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.

Friday, April 30, 2010

Medical Quote Of The Day - 30 Apr 10

"My doctor is nice; every time I see him, I'm ashamed of what I think of doctors in general."
--The Second Neurotic's Notebook, Mignon McLaughlin [1913 - 1983]

Who Does The Public Trust Most In Health Care Reform?

Interesting results of a Gallup poll conducted last month on "Confidence In Each To Recommend The Right Thing For Health Care Reform."

The public probably trusts doctors because as individuals they don't have an opinion.  "I'm too busy to bother with that right now."


Great. Another Wacky Health Care Reformer To Run Medicare

Dr Donald Berwick has been nominated the new director of the Centers for Medicare and Medicaid Services (CMS) by President Obama.

In a speech in the UK, Dr Berwick compared our health care system to Britain's National Health Service(NHS).

The NHS is “universal, accessible, excellent, and free at the point of care — a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just”; America’s health system is “toxic,” “fragmented,” because of its dependence on consumer choice. He told his UK audience: “I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.” (The American Spectator, The Right Prescription blog, Apr 26).

The telling point for me is that the "individual health care consumer's" choice cannot manage a health care system, "that is for leaders to do."  Is that a definition of Nanny State Mentality or what?

And it's great that he wants to bring this system to our shores.  The article linked is well worth the read at the Times Telegraph, 9 Dec 09, "Britain has among worst cancer survival rates in developed world"

Delayed and denied care have been covered elsewhere, and I have written on Britain's system of assigning a dollar amount to the value of a year of life.  But even at the "point of care," as reported in The Guardian (Feb 25)  the NHS Foundation Trust in Staffordshire showed
A lack of compassion among staff. Patients left lying in their own urine and faeces. Others falling, sometimes sustaining a serious injury or even dying as a result, unseen by ward personnel. Meals not provided or put out of reach. Uncaring staff rejecting requests from patients and relatives for help. Lamentable hygiene standards. Family members having to clean, feed or help their loved ones get to the toilet. Too few doctors generally, especially in A&E. Reluctance among patients to ask hard-pressed staff to provide proper care, and fear among staff about the consequences of not meeting targets.
I'm not sure how Dr. Berwick misses the substantial deficiencies of this system of care.  Looks like Trouble Comin' Every Day  (Frank Zappa would disavow my using his song title, but times have changed, Frank.  The Brain Police are a different group of people now).


New Mortality Data: Women--Harder Better Faster Stronger, Men--Not So Much

The gender mortality gap is widening.

We've all heard that women live longer than men, on average, by several years.  That's been true for as long as I've been around  (Note for globalists:  I'm talking USA here).

Here's the good news:  Premature mortality is falling.  That means that deaths in the 15-60 age range are going down.  Yaay.

Here's the not-so-good news for half of us:  Premature mortality in women is falling twice as fast as in men.

As reported in MedPage Today (Apr 29), "From 1970 to 2010, the probability that a 15-year-old would die before turning 60 dropped by 19% for men and 34% for women," and "the difference between mortality risk in men and women grew from 63 per 1,000 to 80 per 1,000."  This all comes from a study published in The Lancet (Apr 30) using vital registration data from 187 countries.

As a card-carrying, muscle-bound male (well...not muscle...maybe hide-bound), I'm not feeling the love.

PS:  Men from Iceland, and women from Cyprus, live the longest.  But who wants to live in those places?

Whoa...Something I Predicted Came True: How To Ration Care

The FDA's approval of Dendreon's cancer drug, Provenge, puts the question of rationing front and center.

As George Carlin used to say, "I'm having Vuja De, that strange feeling that somehow, this has never happened before."

A week ago, I wrote this philosophical post about the President's health care advisor's scheme for allocation of scarce resources in health care (AKA...rationing).  I followed it up two days later with some choice words on other ways we might go about distributing scarce but needed treatment.  Now, The WSJ Health Blog reports (Apr 30) that supply will not be able to meet demand for over a year.

Provenge is not a breakthrough treatment in terms of curing everything from warts to erectile dysfunction.  It's a cancer drug that provides a modest improvement over other therapies.  But it is unusual in that the patient's cells have to be sent to a lab that will brew up an individualized immune therapy.

And it costs a boatload:  $93,000.00 for a course of treatment.

This is where the "supply limitations" part comes in.  There's only one facility to produce the therapy; it expects to be able to process about 2,000 specimens a year.

So, who decides who gets the treatment, and how do they decide?  The manufacturer said, "Not my job," and punted to the medical centers (appropriately).

Recalling my discussion, do we treat the worst off first, or the youngest with the most potential lifetime ahead, a lottery, or first-come first-served (involving a waiting line and back log)?

I'd hate to have cancer right now, or any of hundreds of illnesses that require high-tech treatment as we look to limited revenues available to pay for health care.  Think this is theoretical?  See my post today on the view of the President's new nominee to run Medicare.


Thursday, April 29, 2010

Medical Quote Of The Day - 29 Apr 10

Halsted was a fascinating character in the history of medicine (standing, in Sargent's famous painting, The Four Doctors).  He was one of the four founders of Johns Hopkins, introduced the concept of a patient "hospital chart," performed the first mastectomy for breast cancer (a death sentence previously), pioneered the use of cocaine in anesthesia--becoming addicted himself and requiring treatment in a sanitarium--and started the first formal residency training in surgery.

"The only weapon with which the unconscious patient can immediately retaliate upon the incompetent surgeon is hemorrhage."
--William S. Halsted  [1852 - 1922]

Medical Cartoonville

I guess this is really "Medical Poster-ville," but who cares?
A few years back there was a museum exhibit of advertisements showing doctors and dentists recommending certain brands of cigarette.  There were A LOT of them.

None of the ads actually mentioned people by name, so you wonder where they got the data and testimonials.

In any case, it sounds pretty horrific nowadays.  But, hey, if we want to start whacking figures from the past, let's start with Plato and go from there.


If I Can't Remember What Alzheimer's Is, Does That Mean I Have It?

You've heard the old joke, "I may have Alzheimer's, but at least I don't have Alzheimer's," right?

The National Institutes of Health (NIH) has issued a draft statement on the "State-of-the-Science" regarding Alzheimer's disease.

They find that supplements and vitamins  are useless as strategies to prevent or treat dementia.

Alzheimer's is the most common form of dementia. It was first described in 1906 by Alois Alzheimer.  Dr. Alzheimer had a patient, Mrs. Auguste Deter (see photo, that's her) who died of the disease.  He subsequently examined her brain microscopically and identified amyloid plaques and neurofibrillary tangles that characterize the abnormality.  We owe a debt of gratitude to the unfortunate Mrs. Deter for allowing us to begin to understand this debilitating and lethal disease.

Over 5 million Americans suffer from Alzheimer's. Distinct from this progressive disease is the mild cognitive impairment of old age, which is thought to affect an even greater number of the elderly.  Health care costs in treating dementias amount to almost $150 billion annually in the United States alone.

The NIH draft statement attempts look at those things that reduce the risk of cognitive decline and Alzheimer's. 

Over the years, many factors have been associated with Alzheimer's.  However most of these associations have not been thought to be causative in nature, but rather of mild influence:  diabetes, high cholesterol, depression, diet, lifestyle, exercise.  Vitamins show no association with Alzheimer's risk, with the possible exception of adequate folic acid levels.  Not surprisingly, if your health is poor, you are more prone to a number of diseases...not a very groundbreaking finding.

While there's some doubt about how important the above really are, there's no evidence for any influence of

"other vitamins, fatty acids, metabolic syndrome, blood pressure, plasma homocysteine, obesity and body mass index, antihypertensive medications, nonsteroidal anti-inflammatory drugs (NSAIDs), gonadal steroids, solvents, electromagnetic fields, lead, or aluminum."
Even more pointed, there's no evidence that gingko biloba or any supplements can prevent or alter the disease.  Brain-exercising techniques have been poorly studied.

What about the medicines that are prescribed for Alzheimer's, you may ask?  They treat the symptoms, like memory loss, but don't affect the progression of the disease.  They are like taking Tylenol for the fever of pneumonia; it lowers your temperature but doesn't cure the disease.

So the depressing bottom line of the state-of-the-science is that no strategies that have been proposed to date are effective in preventing cognitive decline or Alzheimer's. 

Keep that in mind the next time you read a newspaper or advertisement that suggests that consuming some noxious weed or shrubbery will keep you disease-free.


Toys Banned From Happy Meals In California County...Natch

Santa Clara County's Board of Supervisors banned restaurants from giving out toys with kid's meals that are high in sugar, fat, salt and calories.

Does anybody not recognize we're talking about Happy Meals here?  The SF Chronicle reports, via Hot Air, that "This ordinance breaks the link between unhealthy food and prizes," according to the law's author.

I've written before that this kind of dietary law is really stupid (here, here , and here).  There's no evidence suggesting a connection between obesity and restaurant toys.  Like the South LA law banning new fast food restaurants, which merely forced people to use street vendors and vending machines, laws like this don't work, even if there was a connection between "meal toys" leading to more unhealthy food, leading to obesity.  Kids aren't influencing the choice of dining in favor of toys ("Yes, Mommy, I want toys for lunch.")

It's hard to imagine that these Santa Clara supervisors actually spend their day leaving and returning to work, carting small children from school to day care, to doctors appointments, to soccer, to gymnastics, to summer camp, etc.  Having done all this myself, toys keep the kids occupied while I'm traveling from one spot to another, and while I'm cleaning up the lunch debris, and washing my hands, and ALL THE TIME TRYING TO STAY ON SCHEDULE...

So, you can see that if we think our kids are eating poorly, and we want to encourage healthy eating such that there is less childhood obesity, the target is the parents.

More importantly, if we want to have a significant impact on overeating, we need to get at the underlying reason we overeat, or overfeed our children, not just impede the ACT of overeating. 

It's the Why, not the How, that's important.


Wednesday, April 28, 2010

Medical Quote Of The Day

Laurence Housman was the brother of the famous poet A. E. Housman, although you probably aren't familiar with him unless you went through grade school back in the fifties.  Schools don't assign reading from any author whose works appeared more than 10 years ago these days.

Housman was a writer and playwright who once said, "For the last half of my life I have had the doubtful benefit of a brother whose literary reputation is much greater than my own."  His work was considered scandalous by Victorian standards.
"If Nature had arranged that husbands and wives should have children alternatively, there would never be more than three in a family."

--Laurence Housman [1865 -1959]

Medical Cartoonville


I'm not sure whether this is a gen-u-ine Snake Oil poster.  There's nothing explicit that gives it away as satire, but I sure wouldn't buy anything that used this color scheme and this rascally-looking character.

But you never know...

Poison Pill #16: Children Covered To Age 26: Not So Fast

Private insurance plans announce immediate coverage under ObamaCare.  For dependents of military and federal employees (8 million), not until next year.

The Administration was quick to counter critics that said elements of the new health care law would not go into effect until 2014 by announcing that some features would be implemented "immediately."  Apparently in the rush to pass the legislation, the Congress forgot that contracts have to run their course, so it will take until next year for coverage to be extended for any dependent covered under a government program, according to the Office of Personnel Management:
"Though we are eager to provide coverage to young adults prior to January 1, the current law governing the FEHB Program specifically prohibits us from doing so," according to an OPM statement.
Kaiser Health News reports that OPM "did not respond to repeated requests for interviews over several days."

Since contractual requirements control the military's health plan (TRICARE), this delay is expected to impact that group, also.

A Tip-Of-The-Hat to Congress for doing such a great job.  May I have another?


Help, I'm A Diabetic Who's Wired Up To Donkey Kong

What's the ideal blood glucose level to max your score at Donkey Kong?

According to Physicians News (Apr 27)  Bayer Diabetes Care has announced a blood glucose monitoring kit for diabetics that attaches to video games.

The meter rewards regular glucose monitoring by advancing the game player to higher levels, among other such incentives that I don't really get.

There's something a little creepy about this.  Is the meter improving my health or just my game scoring?  Would I maintain my blood sugar better if I played Warcraft or Call of Duty 4?

And, ultimately is the game controlling me, through reward, in the same way we train rats to push a button with their nose to get food?

Maybe the government could wire us all up to choose only healthy behaviors and activities.  No more Snickers, no more bungee jumping.  A sure fire health care cost control...

Oh, no...I'm on paranoia overload; time to hook up my thorazine monitoring kit.

Tuesday, April 27, 2010

Medical Quote Of The Day

Wilder Penfield was a groundbreaking Canadian neurosurgeon who pioneered using neural stimulation to isolate parts of brain that cause seizures, leading to surgical treatment of epileptic disorders.  In the process he explored the function of the cerebral cortex, showing that specific areas were responsible for specific movements or sensations.

"The trouble is not in science but in the uses men make of it.  Doctor and layman alike must learn wisdom in their employment of science, whether this applies to atom bombs or blood transfusion."

--The Second Career, "A Doctor's Philosophy", Wilder Penfield [1891 - 1976]


The Drug You'll Love: Chocolate For Depression

The old story about how people eat when they're depressed is true; further, they tend to choose chocolate.

But is it doing anything to treat the Blues?

I'm not assuming here that clinical depression is the same as the Blues, but maybe feeling "down" is related to the medical condition...for those who've had both, it feels similar, but the latter is much worse.

So researchers in the Annals of Internal Medicine (Apr 26)  looked at chocolate consumption as a function of depression scores.  They found that people who scored higher on depression ate 60% more chocolate.  And this is not a gender thing--the association held up for both males and females.  Further the chocolate intake wasn't related to just stuffing anything in your was chocolate, dude.

Anecdotal evidence and even a couple of surveys have reported that people feel better when they eat chocolate.  But that ain't the kind of science that can validate an influence on brain chemistry that influences mood.

To be fair, the authors make no claim that there is a cause and effect relationship ship here, or that chocolate influences mood either way...which is correct; they didn't look at those questions.

for Onion Peelers (math),
Those screening positive for possible depression (CES-D score 16) had higher chocolate consumption (8.4 servings per month) than those not screening positive (5.4 servings per month) (P = .004); those with still higher CES-D scores (22) had still higher chocolate consumption (11.8 servings per month) (P value for trend, <.01).

But to hell with all that science stuff.  This is good enough for me.  From now on I'm keeping some malted mill balls around just in case I feel a little low.


Terminally Stupid Drug Coverage Rules: IV Drugs Yes, Pills No

Researchers and policy makers are looking at so-called "chemo parity" initiatives.  See here in the WSJ Health Blog (Apr 27).

The way insurance plans (both government and private) are organized, medical "treatments" are covered, but drugs are considered separately.  So, if you're a cancer patient and there's an expensive drug that you require, but which can be taken either intravenously (through a vein) or orally (swallow a pill), your plan covers the surgical procedure to put in an IV portal and covers the drug that goes in it, but that same plan doesn't cover (to the same extent) taking the same drug by mouth--most drug plans are capped.  The cost of the drug itself is about the same whether given IV or by mouth.

Note that we're talking about drugs that cost in the range of $1,000-$5,000 a month. 

Follow me here:
1.  Most patients can't afford to pay for the pill (limited coverage).
2.  The IV treatment involves pain and inconvenience of a portal strapped to you and having to go somewhere every time a treatment is needed.
3.  Dumbest of all, in the final analysis the total cost is more to have the treatment done IV than it would to complete the therapy with just the pills.
4.  Lastly, the icing on the cake, primary drug treatment for some cancers exists only in pill form--still not covered even when there's no IV alternative.

There are good reasons for health care reform.  This has been one of them (Dragnet theme in the background).

But here's where I differ.  In a WaPo article (Apr 27),
Insurance industry officials say that the high cost of oral drugs, not paltry reimbursement rates, are the primary obstacle. "If you look at a drug that costs $60,000 a year, the real question is, 'Why does it cost $60,000 a year?' not 'Why doesn't a plan cover it?,' " said Susan Pisano, a spokeswoman for America's Health Insurance Plans, the industry trade association. "Our member companies are trying to do everything they can, but I would say this is a real hardship for people."

Really?  This is the same finger-pointing we've seen for the last year.  It's the doctors, no it's the insurance companies, no it's the drug companies, no it's Congress, etc, ad nauseum.  It's a coverage issue for the plans, not a cost issue for the drug companies.  And it's a problem that needs fixing with "chemo parity" rules, but don't try to shift the blame.

Why does the drug cost $60K?  Because it costs about $1-2 billion dollars in research, development and testing, followed b the drugy 7-10 years of trials before a company gets the drug approved.  And, the drug is for a not-common illness so there won't be any high-volume sales to bring the price down.

If you ran a drug company and you told your employees and investors, "Hey, we went $2B in the whole, but I decided to sell the product cheaply, so sales will only cover a small fraction of what we spent; that's OK with you, right?"

Get in line for your unemployment application ->


Monday, April 26, 2010

Medical Quote Of The Day

"Half the modern drugs could well be thrown out the window, except that the birds might eat them."
"Facts are not science — as the dictionary is not literature."
"Whenever ideas fail, men invent words."
--quoted in Fischerisms (by Howard Fabing and Ray Marr), Martin H. Fischer [1879 - 1962]

Why Chatanooga Employee Health Program Costs Decline: Wellness

Health care costs for the city of Chatanooga are expected to decline next year, when most cities are experiencing double-digit increases.

In a demonstration of the power of local initiative, Chatanooga opened an employee clinic, fitness center, and city-operated pharmacy.  Combined with wellness incentives, the Well Advantage program looks to be controlling costs.

It remains to be seen whether those cost reductions can be sustained for the long term, and whether the incentives will result in reduced risk of illness and injury.

But for now it bucks the trend of increased public outlays for health care.


New And Improved Nostrums

This is the new look.  Be not afraid...

However, if there are any problems with your browser, please let me know.

Thanks for your visits.


Sunday, April 25, 2010

Medical Quote Of The Day

"Some drugs have been appropriately called "wonder-drugs" inasmuch as one wonders what they will do next."
--Annals of Internal Medicine 64:460, 1966, Samuel E. Stumpf [ 1918 - 1998]

Medical Marijuana Prescribing Standards. Balancing Risk

Isn't medical marijuana, when smoked, a health hazard?

How come we never hear about that?

At the same time the Administration announced it would no longer prosecute medical marijuana users that were in compliance with their respective state law,  the FDA was given greater authority to control and restrict the manufacture, marketing, distribution, sale, and importation of tobacco products. 

So we're loosening legal requirements for marijuana smoking while tightening the law regarding tobacco smoking.  For the record, I'm not a user, but that doesn't mean I have strong objections to medical marijuana use in itself.  What bothers me is the inconsistency. 

Cause-specific mortality tables show that tobacco use is ranked second as cause of death in this country.

There are a boat-load (pun intended) of well-controlled studies on marijuana that show increased risk of disease with marijuana use--besides lung cancer.  Here are a couple of recent findings:

1.  Daily marijuana use has been implicated in increasing the rate of liver fibrosis in patients with hepatitis C.

2.  Controlling for age, sex, race, education, alcohol consumption, pack-years of cigarette smoking, and passive smoking, the risk of squamous cell carcinoma of the head and neck was increased with marijuana use.

For Onion Peelers (the boring statistics)
Risk of head and neck cancer was increased  [odds ratio (OR) comparing ever with never users, 2.6; 95% confidence interval (CI), 1.1– 6.6]. Dose-response relationships were observed for frequency of marijuana use/day (P for trend < 0.05) and years of marijuana use (P for trend < 0.05). These associations were stronger for subjects who were 55 years of age and younger (OR, 3.1; 95% CI, 1.0 –9.7).  These are large confidence intervals, but statistically a minor caveat.

The volume of research showing other adverse risks is legion, going back at least 50 years.  It's clear that marijuana has deleterious effects on the immune system, cancer development, respiratory illnesses, and brain function.  Not counting behavior, dude.

It would be irresponsible not to recognize that even for medical purposes, there are both benefits and risks.  These must be weighed in order to make a decision regarding public policy and law with regard to its use.  Blanket policies in the states allowing its use for specific diseases doesn't explore the entire realm of medical benefit, but ignoring the adverse impact when smoked isn't the right approach either.


Does Prevention Lower Health Care Costs? Depends On Perspective

Facetious question:  if I die very young, haven't I "prevented" high lifetime health care costs?

The President, his health care advisors, and other experts often point to the cost-controlling value of preventive care.  To make sense of that claim consider some examples.

First example:  I am a 60-year old diabetic and hypertensive, controlling my blood pressure and blood sugar is good for me personally by keeping me healthy, and lowers the risk of being hospitalized for care.  Hospital care is very expensive, so keeping me at home and going strong lowers cost.  I go on relatively healthy for another 20 years before dying of complications.  The last year of life requires a lot more care as my health fails.  For a guy who made it to 80, I've kept lifetime costs as low as they could be through prevention.

Second example:  roll back the clock 10 years.  I'm now 50 but don't yet have high blood pressure or diabetes.  I have a heart attack and die.  While my dying event may be expensive--or not--it still is less expensive than living another 30 years being monitored and followed regularly for multiple chronic illnesses.  On top of that is the cost of my eventual decline in the last year of life, as in the first example.  But overall, my life, in terms of medical costs, has been much less of a financial burden.

So, the cost-containing influence of prevention depends on the diseases, the phase of the life cycle, the acute versus chronic nature of the health care, and a lot of other factors.

It seems to me that the underlying difference is one of perspective:  am I looking at cost in a short-term or single disease-focused way, or am I looking at what it costs for a complete life?

You can construct these mind experiments in a lot of different ways, making the cost come out one way or the other.  But all of them, like the two above, can be realistic.

In summary: prevention MAY lower cost, but not always.  Prevention ALWAYS is good medical care.

Some Data On Medical Malpractice In The US

Another perspective on tort reform in medicine, from the textbook Legal Medicine (5e, 2007) , via Kevin MD.

I don't have a lot of original thoughts to offer on the following.  The last time I looked at medical liability data, about half of doctors were being sued at some point in their career.  But this is shocking.  Now I wonder how I managed to practice (and run hospitals) without getting sued--for over 30 years. 
"Nearly 77% of obstetrician/gynecologists have been sued at least once in their career and almost half have been sued three or more times. ...The public has responded by escalating the “punishment” associated with malpractice claims where multimillion-dollar jury awards are commonplace."
"Obstetric claims account for the majority of claims against obstetrician/gynecologists, forcing many to change their practice either by stopping obstetric practice altogether, reducing high-risk deliveries, or reducing total deliveries....childbirth cases are routinely listed among the top jury awards."
You have to be pretty cynical to think that most doctors make lethal mistakes on a regular basis.  That's not been my experience.  But I suspect that the public doesn't think so either:  they think that insurance companies can afford to pay for bad results, whether or not anyone is at fault.

My first reaction is, why would anyone want to become an obstetrician?  Give me a moment...OK, the real reason they do is because they love bringing new life into the world, despite the potential liability. 
Alternatively, you may think that they are so ravenous for high income that they will gamble their reputation and medical practice against the odds of squeaking by without lawsuits.    I don't think so.
Less severe, I've heard people say, "You make a good income, that's the price you pay."  I guess so.  But I can't help a smidgen of bitterness about dragging my tired ass in at all hours over decades for someone in need.
OK, I got it out of my system.

Saturday, April 24, 2010

Medical Quote Of The Day

Jean Martin Charcot is considered the father of modern neurology, and was the first to explore hypnosis and the diagnosis of hysteria.  Freud was a student of Charcot.  The image shows him demonstrating hypnosis.

[For extra credit, have you ever had a doctor scrape the bottom of your feet with the percussion hammer?  This elicits a reflex, which, if abnormal, is called Babinski's sign.  The guy holding up the woman in the picture is Joseph Babinski.]

In the quotation below, Charcot is using the word "nervous" in the old sense of a patient with a neurological or mental illness.
"In dealing with a nervous patient, you should regard the malady before you merely as an episode.  Thus, in a case of chorea, it is only necessary to inquire how long it has existed.  The condition of the patient is only an accident in the history of the disease, just as each of us is only an accident in the history of humanity."
--De l'expectation en medecine, Jean Martin Charcot [1825-1893]

The Hits Just Keep Coming: Poison Pills #14 and 15

The flow of bad news that didn't surface when reform was being pushed has now become a steady stream. 

From Kaiser Health News (Apr 23), "The federal agency that oversees Medicaid confirmed Thursday that some money states receive as rebates from drugmakers will now be redirected to the federal government to help pay for the new health overhaul."  This increases the bill to the states, and give DC more revenue to spend.

From the Associated Press (Apr 22), "A report for the state by Milliman, an actuarial consulting firm, found Indiana's Medicaid costs would increase $200 million through 2019 and go up by a total of $2.3 billion over the next 10 years."  This report is in line with what other states are reporting.

As expected, supporters and the Administration disagree.  Time will tell.


Rational Rationing: Tautology Or Oxymoron?

Don't you just love those high-falutin' words?  They're the last ones I'll use today.

Two days ago I wrote about the President's health care advisor, Dr. Ezekiel Emanuel, and his concept of how "allocation of scarce resources" (rationing?) could be accomplished.

I can never tell how interested readers are.  I taught this subject at the University of Maryland, so I feel pretty confident about it.

Other than "Zeke's" complete lives concept, there are a number of principled approaches to deciding "who gets the medical care" when there are resource limitations--whether they be stocks of a drug, number of specialists qualified to care for a particular malady, or the pot of money available.

The issue of distributing medical assets is a wider one than just how to respond in a crisis, or how to deal with an ever-expanding demand for health care.  In any system of supply and demand there are imbalances:  more is available in one geographic location than the demand could support, but in another location supply may be short.  These are questions that economists deal with daily, and I'm not an economist.  I'll focus on the ethical issues only.

My hope is that the next time you watch a disaster unfold, like the earthquake in Haiti, or the next time a public health threat arises, like the H1N1 virus and its vaccine, you will say, "I see, they are maximizing benefit, or helping the highest value people, or--worst case--they have no plan and are screwing it up."

Here's a quick list.  There are four main strategies:  (1) pick the worst off, (2) everybody gets an equal shot, (3) the greatest benefit to the greatest number, and (4) favoring people with the most value.

[If you think valuing some over others is un-American, consider the fact that doctors and nurses got the H1N1 first--each strategy has its place.]

There are technical names and definitions for each of these strategies, but the common sense description works best.  From here, you can break down each strategy into some subcategories.  For instance, under the "equal" treatment category do you give the resources to those who show up, or conduct a lottery?

Each strategy has moral implications for (1) what value we put on a human life, and (2) what we owe to one another.

That's enough for now.  Homework assignment?  (No way).   As you watch TV, not a day goes by that some situation doesn't arise where people need to make these allocation decisions.  See if you can identify the situation and what approach is being taken.  Given the huge flap over rationing and Death Panels in the health care reform debate, stuff like this will be "in your face" for some time.

More on this in later posts.


Friday, April 23, 2010

Medical Cartoonville


  When I was an ER doc, orthopedists were always telling me, "put it in a sling and have them see me in the office tormorrow."  They meant "arms," of course.


(Non-)Medical Quotes of the Day

OK, I want to break out of the medical mold today.  Here are a few more quotes and aphorisms I've collected over the years.

--The best argument against democracy is a five-minute conversation with the average voter.—Winston Churchill
--Men don't change. The only thing new in the world is the history you don't know.—Harry S. Truman
--The only thing that stops God from sending another flood is that the first one was useless.—Chamfort

And this one goes out to Tiger Woods,

--I regard golf as an expensive way of playing marbles.—G. K. Chesterton

Quackery Is Flourishing On Stem Cell Opportunities, Says CBS

CBS "60 Minutes" program shows that people are still vulnerable to high-tech flummery.

Watching the video on conmen who promise cures using stem cell techniques that don't exist was really sad.  The patients profiled suffer from amyotrophic lateral sclerosis, or ALS, commonly known as Lou Gehrig's disease.  The progressive paralytic condition has no known cure, patients suffer increasing lack of control and strength of all muscles in the body, and once diagnosed is universally lethal with an average life expectancy of 5 years.  See image for endstage disease.

Can you imagine how desperate you would become if given that prognosis?  It's no wonder that people are willing to fork over huge sums--in one of the highlighted cases, $125,000--for the promise of cure.  Under a death sentence  money makes no difference, and critical faculties can go out the window.

General rule:  if something sounds too good to be true, it is.  Watching Part 1 of the CBS video, put yourself in the place of the sufferer who is being assured of a "way out" of what he's been told is a death sentence.  How rational would you be under these circumstances?  The entire video is too long for most of us (13min), but you can skip the first few minutes while the narrator sets the stage. 

Then check out Part 2, where Lawrence Stowe, of Stowe Biotherapy, is confronted by the producers.  The sequence is a classic demonstration of psychopathic indifference.  Again too long (11min), but just watching part of it might help when the next conman approaches you.

I've seen patients turn from what medical science can offer when the treatment is painful, unpleasant, expensive, or misperceived.  It's incumbent upon doctors to know when their patients are torn by conflict, to work through their concerns and provide alternatives where necessary.  I would much rather try a less than perfect antibiotic that will do the job in most cases, and is cheaper, than have patients rely on Echinacea, or other herbs and enchantments.



What I'm Reading - Updated 3 May

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