechanisms in place are experiencing rising costs.


Task force recommends daily use of aspirin for men over 45, women over 55.

ABC World News (3/16, story 7, 2:15, Gibson) reported that "a highly regarded medical group has solid evidence that men at risk for heart attacks and stroke should take a daily dose of aspirin beginning at age 45. Women should do it at age 55."

        On its website, ABC News (3/16, Potter) added that the new guidelines by the US Preventive Services Task Force, "an independent panel convened by the Department of Health and Human Services," also notes that "for both sexes, a baby aspirin -- typically 81 milligrams a day -- will do the job. There is no evidence that a larger dose makes a difference." And, "both sexes should stop by age 80, unless their doctors say otherwise. As you get older, there's a greater risk of bleeding in the brain or the digestive system -- a risk that is small, but can be fatal in some cases."


Doc D:  No politics here (thank goodness, huh?).  The evidence for aspirin as a prevention for heart attack and stroke has been suggestive for decades.  I’m convinced at this point, but it’s important to clarify EXACTLY what we are talking about.  Aspirin stops the platelets in the blood from sticking together when they sense that a clot needs to be formed.  How this works to prevent risk is not exactly clear, but evidence suggests that it reduces the likelihood that fatty deposits in the arteries can make the platelets think they need to stick together to “heal” the deposit.  This is a long-term process.  They also keep platelets from attaching to a clot, contributing to complete blockage of a narrowed artery  (it’s more complicated, this explanation works for my simple mind).  BUT, it doesn’t do a thing to prevent the fatty deposits that are the result of cholesterol, bad diet, no exercise, and family history.  You can’t take a baby aspirin and overcome all the rest.  Take an aspirin, but exercise your mind and body, eat right, get your rest, and have fun.  I’ll write you a prescription for that.


Medical quote of the Day:

He hath abandon’d his physicians, madam; under whose practices he hath persecuted time with hope, and finds no other advantage in the process but only the losing of hope by time.—William Shakespeare [1564-1616]  All’s Well That Ends Well



Nature Note:    STEM CELL RESEARCH.  As I said some months ago, in a previous newsletter, this whole stem cell issue is a tempest in a teapot.   You and I, all of us, have stem cells in our bodies.  They’re few and far between, but they can be harvested and used to treat serious disease.  In fact, it’s done regularly for certain types of cancer cures.  Stem cell research using these cells was not prohibited, and has skyrocketed during the so-called ban.  For instance, several months ago researchers produced a multi-potent stem cell (able to transform and grow into multiple kinds of cell) from adult human skin cells.    

The moral argument, except for people who see any tinkering with human genetic material as taboo, comes from the use of human embryo stem cells.  As you might guess the human embryo requires stem cells to develop…a lot of them.  Obtaining human embryo stem cells means grinding up human fetal material to obtain large amounts of ready-made stem cells that could be made into whatever tissue is needed.  It was disingenuous of some scientists to insist that only this method would result in steady advances in the treatment of disease.  It was actually just convenient, and less costly (with a few ego and ideological issues on the side).  Stem cell research has actually skyrocketed under the ban, and new treatments have been appearing monthly.

The President’s executive order lifting the ban is repugnant to a large percentage of the public.  Why court this moral controversy unnecessarily?  I don’t get it.

I don’t have any hard and fast philosophical belief on the status of human embryos.  But there is something life-demeaning about such a cavalier attitude.

I’ll give the President this, though.  He preserved the ban on cultivating human embryos for the purpose of harvesting their stem cells (which the advocates wanted).  Can you imagine women hiring out as stem cell farms?  And, of course it will be the poorest among us who would be the most vulnerable.

In summary, then, an unnecessary ideological struggle over a non-problem.


Recommended Reading:

See No Evil, The True Story of a Ground Soldier in the CIA's War on Terrorism, by Robert Baer.  We live in a time when CIA agents have needed to purchase personal liability insurance.  I wanted to know why we have had intelligence failures, alongside some successes.  Robert Baer served in foreign countries from the seventies through the nineties.  His theme is that the country has dismantled its “human” intelligence systematically for several decades.  What began with a turning away from overt acts in foreign countries under Carter, became a shutting off of sources and posts around the world under Reagan and Bush, that culminated in cuts in intelligence resources across the board as a result of the Peace Dividend in the Clinton Administration.  The nineties alone saw a 25% reduction in funding for intelligence gathering, little replacement of retiring case officers, and an over-reliance on satellites and imagery (SIGINT) over face-to-face work with people in unfriendly countries (HUMINT).  His argument that imagery says nothing to you about what is going on inside buildings, and inside people’s heads, is strong.  The result was intelligence services that were incapable of meeting the demands of the 21st Century.  The book is an exciting boots-on-the-ground view, detailing famous attacks, what we know about them, and the part he played in uncovering the information.

The Next 100 Years – A Forecast for the 21st Century, by George Friedman. Friedman is something of a maverick thinker.  He makes the case that in every twenty year period over the last 100 years, what everybody thought was important and enduring, was wrong…and he marches through the years illustrating his points.  That means, he says, that in twenty years we won’t even remember Islamic Jihadism.  Further, the US, as the single superpower, needs only to make sure that other nations don’t form a coalition that could challenge it, and we have done that so far.  Winning and losing wars, of which he believes there will be many, is only secondary.  The book challenges common assumptions on population growth, computers, culture, and warfare on almost every page.  If you’re looking to shake up your thinking, even if you don’t change it, this book will do the job. 


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.


Thursday, March 5, 2009


Sorry, folks.  It’s been a long time since I last wrote, but there hasn’t been much medical news that’s informative and entertaining.  Quite the contrary, most of it has been the opposite of entertaining…more like, very scary.  The entrepreneurs that have been lobbying for their pet healthcare project are lining up to milk the federal cash cow.  Congress is on a spending spree that has them drooling.

But among the chaff there are a few nuggets, some pitiful and some hilarious.


Obama's budget includes creation of 10-year, $634 billion "health reform reserve."

Media reports are casting President Obama's first budget plan as a clear break with past US policies on a variety of issues. The story led all three network newscasts and appears on most major newspaper front pages. ABC World News (2/26, lead story, 3:20, Gibson) described the size of the budget as "staggering" and notes that "one out of every two dollars spent by the government will be deficit spending." But "it would lead to a seismic shift in policies, and would touch the lives of nearly every American."

Doc D:  I’d like to spend another dollar for every dollar I earn.  It would solve my personal financial limitations.  Just so long as I don’t have to pay it back (my grandkids can take care of that).

Seriously, this is not the solution to healthcare costs; frontloading a deficit “reserve” just gives you the feeling of having some “walking around” money, like a wad of cash in your pocket.  It’ll be gone before you know it, and the same forces driving increased cost will still be in place.


Researchers say prescription drug labels should quantify drug's benefits versus placebo.

The New York Times (2/26, B3, Singer) reports, "researchers...are urging federal regulators to" require the labels of prescription drugs to carry "numerical tables that quantify the benefits of taking a drug compared with a placebo, and that list the odds of having side effects."  Tomorrow, Dr. Steven Woloshin and Dr. Lisa Schwartz "plan to present their case to the" Food and Drug Administration (FDA) "during a meeting of the agency's advisory committee on 'risk communication.'"  The researchers "are scheduled to present the results of two randomized trials, published last week in Annals of Internal Medicine, in which they examined how well drug fact boxes worked on several hundred people."  The trials "indicated that most people presented with comparative risk and benefit information were able to identify the more effective of two drugs."

Doc D:  This will be interesting.  Sometimes the placebo effect (where people get better, thinking they are taking medicine, but they’re not) is as high as 30%, even for non-psychiatric drugs.  Also, sometimes people don’t get better with a highly effective drug…who knows why:  genetic resistance, cantankerous personality, etc.  I anticipate some big litigation out of this one, and some income growth for lawyers.


Nevada bill aims to legalize quackery.

Quackwatch, (Feb 26) reports that “Nevada State Senator Michael A. Schneider has introduced S.B. 69, an 85-page bill that would:

**Declare Nevada a "freedom of health" state.

**Affirm that patients are "entitled to access to and the use of the products and services of any provider of health care chosen by the patient, including, without limitation, a complementary integrative medical physician or any other provider of health care."

**Replace the current homeopathic board with a Board of Complementary Integrative Medical Examiners that has the same powers but can authorize people to become licensed or certified as a "complementary integrative medical physician," "advanced practitioner of complementary integrative medicine," "complementary integrative medical assistant" or "complementary integrative medical nutritionist."

The practices that would be permitted under the bill's umbrella would include biofermentics, bio-oxidative therapy, electrodiagnosis, herbal therapy, homeopathy, naturopathy, neural therapy, neuromuscular integration, orthomolecular therapy, nonembryonic stem cell therapy, peptides, and "any intravenous infusion, intramuscular injection, subcutaneous injection and intradermal injection of nutrients, including, without limitation, vitamins, amino acids, minerals, enzymes, compounded pharmaceutical preparations, homeopathic medications, organ preparations, ozone, hydrogen peroxide and chelating agents."


Doc D:  This has to be a joke, right?  This is a free ticket for every quack and wacko to hang out a shingle.  The trend toward anti-rationalism in healthcare continues to grow.  (Note that this is not “irrational”, which means “lacking” reason; this is “against reason,” meaning to use alternative modes of knowing.)  On the other hand, if any of you want a career change, invent a form of therapy (anything, just make it sexy-sounding) and move to Nevada if this bill passes.  For those whose feet are NOT firmly planted in air, remember the case of Rhea Sullins:  a 7-year old who became ill, and whose father, a past-president of the American Natural Hygiene Society, put her on a diet of water-only for 17 days, followed by juice-only for 18 more until she died of malnutrition.


Medical quote of the Day:

There are no really “safe” biologically active drugs.  There are only “safe” physicians.—Harold A. Kaminetzky [1923- ]



Fraud Alert:    Chelation Therapy.  Some of you have heard of this:  the basis for this treatment is that heavy metals are found in the urine of tested subjects, and compared against norms to establish the need for chelation therapy to remove them.  Heavy metals such as lead and mercury have been implicated in several diseases.  The problem is, the patients are given chelating agents that raise the level of the metals in the urine, then the tester compares those results against the standard, which is calculated from urine specimens from subjects who did not receive the chelating agent (as the patients did).  This all but guarantees that the patient will be abnormal, and require therapy.  It is my belief that the advocates of chelation therapy know very well they are cooking the books:  the failure to adhere to a basic principle of scientific validity is too blatant.

The best approach is to be skeptical of any new therapy that is not in the mainstream of healthcare. 


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.



What I'm Reading - Updated 3 May