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.

Wednesday, June 30, 2010

Medical Quote Of The Day - 30 June 10

"An apple a day makes 365 apples a year."


HCR Will "Create Savings" (Maryland) Or "Bankrupt The State" (Virginia)

Budget projections are like opinions, everyone's got one.  Wait...they ARE opinions.

An interesting article in the Washington Post (June 24) talks about how fuzzy the math will be in estimating the costs of health care reform (HCR).  Two states, Virginia and Maryland, make opposite predictions.  Virginia bemoans the large unfunded mandate that the law places on states, while Maryland trumpets the savings they expect from reform implementation.

The article goes on to explain why two adjacent states would have such widely different assessments.  Numbers are numbers, right?  But the article portrays the uncertainty among the assumptions both states make.

And it's not insignificant that politics plays a part:  Virginia is a Red State; and Maryland is among the Blue.

Given the government's history of controlling costs--that is, never doing so--would suggest that we listen more to Virginia, but that's just another assumption.

The best view is quoted in the article:
Darrell Gaskin, an associate professor of health economics at the University of Maryland, said the biggest unknown for states is that all of their models hinge on a larger question of whether the overhaul will succeed in bringing down the costs of care. "The real question is: Can everything together really bend that cost curve of care?" he said. "Without that, none of this will be sustainable."
My guess is that the reform will be re-formed to take out the toxic elements and minimize the damage, and we'll be left to cope with what's left, getting health care as best we can.

Doc D

What "Patient-Centered" Health Care Means...And Doesn't

The term "patient-centered" gets tossed around a lot, and sounds like an obviously good thing, but people who are promoting the concept can have radically different views of what it means.

Most people will read the words "patient-centered" and adopt a common sense definition:  the health care is there to benefit the patient...the patient, and their needs, are at the "center" of what gets done and how.

But take a look at one description of what Patient-Centered does:
Respect patients’ values, preferences and expressed needs. Coordinate and integrate care across boundaries of the system.  Provide the information, communication, and education that people need and want. Guarantee physical comfort, emotional support, and the involvement of family and friends.
All great-sounding words, but notice that the patient is not involved in directing how the health care comes about.  Behind the high-minded words is an agent that makes sure things are respected, coordinated, provided and guaranteed.  In a word, the government (or an insurer, government or private).

What would Patient-Centered care look like if the patient was not only at the center, but also directing the process?

Consider this definition of how to keep the patient at the hub of the health care wheel:
Consumers [patients] will work with their physicians and health care providers to create a better health care outcome for themselves and their families.  Health care usage is more cost efficient with empowered and knowledgeable consumers who use information tools.  Price and quality transparency about health care professionals is a key method for effective consumer health care choices.

Also great-sounding words.  But... although both definitions keep the patient as the focus, the difference is who's in charge?    The former is plan-directed and patient-centered.  The latter is patient-directed and patient-centered.

Plan-directed care, as exemplified by Medicare and the new government-regulated health care exchanges, will make some decisions for you, in your best interest, as they best see it.  Patient-directed care puts you in the driver seat, preserving freedom to choose, but--and make no mistake--the patient incurs responsibility along with the freedom.  You get to decide, but you take responsibility for your decisions.  All the stuff in the first system, you do yourself:  get the information, compare cost and quality, make a judgment about your unique needs.

Each approach has its own kitbag of tools, and there are examples to illustrate how they work.

The former, plan-directed care is how the Obama Administration and Congress saw health care improvement.  The President's nominee to run Medicare and Medicaid is Dr. Donald Berwick, who is CEO of the Institute for Healthcare Improvement.  The first quotation above is from IHI, and encapsulates how he sees a high-quality, cost-effective system should run.  He also loves the British National Health Service, which in my opinion, is a disaster.  Their tools are comparative effectiveness, price controls, government-regulated health plans, denial of payment for complications, incentivizing primary care payment, etc.

The latter, patient-directed care, can be implemented in different ways.  The two most prominent are HSA's and HRA's.  The second of these, Health Reimbursement Accounts, are employer-funded plans that reimburse employees for incurred medical expenses that are not covered by the company's standard insurance plan. Because the employer funds the plan, any distributions (money the employee gets to keep) are considered tax deductible (to the employer). Reimbursement dollars received by the employee are generally tax free.

Put simply, HRA's have an insurance plan that covers high-cost care, and prevention vists.  For routine and acute care, the employer gives the employee a bag of money and says, "go find the best and most cost-effective care; if you don't spend it all, you get to keep the rest."

This incentivizes people to take the time to judge who's the best doctor, and what's the best price.  All this information is available online (as I've written before here).  Critics of HSA's and HRA's have said people will not seek care when they need it.  This has been disproven; actually they seek care ONLY when they really need it, unlike plan-directed care.*  Other critics have claimed the employer can decide not to fund the employee's account.  This has also not occurred.  In fact, the savings the employer incurs from having employee's make good choices have been so substantial it saves money overall for the company, even while rewarding good decisions by employees.

The state of Indiana is reaping the benefit of patient-directed care.  Enrollment is voluntary, but has grown rapidly to 70% of state employees.  Unused funds in the account, about $30M, are the property of the workers.  The state expects to save about $20M this year (an 11% reduction), and premiums are about half of what employees pay in traditional plans.

The bad news:  Provisions in ObamaCare regulate what health plans must cover, and may force these patient-controlled, cost-savings plans to disappear.

Quelle horreur!

Doc D
*As one academic put it, supporters of HRA's "believe, as do a fair number of health economists, that people use too much health care, and use too much health care of little value...[with HRA's] people will think twice. If I have a sore throat, instead of going to my physician, I'll have a cup of tea instead."

Tuesday, June 29, 2010

Medical Quote Of The Day - 29 June 10

"Doctors record patient’s medical history without paying much attention to the patient. But we must never forget that the look on the patient’s face, the tremble in his hands, the falter in his speech, the dreams he has, the drawings he makes, are all potential signs (windows ) of what really troubles him."

--Sir William Osler [1849 - 1919]

Cholesterol-Lowering Drugs And Prostate Cancer Study: Read The Fine Print.

OK, I ate peanuts because they said it would help my, I don't know.  Should I take statins now?

There is press interest in a new study appearing in the journal Cancer (June 28) about cholesterol drugs helping prostate cancer patients.

The headline, "Study: Statins May Protect Prostate Cancer Patients," is classic for not telling the full story.

Many of you may not care about prostate cancer unless you're an older male, or have the disease, or a loved one with it (or just like learning new stuff), but this post is not about treatment of prostatic cancer.   It's about how the press portrays medical advances, a Nostrums specialty.  It reinforces the message that you have to take the time to read beyond the media's superficial assessment.

The research looked at ~1200 men who underwent radical prostatectomy and assessed their PSA test (prostate-specific antigen) level, comparing those test results between two groups: men who were taking a cholesterol drug (a "statin" called simvastatin) and those who weren't.  Take a look at the actual results of the study, keeping in mind the media article title above.

For Onion Peelers (skip, you can come back if you don't like my take on it)
In total, 236 (18%) men were taking statins. Statin users were diagnosed at lower clinical stages (P = .009) and with lower PSA levels (P = .04). However, statin users tended to have higher biopsy Gleason scores (P = .002). ...statin use was associated with a 30% lower risk of PSA recurrence (hazard ratio HR, 0.70; 95% confidence interval CI, 0.50-0.97; P = .03), which was dose dependent (relative to no statin use; dose equivalentsimvastatin 20 mg: HR, 0.50; 95% CI, 0.27-0.93; P = .03).

A lot of gobbledygook.  Translated into English,
1.  The study deals with only one approach to prostate cancer:  radical prostatectomy.  It says nothing about any other way of dealing with this disease.
2.  Guys on statins got diagnosed earlier, but when the tissue was examined they had more aggressive forms of the cancer (a higher Gleason score means worse cancer).  So maybe the statin just "covered up" the cancer, or even made it more aggressive...who knows?
3.  The study looks at the PSA test (prostate-specific antigen) as a measure of disease activity.  While high PSA correlates with occurrence (or recurrence) of disease, it's not a diagnostic test, it's a screening test.
4.  To see the effect of statins the men had to be on 20 mg per day or more.  Some people take less than this for various reasons, and they didn't experience any benefit.  Even with 20 mg, the data was right at the point where statistical significance appears...i.e., not a knock-down result.

Bottom line...there are a lot of questions to answer here.  Do statins protect prostate cancer patients, as WebMD's journalists indicate?

Not enough info.

Doc D

Doctors Get Sick, Too - My Appendicitis Story

For thirty years, I managed to catch everything patients came to see me about.  Or so it seemed.  But appendicitis isn't contagious.

This is a lesson in how to make poor health care decisions.  You'd think that after all those years of education, I would know better, but one of the things they drummed into our heads is, "Never treat yourself or your family," because it's impossible to be objective...or, as objective as you need to be.

We'll get to that, but the most interesting part of all this was to watch and observe myself in all this.  It sounds weird, and I'm not saying it was an "out-of-body" experience, just that there was a part of my mind that was watching this unfold, and fascinated by the whole thing.

The saga began one evening, before bedtime.  Patients over the years have described the onset of serious illness as if there was a perception that "something" was happening or about to happen.  They say that they "ate something wrong", or "didn't feel quite right" or "worked out too hard" etc.  I think their perceptions are just a "hindsight" phenomenon:  we look to find reasons and portents for things, even when there aren't any.  Not for me.  There was almost a sudden onset of right-sided abdominal pain.  Not stabbing, just an ache that was not there one second, and there the next.

Side note:  I was 52 years old.  Most people who get appendicitis are in their 2d or 3d decade.  That's true, BUT, there is a blip in the curve in the 50's, where there's an increased risk.

It wasn't severe, and at first I thought little of it.  But it persisted, and got somewhat worse.  In an hour or two it became tender to push deeply over it. 

Side note 2:   the pain of appendicitis is not very specific--in the beginning.  Usually patients will describe a diffuse abdominal pain, and there may or may not be tenderness.  At first, it may be indistinguishable from your basic intestinal "flu"  (there's technically no such thing, that's just what everybody calls it, or "the crud", etc).  But not always.

But, I had a nagging suspicion that something wasn't typical.  I've had cruise-ship virus, stomach flu, gastritis, etc. multiple times over the years (thanks to those patients I matter how often you wash your hands, it's gonna get ya, eventually).  I've had 'em all, and this didn't feel like any of that.  It wasn't a colicky pain (rising and falling, like cramps--caused by stones, kidney or gall bladder).  It was steady.

So, here I am, its 10PM, and I think this may progress.  I'm already thinking "appendix."

Side note 3:  Many will experience nausea and vomiting...and a low grade fever.  But not always.  And not me.

It's decision time.  Go to the ER, or wait.   I knew the local ER, and expected that, at this time of night, I would be among a dozen belly pain patients who would wait for some hours while all the gunshot wounds, auto accidents, and heart attacks slowed down the care for the less urgent.   The place would clear out about 3 or 4 in the morning, and the staff would start going through the other patients waiting.

So, hurt there, or hurt here.  That was the choice.  I was getting more sure that this was appendicitis, but (in my arrogance) I knew it would take at least 12 hours to get really "hot."   And until that time, the chance of rupture was small.  If rupture occurred it would be bad, bad, bad...

So, I got the heating pad and some acetaminophen, and went to bed.  It was not a restful night, but bearable.

By early morning, the situation seemed clear.  I had point tenderness in the right lower quadrant with rebound (where it hurts more when you let go, than when you press in on the abdomen...a sign that inflammation has spread to the lining of the belly.)

So, I approached my spouse and said, "I have appendicitis and need to go to the ER."  After several minutes of "You dumbass", and "why didn't you tell me" etc, and so forth, it was time to go.  I checked my diagnosis by consulting a friend and he agreed. 

At the ER I had timed things perfectly:  a weekend morning when the place was empty...and before the weekend rash of miscellaneous stuff began to pour in.  It took 2 minutes to be taken to an examining room.  The surgery resident asked where it hurt and I pointed with one finger to McBurney's point.  He said, "Well, that's pretty specific."  (McBurney's is the focal point for pain when an appendix is fully hot...but not always.)

Side note 4:  Nobody likes to wait.  Years of ER duty had taught me how the ebb-and-flow of care worked.

From there, things happened fast.  Pre-op sedation 30 minutes later.  Next thing I know I'm in up on the floor, and the nurses are poking me, saying, "breath deeper."  Apparently the docs got a little heavy with the narcs, and my blood oxygen saturation would drop every time I nodded off.  But that wore off in a few hours.

Next day I was eating and went home.  Total hospital time 24 hours.  Fast, huh?   Here's the explanation:  I had my appendix taken out through a small incision in the belly button with a fiberoptic scope.  That way you don't upset the rest of the GI tract, which tends to shut down for a few days if you mess with it.

I had a wound infection several days later, but that was no biggie.  Things went well and I was eating and up and around almost immediately.  The surgeon told me later that I timed it narrowly; when he got the appendix out it was about to rupture.


1.  Appendicitis is still one of the most difficult diagnoses to make.  Scans have made it easier, but all the rest, the symptoms and signs, can fool you big time (gall bladder, kidney stone, flu bug...a long list).  Note how many times I said, "But not always," above.
2.  There's a time when making your own decision about seeking care is reasonable.  There's a time when you need to give up control and seek help (as I failed to do...a couple of more hours and "pop" goes the appendix).  I've seen too many heart attack victims (usually me) who had been having warning pains for weeks.
3.  Many operations that used to require major incisions and long hospital stays are now done with minimally invasive techniques and recovery is much quicker.  The sooner you are up and around the less likely there will be complications.

So, did I learn my lesson?  Probably not, I'm still the same person.  And the story played out again last year when I needed back surgery:  I waited until I was absolutely sure there were no other alternatives and it was the right thing to do.

I am convinced our bodies are marvelously designed to do the job, and you shouldn't mess with it unless absolutely necessary.  I always undergo conservative therapy first, I get second opinions, I research the medical literature and learn the latest on my condition.

And so can you.

Doc D

Monday, June 28, 2010

Multiple Choice Question: Highest Dutch STD Rate? 1. Gay, 2. Young, 3. Swingers, 4. Prostitutes

Apparently, over-45 folks think they're less likely to get STD's, so swingers are showing up with more disease. 

But then they're Dutch, the hedonistic sheep of the world.

Via the BBC News (24 June)
"In this study, the team from the South Limburg Public Health Service studied patients seeking treatment during 2007 and 2008 at sexual health clinics serving a population of 630,000.  Combined rates of chlamydia and gonorrhoea were just over 10% among straight people, 14% among gay men, just under 5% in female prostitutes, and 10.4% among swingers.  Female swingers had higher infection rates than male swingers.  More than half (55%) of all diagnoses in the over 45s were made in swingers, [emphasis mine] compared with around a third (31%) in gay men."
If abstinence or monogamy are de trop, then condoms, condoms, condoms...

Doc D

Medical Quote Of The Day - 28 June 10

"Despite all our toil and progress, the art of medicine still falls somewhere between trout casting and spook writing."

--Ben Hecht [1894 - 1964]

Health Care Quality: How Experts Analyze It V. How Patients Experience It

[I'm back from my daughter's wedding, and back in the saddle.  A great celebration, and exhausting.  Sorry for the minimal output yesterday]

More expensive placebo's work better than less expensive ones.

...Says a study in the Journal of the AMA (March 5, 2008), resurrected at The Healthcare Economist blog.

This is the difference between what objective quality measures tell us about health care and how patients experience health care.

The Dartmouth Atlas controversy is a case in point.  For those who aren't academics, the so-called Atlas is a large scale effort that attempts to relate cost to health care outcomes.  The White House used the Dartmouth work in its assumptions about what type of health care reform to pursue.

In this JAMA study, 82 paid volunteers were enrolled to evaluate whether the cost of a placebo pain-killer drug had an impact on "how well" the subject's pain was controlled.  One group of subjects were told the pill costs $2.50 per pill, the other $0.10 per pill.  The subjects were given electric shocks, asked to estimate the pain level, then took their pill and after a suitable period the shocks and estimates were repeated.

Results:  Better pain reduction from the "higher-cost" placebo.

For Onion Peelers,
In the higher price group, 85.4% (95% confidence interval [CI], 74.6%-96.2%) of the participants experienced a mean pain reduction after taking the pill, vs 61.0% (95% CI, 46.1%-75.9%) in the low-price (discounted) group (P = .02).

The research literature is filled with examples of how patients (and doctors and nurses) "perceive" the outcome of care in ways that are at odds with the actual outcome.

This should be a caution to researchers who design studies based on their own assessment of what's the best result.

Doc D

Good News For Vaccine-Deniers -- More Non-Issues To Proclaim

Vaccines for children are critically necessary.  Find out how to deflate the Deniers panic attack.

California is already experiencing an outbreak of pertussis from non-immune susceptibles passing it around.  While not the scourge it once was, it still kills kids sometimes.

Readers of Nostrums know that I shake my head every time the Irrational Voice of Vaccine Critics raises its head.  (See here, here, and here)  They'll try to make hay from the latest study which the says that giving chicken pox vaccine and MMR in a combined shot together minimally increases the risk of a febrile seizure.

Lest you think something is going on about the vaccines here, it's important to understand that being vulnerable to a febrile seizure (a benign occurrence when a child's temperature rises very rapidly) is a common feature in children:  a little less than 1 in 10 can, under the right circumstances, have a fit.

As an ER doc, my main job under these circumstances was to rule out other causes of the seizure (i.e., not just assume it was due to the fever), and then spend a lot of time with freaked out parents who needed to understand how this comes about.

Those children who are vulnerable can get a seizure from fever of any kind:  a cold, sore throat, etc.  It's not the vaccine itself, just the immune reaction caused by the shot (which is what you want to happen) that ends up making them immune to the disease.  Along the way many kids will get a fever which is in almost all cases minor.  The risk of seizure overall is about 1 in a thousand.

Also, kids who are vulnerable to febrile seizures grow out of it.

Want to deflate panic attacks by the Vaccine Weirdo's?  I bet they will fail to notice a crucial fact from this study.  Point out that the study only addresses a COMBINATION vaccine (see above).  If you give MMR, then chicken pox, in the same visit, one after the other, the febrile seizure risk is not increased. 

So, there...

Doc D

Will The Rain Of Bad News From HCR Ever Stop?

Health Care Reform Is Likely To Widen Federal Budget Deficits, Not Reduce Them

A new analysis appearing in the prestigious journal Health Affairs looks at the projection of cost in the health care reform law that was passed in March.  The authors, former Congressional budget analyists, give a sobering summary of the chicanery that allowed the law's supporters to argue that it would be cost-neutral or deficit-reducing:
"We examine the underpinnings of the CBO’s projection and conclude that it is built on a shaky foundation of omitted costs, premiums shifted from other entitlements, and politically dubious spending cuts and revenue increases. A more comprehensive and realistic projection suggests that the new reform law will raise the deficit by more than $500 billion during the first ten years and by nearly $1.5 trillion in the following decade."
I've lost count of the Poison Pills in the law, so I won't bother to number this one.  As with all "political" estimates of cost the truth never is as low as predicted initially in order to get support for the legislation.

Doc D

Sunday, June 27, 2010

Medical Quote Of The Day - 27 June 10

"The fact that your patient gets well does not prove that your diagnosis was correct."

--Samuel J. Meltzer [1851 - 1920]

Saturday, June 26, 2010

Health Care Reform In Action: Brits Say No To Liver Cancer Drug

Rationing in action:  Great Britain decides the new (and only) liver cancer drug is too expensive to offer to cancer patients.

For Americans who wonder how "scientific" decisions will be made about what treatment choices are considered effective, please go here for the rationale.  I've written before about comparative effectivenesss on multiple occasions (the US term for deciding what works best, based on the views of experts, convened by the government.)  Go here, here, and here for my concerns about how this process will be implemented in the US.

In Britain, the cost-effectiveness organization is the National Institute for Health and Clinical Excellence (NICE).  Supporters of comparative effectiveness in the US insist that the goal is merely to provide expert opinion, and not meant to drive insurance coverage decisions, emphasizing, from the name "comparative effectiveness," that this is all just a comparison and focusing on what works.   However, notice that the title "NICE" says the same, but the Brits are honest enough to admit that it's an organization that makes "monetary cost" versus "value of human life" decisions...and their decisions become government policy.

Here's how that works.  The new drug is expensive, about $5,000 per month.  The average survival from using the drug extends life by, on average, 2.8 months.    Put another way, it would cost the British government $59 a day to pay for that treatment--on average.

I keep saying "on average" because that's part of the flaw in this thinking, and perfectly illustrates my objection to all this.  First, read the official British announcement:
NICE has been unable to recommend sorafenib (Nexavar, Bayer) for treating advanced hepatocellular carcinoma (HCC) because its high cost could not be justified by its marginal benefit.

HCC is a cancer that originates in the liver, not as the result of tumours spreading to the liver from other parts of the body. The only potentially curative treatment for HCC is surgery, but only a small proportion of patients will be eligible for this. Normal life expectancy for these patients is less than 24 months. The trial evidence seen by NICE’s independent advisory committee showed that sorafenib increases survival by an average further 2.8 months, but at a cost of £27,000 per patient. Half of the patients who gained some benefit received less than this amount of additional life.
Three flaws here, two technical and one philosophical:
First flaw:  NICE disingenuously says that "half the patients" who benefit would receive "less than this amount of additional life" (2.8mo).  They fail to give the benefit to the "other" half, who would live some cases a year, maybe?  More?  But since their life is being judged as equivalent to that of the calculated "average" response, those patients who would live considerably longer must suffer the same fate as all--no treatment offered.  And we don't know which ones those potential longer-survivors are.

Second flaw:  Imagine yourself one of these cancer patients.  Surgery is the only cure; if that doesn't work, your alternative is...nothing...because the new denied drug is the only one that's been developed that works at all in liver cancer.  Imagine further that you are one of those patients who would have lived a lot longer from use of the drug.  How does it feel?

And that leads to the third, philosophical  flaw:  analyses like this take human lives and turn them into data, a statistic to be analyzed and manipulated in order to place a "scientific" limit on the cost society should be willing to pay to let you stay alive.  This turns precious human life into an object, like a car, or a refrigerator...

Au contraire, persons should rightly be ends in themselves, not means to an end (cost-control).

Doc D

Medical Quote Of The Day - 26 June 10

"Don’t think of organ donations as giving up part of yourself to keep a total stranger alive. It’s really a total stranger giving up almost all of themselves to keep part of you alive."

--Author Unknown

Adolf Hitler Alive And Well At The Beautiful Babies Sperm-And-Egg Bank

A new twist on Improving The Species.  Instead of ovens, limit the germ cells to the select few.

I'm not kidding.  These morons are actually pursuing eugenics, 1930's style, using modern genetic knowledge, to produce beautiful babies.  See BeautifulPeople.comCBS News reports on the site's initiative to allow the beautiful people to search for genetic material from beautiful people.  According to Managing Director Greg Hodge,
"There are no financial benefits for us in doing so — we are simply responding to a demand for attractive donors. Every parent would like their child to be blessed with many fine attributes, attractiveness being one of the most sought after. For a site with members who resemble Brad Pitt, George Clooney and Angelina Jolie you can imagine the demand."
It's the "place to be" for folks who want that beautiful baby, where members rate applicants on their attractiveness, and you have to be voted into membership.  AND, where you can be expelled if you don't "keep up appearances." (“Letting fatties roam the site is a direct threat to our business model and the very concept for which was founded.” said founder Robert Hintze.)

With a beneficence bordering on the extra-planetary, the founder described their generous decision to open the doors to ugly people.
“Initially, we hesitated to widen the offering to non-beautiful people,” site founder Robert Hintze told the Vancouver Sun. “But everyone – including ugly people – would like to bring good-looking children into the world, and we can’t be selfish with our attractive gene pool.”
Such magnanimity is beyond my power to express.

May they all shrivel up and blow away, along with all the ash from the Nazi ovens.

Doc D
 [PS:  The idea doesn't work.  The gene pool is too complex, and, combined with the random recombination, you can't predict the result.  Another anti-scientific fad.]

Medical Latin...A Lost Art, Thank Goodness

When I went to medical school, we still used some of the abbreviations that orignated from Latin phrases.

Most people know PRN (as needed) and NPO (nothing by mouth).

But how about these?

Cras mane sumdendus - to be taken tomorrow morning.  [delay a day?  when do you do that?]

Deglutiatur - let it be swallowed.  [instead of what?]

Divide in partes aequales - divide into equal parts.  [break in two?]

Dosi pendententim crescente  - increase the dose gradually [kinda vague,huh?]

Extende super alutam mollem - spread it on soft leather [Huh?}

Femoribus internis - to the inner part of the thighs [Not me, buddy.]

Horae unius spatio - at the expiration of one hour [I can't think of a single bloody reason for this]

Manipulus - a handful [does anybody know how much that is?  how big a hand do you have?]

Permittentibus viribus - the strength permitting [your strength better be permitting or you're not getting well]

Quantum sufficit - as much as suffices [well, how do we tell that?]

Ubi pus, ibi evacua - where there is pus, evacuate it.  [well...yeah]

Most agree that all this Latin garbage was used to make medicine sound mysterious and beyond the normal person's ability to understand.  I agree, it's all BS.

Doc D
PS:  I'll write a post soon on medical eponyms which I love, like McBurney's point, and Wernicke-Korsakoff syndrome.

Friday, June 25, 2010

Long-Term Care Costs In ObamaCare Kill the HCR Golden Goose (The States)

HCR's costs for Medicaid long-term care (LTC) could cause collapse of states' budgets.

A new study, described by Blaire Brody at The Fiscal Times (June 23), via Health Reform Hub outlines the best- and worse-case scenarios for the states under the LTC provisions of ObamaCare.

Best case:  Medicaid costs double (by 2030) as a percentage of state budgets.
Worst case:  Costs triple, accounting for 35% of a state's entire operating budget, 50% in one case.

The perfect storm.  How are we going to pay for all this?

Doc D

Medical Cartoonville - 25 June 10



Medical Quote Of The Day - 25 June 10

"The field of Western medicine has become literally nothing but medicine. Doctors are on their way out, to be replaced by self-serve pharmaceutical vending machines."

--Grey Livingston (?)

The Latest On Cell Phone And Cancer: It's Protective, No It Isn't, Yes it is....

It's never made sense from the point of view of radiation physics that cell  phones would cause cancer, but they prevent cancer?

Preventing cancer is just as biologically implausible.

PART 1:  A new study prublished in the  International Journal of Epidemiology (as reported by the WSJ  Blog, May 29) looked at cell phone use across 13 countries in adults 30-59 years old who had been diagnosed with one of two types of brain cancer:  glioma or meningioma.

[Forget the jargon.  Brain cancer isn't common as a type of cancer, but among tumors of the brain, these are the more common ones.  The first is usually bad, the second can be relatively benign, sometimes.]

This group was compared to matched controls. 

The result?  Cell phone use protected against these tumors. 


OK, there are some problems with the research.  The control group tended to be more frequent users than those who declined to participate.  That can blur any finding of increased risk (...but decreased risk?).

Second, even though at the very highest level of cell phone use there was an increased risk of tumor, the trend from low use to high use wasn't dose-related.  If cell phone radiation is causing tumors, then the more exposure the more tumors.  But that didn't happen.

PART 2:  A study published in the British Medical Journal (June 2), found no correlation between cell phone towers and childhood cancers.  The authors looked at 1397 cases of cancer in children and 5588 controls, then looked at how far they lived from cell phone towers and calculated the exposure from the power generated by each of those towers.  Result: no effect.

For Onion Peelers, (boring statistics...skip it)
For radiation exposure at the address at birth, they divided results into three categories--low, medium, and high exposure.  Compared with the lowest exposure category the adjusted odds ratios were 1.01 (95% confidence interval 0.87 to 1.18) in the intermediate and 1.02 (0.88 to 1.20) in the highest exposure category for all cancers (P=0.79 for trend), 0.97 (0.69 to 1.37) and 0.76 (0.51 to 1.12), respectively, for brain and central nervous system cancers (P=0.33 for trend), and 1.16 (0.90 to 1.48) and 1.03 (0.79 to 1.34) for leukaemia and non-Hodgkin’s lymphoma (P=0.51 for trend).

So none of these odds ratios are significantly different from 1.0, that is, no increased odds of cancer.  And the p-values were all way above the threshold of 0.05 needed to show a difference.

The bottom line is we're gonna have to keep working at this, but it's clearly a setback for the Precious Bodily Fluids crowd.

Doc D

Health Insurance Premiums Accelerate Under ObamaCare Lite in Massachusetts

A new study shows that ObamaCare Lite in MA raised premiums by 6% more than the increases nationwide.

A study out of Stanford University published in the Forum for Health Economics and Policy  looked at national employer-sponsored insurance data to see what effect health care reform in Massachusetts had, over and above the trend in the rest of the nation, on health insurance premiums.
"We find that health reform in Massachusetts increased single-coverage employer-sponsored insurance premiums by about 6 percent, or $262. Although our research design has important limitations, it does suggest that policy makers should be concerned about the consequences of health reform for the cost of private insurance." [emphasis mine]
Massachusetts reform has been touted as the analogue of the nation's new reform law.

Note that we're not talking about a 6% increase in premiums.  We're talking about an increase of 6% ABOVE what the increase was elsewhere (without reform).

You said we had to pass this law to learn what's in it, Ms Pelosi.  And we're learnin', we're learnin'....

Doc D

Thursday, June 24, 2010

Medical Quote Of The Day - 24 June 10

"When you are called to a sick man, be sure you know what the matter is – if you do not know, nature can do a great deal better than you can guess."

--Nicholas de Belleville

Take Two Pets, And Call Me In The Morning

The all-purpose pet.
A new piece in the New York Times Well blog talks about how pets are good for our health, and can help keep us well. They invite readers to send in their videos of pets performing their health-promoting activities.

Remember Steve Martin's routine on the shame of Cat Juggling?  Now it can come out of the the closet.  Cat Juggling can take it's rightful place in the therapeutic armamentarium of the species.

I look forward to prescribing pets for my patients:  Take 1 by leash every 4 hours as needed for nirvana.

I have another suggestion:  watching pets breed.  What could be more healthy for us, when they won't let you watch porn at work any more?

Doc D

ObamaCare Regulations Drive Up Premiums, Dems Try To Mitigate By Threatening Insurers

[Things will be touch-and-go for the next three days.  I'm away at my daughter's wedding]

The Obama administration has been issuing new regulations for ObamaCare as fast as they can. 

The President's supporters are between a rock and a hard place in their efforts to turn around negative opinion about the new health care legislation.  The strategy is to offer as many new features as possible, increasing costs, and leading to higher premiums in the short run.  But the main provisions for coverage under the new law don't begin until 2014.
The administration recognizes that rising premiums may force many people to drop insurance plans before the new coverage picks up.

According to an AP story (June 21),
"The law's consumer safeguards, called the patients' bill of rights, are limited steps that take effect this year. The main provisions, including federal funding to help 32 million uninsured people get coverage, won't come until 2014. The administration worries that escalating premiums will force more people drop their policies before the law is fully implemented.  Consumers who buy their policies directly face increases averaging 20 percent this year, according to a survey released Monday by the private Kaiser Family Foundation."
Hence the President has met with health insurance executives in an attempt to threaten them about "jacking up" premiums.  If the politicos can intimidate insurance plans into more modest increases as health care costs rise, then there will be less outcry as the insured are forced out by higher premiums.

Health care costs are expected to rise by 9% next year.  Insurers will want to avoid losses by meeting that cost increase with increased premiums.  However, recall that the "grandfather" provisions of the new law do not allow an insurer to increase by more than 5% in order to continue to offer a policy (including the one you have and like).

Once again we're back to the false promise that you can keep your insurance plan.  No you can't; Congress and the President engaged in an intentional effort to straight-jacket plans into unsustainable status-quo's that the companies can't meet and still stay in business.

No matter what Speaker Pelosi says about legislative "moral issues,"  all of this is really about damage control prior to a mid-term election that bodes ill for the party that passed an unpopular and unwanted bill.
Doc D

Wednesday, June 23, 2010

Medical Quote Of The Day - 23 June 2010

"I am very abnormal… But it wasn’t very long ago that I wasn’t so abnormal. I was very normal and headed for a lifetime of paying medical bills as proof of my normalcy."

--actor Dirk Benedict [ b. 1945 - ]

Another Wasted Effort: Suing McDonald's Over Happy Meal Toys

The Center for Science in the Public Interest needs to get a life.  Suing McDonald's over Happy Meal toys is a worthless pursuit.

LA Times Booster Shots (June 22) quotes a CSPI statement that
"Using toys to lure small children into McDonald’s is unfair and deceptive marketing and is illegal under various state consumer protection laws. CSPI today served McDonald’s a notice of its intent to sue."
You can see my post here on why this is a waste:
"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. "
Nanny state experts on the move, making the nation safe from french fries.

Doc D

Commonwealth Fund Blasts US Health Care: Helpful, But Subject To Criticism

US comes in last on Commonwealth Fund study of seven countries' health care systems.

There are some good points for the US system, but not many.  You can go here to see an interactive chart of the comparison criteria.

If you examine the study, ask yourself whether the comparisons are valid.  It's not easy to know for sure.

I've written more than once on how the longevity data misinforms as a measure of long and healthy lives:  when you take out death by violence and auto accidents (which are not issues of health care infrastructure or policy), the US moves from 31st to the top in one famous study.  See my post on's analysis here.  FactCheck agrees, but says the violence and auto data should be left in (presumably because it keeps the results where they would like them to be; i.e., the US does poorly).

The same thing applies to data on prematurity and infant mortality, a common comparison made between the US and other countries that shows the US to be lagging behind.  In that instance, several countries do not count certain births as "live" if less than a certain weight, or date of birth, or length--despite the fact that the newborn is breathing and moving.  A couple of countries make no effort to resuscitate the severely premature, and others don't count a living neonate as a live birth until they reach the age at which they would have been born if they reached full term. This allows them to not count those newborns in their mortality data if they don't survive.  This skews prematurity and mortality data in favor of those other countries.  See my post on this.

Quality data can also be misleading because it measures performance on a statistical basis, but says nothing about how individual patients experience their care.  For instance, low infection rates on hip replacements don't tell the story if many people are waiting up to a year to get it done, suffering pain and disability every day.

It's going to take me a week or more to go through all of this report to find out how evenly the authors applied the criteria between the countries' health care systems.  So, more on this later.

But for now, consider just one criterion.  As a hospital CEO, I was always being evaluated on how good my access and quality were.  As you might imagine, budget reviews--whether I was staying on target--were continual.  So I've seen every one of these criteria before, andI  know how people who worked for me, and other hospitals, tried to wicker the data to show they were doing better than they really were.
So, as I say, take one criterion as an example: 
"Percent of primary care practices who report almost all patients who request same- or next-day appointments can get one."
1.  The first dodge is to jinky around when the "day" clock starts.  Is it when the patient first calls, or when you call them back, or does the clock begin at the next business day and run until the second morning  (the Post Office, UPS, and FEDEX all play around with this in claiming 2-day service)?
2.  Is the data on appointing available for review centrally, or is the practice providing the data?  If the latter, this gives them a way to judge whether something meets the criteria (remember our "jobs created or saved database", with the examples of created jobs where current employees just got a raise, but it was reported as new jobs?)
3.  What if someone wants a same-day appointment and you arrange it somewhere else, or through the emergency room, so the data shows they WERE seen same-day (just elsewhere)?
4.  What type of appointments do you have?  Are a lot of people being funneled into 5-minute "refill" appointments so you can crank out the demand, even if some of them would have been better served by a real appointment?
5.  If a same-day appointment is available, but the patient doesn't accept it (they have a conflict, say), does that go into the "criterion not met" category?

The list goes on and on, and given the state of data collection world-wide, I doubt that many of these criteria are fully explored by the Commonwealth Fund's study.  When I was looking into the infant mortality claims, I found that in Canada birth registration data is missing for tens of thousands of births.  I'll hold fire for now.

Caveat:  We have a long way to go in this country to improve access, cost, and quality.  But advocacy group studies need to be examined carefully.  That's what Nostrums is all about:  to peel away the surface of articles and studies that are meant to persuade us.

Doc D

Tuesday, June 22, 2010

Medical Quote Of The Day - 22 June 10

"The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated. "
--Plato [ 427 - 347 BC]

Paternalism In Medicine: Taking Away Your Ability To Choose

Why do reformers talk about Patient-Choice, then form agencies to direct that choice?
I read an article that encapsulates a lot of what you read on Nostrums.  Readers know that I think medical care should be a choice that patients make in concert with their physician.  I'm suspicious of any government organizations that exist to funnel that choice into areas convenient for the government's intentions.

I'm derisive of nutritional laws that take toys from Happy Meals, and ban fast food restaurants in city districts that have few alternatives for dining, and dismissive of calorie labeling that has no impact on food choice.

While I think medical science should continue to define clinical guidelines for the best treatment in any given disease, I insist that each patient is unique and likely to need care that doesn't follow a formula.  Particularly one developed by a bureaucracy charged with "effectiveness"  (as in "comparative effectiveness").

So it was a pleasure to read the following paragraph from an article by Kenneth Minogue in the The New Criterion (June 2010).  Minogue is a political theorist and Emeritus Professor of Political Science at the London School of Economics.
"...while democracy means a government accountable to the electorate, our rulers now make us accountable to them. Most Western governments hate me smoking, or eating the wrong kind of food, or hunting foxes, or drinking too much, and these are merely the surface disapprovals, the ones that provoke legislation or public campaigns. We also borrow too much money for our personal pleasures, and many of us are very bad parents. Ministers of state have been known to instruct us in elementary matters, such as the importance of reading stories to our children. Again, many of us have unsound views about people of other races, cultures, or religions, and the distribution of our friends does not always correspond, as governments think that it ought, to the cultural diversity of our society. We must face up to the grim fact that the rulers we elect are losing patience with us."
"Our rulers are theoretically “our” representatives, but they are busy turning us into the instruments of the projects they keep dreaming up. The business of governments, one might think, is to supply the framework of law within which we may pursue happiness on our own account. Instead, we are constantly being summoned to reform ourselves."
Doesn't make me a libertarian.  I elect representatives to build that framework of law, not tell me what to choose.

Doc D

Heroin Cheaper Than Cigarettes In NY City

Great Incentive to stop smoking:  City raises taxes on cigarettes--cost per pack now almost $11.00

Courtesy of the WSJ Health blog (June 18)

But will it bring about any other incentive?  Some have noted that tobacco patrons with $11 to spend can now buy "other" things--cheaper.  Let's hope not.  I hate cigarettes and wish I had grown up in a world without tobacco.  But I know that human nature doesn't change.  If cigarettes aren't around, what shape will our need for addiction and dependency take in its place?

Whatever theory you subscribe to about how people come to adopt harmful habits--peer pressure, physiological effects--attacking each harmful activity directly doesn't deal with why humans are motivated to engage in them.

Whether it's fatty foods, sugar, tobacco, drugs, alcohol...or marathon running and religious cults, we need to do things obsessively and addictively.  It doesn't seem to matter whether it's a beneficial or harmful thing, just something that takes us to another life than our own--more pleasure, more money, more satisfaction, more relief from stress, more meaning....

Change that restless striving for "more" of whatever, and you've accomplished something.

Doc D


Monday, June 21, 2010

Medical Quote Of The Day - 21 June 10

"Pharmaceutical companies will soon rule the world if we keep letting them believe we are a happy, functional society so long as all the women are on Prozac, all children on Ritalin, and all men on Viagra."

--Terri Guillemets

The Results Are In: Govt Drug Price Controls Lead To...Increased Cost.

This interesting new study published in Health Affairs (June 17) has a message for reformers:  actions have consequences, frequently unintended.

The authors looked at data subsequent to the implementation of Medicare reform in 2003 (the Medicare Prescription Drug, Improvement, and Modernization Act,), which
"aimed to lower Medicare spending by reducing reimbursements for specific drugs. It also aimed to reduce the incentive to prescribe certain drugs that afforded particularly higher margins for the doctors and clinics but did not offer any clear clinical advantage for patients."
Does this sound familiar?  Can you say "comparative effectiveness?"

The study looked at chemotherapy in lung cancer and found
"Physicians switched from dispensing the drugs that experienced the largest cuts in profitability, carboplatin and paclitaxel, to other high-margin drugs, like docetaxel. We do not know what the effect was on cancer patients, but these changes may have offset some of the savings projected from passage of the legislation. The ultimate message is that payment reforms have real consequences and should be undertaken with caution."
So when the government instituted a price control on certain drugs, there was a switch to other drugs.  Your basic government-run health care supporter would say that stronger prohibitions are needed to keep doctors from switching to higher cost drugs, but hold your horses...

1.  Although doctors shifted somewhat to more expensive drugs, there was no data that showed they benefited financially from doing so.
2.  The authors weren't able to look at whether these drugs were used differently; that is, before radiation or after, at the same time, etc.
3.  Percent profit on the drugs converged on a stable amount, so prices weren't being jacked up along the way.
4.  Medicare started to cover a new breakthrough drug (Avastin) during the study.
5.  Data wasn't available for managed care-covered Medicare (conceivably more responsive to cost efficiencies).
6.  Throughout the study no research suggested that there were survival advantages across the different chemotherapy regimens.

In summary, the authors "could identify no major, coincident changes in practice patterns that plausibly explain our results."  The payment changes, designed to save money may have had effects that "offset some of the savings projected from passage of the bill."

Finally, the researchers "urge caution for health care payment reform."

So what does this tell us to do about reigning in health care costs?  Nothing.  Of major concern is the fact that by the time we get data on comparisons and prices, medical care has moved on... and the conclusions are no longer relevant.  This happened with drug-eluting stents in Great Britain:  by the time the govt decided to deny care for this new more expensive care, the denied treatment was already the new standard for narrowed coronary arteries.

Boil down all the facts above to this simple conclusion:  price controls correlated with an increase in costs.

Actions have consequences.

Doc D

Sunday, June 20, 2010

Medical Quote Of The Day - 20 June 10

"What would you prefer - a doctor who holds your hand while you die or one who ignores you while you get better? I suppose it would particularly suck to have a doctor who ignores you while you die."
--House, MD

LA Times Blog Wins 2010 Waste Of Time Apogee Award

I saw the title of the following article in the LA Times Booster Shots blog (June 18)

"Killings in the neighborhood take toll on young minds"

And I thought, "What a stupid waste of effort and of our time."   Info content = zero.  Here's my suggestion for some more articles, which the LA Times is free to use:

"Death of a Parent a Significant Event for Children"

"Lack of World Peace Brings Unease to Toddlers"

"Oil Spill Creating Gas Station Phobias in Pre-Adolescents"

"Global Warming Concern Causes Children to Quit Burning Ants With a Magnifying Glass"

"Our Youngest and Brightest Note that When Drought Ends It Rains"

"Pre-schooler Asks Parents If They Will Fill Their Car at the Beach From Now On"

I'm available to any media organization for more ideas.

Sarcasm aside, it's hard enough to wade through the information attempting to influence us with half a story, selective data, and advocacy assumptions.  When the topic is nonsense from the get-go, it's an insult.

Doc D

Don't Worry, Be Happy (On SIX Cups Of Coffee A Day)

Another study saying coffee and tea are good for you...probably.

After my post of yesterday, I'm not making any great claims for this.  I'll just let you have the data and you can make up your own mind.  The quotation is from BBC News (June 18)
"A 13-year-long study from the Netherlands ...adds to a growing body of evidence suggesting health benefits from the most popular hot drinks. Those who drank more than six cups of tea a day cut their risk of heart disease by a third, the study of 40,000 people found. Consuming between two to four coffees a day was also linked to a reduced risk. " (20%)
The authors noted that having a cigarette with your coffee or tea cancelled all the benefit.  Also, at high levels of daily caffeine the physical dependence gets stronger (try going cold turkey if you're longstanding regular coffee drinker:  I did, in medical school, and had a migraine by afternoon).

Which just makes my point from yesterday.  Everything we do or avoid is mixed in with a thousand other influences.

Happy Fathers Day to all you Dads!

Doc D

Saturday, June 19, 2010

Medical Quote Of The Day - 19 June 10

"Quackery has no friend like gullibility."

One Of A Million Roads To Irrationality: "Thinspiration" Websites That Promote Starvation And Malnutrition

  The Age of Aquarius brings you "Thinspiration" websites to cure the biological requirement for nutrition.

What a deal.  If we didn't have to eat anything, think of the money we could save on groceries.  Oh, would put farmers out of business...but, but they could save money and survive (for a while) by becomining anorexic, too.

Researchers at Johns Hopkins did a study that surveyed 180 pro-eating disorder websites.  The findings are sad, a symptom of our need for belief, in something, irrational or not.
"About 91% of sites were open to the public — though many warned that "wannabes" should stay away — and about 79% had interactive features, such as calorie and body-mass index (BMI) calculators.  About 16% had a "creed" or "oath to Ana," such as the "Thin Commandments," or 10 rules for eating disorders, such as: "Thou shall not eat without feeling guilty," "Thou shall not eat fattening food without punishing oneself afterward," and "What the scale says is the most important thing."  ...about 43% provided specific instructions on concealing eating disorders" (from USA Today's Health blog (June 19).
This study comes at a time when I'm reading The World Turned Upside Down, by Melanie Phillips.  Phillips is a journalist who became perplexed at how "Reality seems to have been recast, with fantasies recalibrated as facts while demonstrable truths are dismissed as a matter of opinion."
"Nothing is really as it is said to be.  Society seems to be in the grip of a mass derangement.  The sense that the world has slipped off the axis of reason has been greatly exacerbated by the fact that so many prominent people--professors of this and research directors of that, chief scientists and Nobel Peace prize winners and fellows of the Royal Society, judges and diplomats, intelligence agents who suddenly materialized from the shadows and starting firing off in public--have been saying all these strange and disturbing things.  How could they all be wrong?  Am I perhaps wrong?  How is anyone to work out who is right in such a babble of "experts" and with so much conflicting information?"
This strikes a chord with me.  I once watched a physics department chairman forced to share a news broadcast--to "debate" ridiculous cold fusion theories--with a guy who claimed to have invented a perpetual motion machine.  Why did such lunacy receive validation through a public forum?

For every rational and common sense conclusion, there's an "expert" who argues that it's all an illusion, or prejudice, or just the opposite, or "only true for you."  How can we function under these circumstances?  Battered by Truthers and Birthers and Princess Di murder advocates, it's hard to decide how to live, or even to decide how to decide.

Phillips concludes that the abandonment of reason is driven by those with a desire for power--not that startling--but she goes on to say that at bottom all these irrational power-seekers share an intent to unmoor our sense of reality, to disorient us in a way that creates a vulnerability to false visions of human perfectability.  The "Thinspiration" websites fit right in, taking advantage of this chink in our rational armor; promoting denial and punishing the body to reach a state of personal power and worth.

Recommended reading.

Rule of thumb:  If something sounds new and startlingly at odds with accepted knowledge, it's not because centuries of evidence have been shown to be false, that all the uncertainty  and confusion we experience has been overcome by this singular insight... it's probably because it's crap.

Doc D

High Quality Care At Low Cost: One Doctor Makes It Work

Here's an example of reform that's working for this doctor and his patients (brought to you from the little town of Apex, NC)

A prologue for those who aren't familiar with medical practice:
1.  Seeing 30 patients a day is a typical standard, in order to keep up with patients seeking care (access) and billing expenses.   This is why you sometimes think your doctor is in a hurry or doesn't spend enough time with you.
2.  6000 patients is a big practice.  If he's following that many, he's probably doing a great job at prevention.
3.  You can be a per-visit patient, which he talks about.  Or you can pay a $350 annual enrollment fee which includes a free annual physical (with labs)  and prevention screening.  Enrolled patients pay only $20 per visit.  My insurance enrollment fee is $460 per year and I don't get anything with it.
4..  Some of the blood pressure and lab test results he talks about may not be familiar to you.  I will attest that he's talking about REALLY bad situations.
5.  His complaint about spending 30 minutes, convincing Medicaid to authorize a test you need, is accurate.
6.  Lastly, this is an office practice.  These days doctors do either office work or hospital work ("hospitalists").  This practice model couldn't work for hospitalization; people have to fall back on insurance, Medicare, and Medicaid for that.

See Dr. Forrest's practice webpage here.
I would love to hear comments or experiences any of you have had from similar medical practices.

Physicians for Reform Forum - Brian Forrest, MD from Lawson For Congress on Vimeo.

Doc D

Friday, June 18, 2010

Medical Quote Of The Day - 18 June 10

"Whiskey is by far the most popular of all remedies that won't cure a cold."

--singer Jerry Vale [ b. 1932 - ]

Another Poison Pill (Sigh): Medicaid Money May Not Be Coming

Kudos to Virginia for passing a law back in March that anticipated the money might not be coming, giving the governor the authority to re-program funds to cover care for the needy from state funds.

Just last week supporters of HCR were saying that states who complained about the Medicaid cost were falsely alarming people because the law substituted federal funds for the state share of Medicaid in the first several years.

[Duh.  Like the federal government gets their funds from a money tree instead of from taxpayers in the states.]

But, now it looks like that supplement may not be coming. A bunch of articles were published in the media today warning that it's looking grim for states who were expecting the federal money.  As reported in the Richmond Times Dispatch (June 17),
"Gov. Bob McDonnell is prepared to shift dollars within Virginia's budget to shield a health-care program for the poor from further cuts. 'Language in the budget authorizes the governor to transfer money from the second year to the first year in response to federal mandates,' said McDonnell spokesman J. Tucker Martin. Virginia had anticipated more than $400 million for Medicaid under a six-month extension of the Federal Medical Assistance Percentages. But the money is in limbo because Congress has yet to agree on an extension."
The US Senate is currently at an "impasse" over a new funding package that would have helped the states meet expanded Medicaid needs pushed by the new HCR law.  As concern rises across the country about the government spending money it doesn't have, legislation funding expanded benefits in the states is getting harder to pass.

The states would do well to prepare, and protect themselves from fears over financial instability at the federal level.

Doc D

Clinics Of The Past For The Future: Volunteers And Free Medical Care

Using the 19th century model of "doing good works," a network of free clinics has grown in the US.

The Archives of Internal Medicine (June 14) published a survey of free clinics in the nation, something that hasn't been looked at in 75 years.
"Clinics were open a mean of 18 hours per week and generally provided chronic disease management (73.2%), physical examinations (81.4%), urgent/acute care (62.3%), and medications (86.5%)."

For those of you, like me, who were around in the 60's, the notion of a "free clnic" probably brings up the Haight-Ashbury clinic and images of hippie communes.  But, this type of medical care has always been around, and not just for specific purposes like drug rehab, or whatever.  Sanitariums and other public supported facilities were a constant feature of Western medicine over the last several centuries.  Churches have been running them all the way back to medieval times.

The research indicates that the number of these clinics has grown steadily, providing care today to almost 2 million needy patients, with over 1000 facilities in 49 states, and an annual avg budget of $287K.  The paragraph cited above shows that the clinics, short on major resources, reasonably limit the type of care to everyday things and the ongoing sustainment of chronic conditions.  That's appropriate and safe.

The article doesn't mention it, but one weakness of these facilities is their referral process.  If someone comes in who requires specialty evaluation or admission to a hospital, it's sometimes difficult to arrange.

The authors recommend that the level of care being provided to this many people needs to be programmed into the nation's overall health care system as a significant safety net.

Good point.  For very little money, they provide a lot of care.

Doc D

Organ Transplants Between AIDS Patients. The Technology Can Help Or Harm

Is it good medicine and ethical to transplant an organ from one infected person to another person infected with the same disease?

South Africa has a big problem with HIV.  HIV also causes kidney failure in some cases, requiring dialysis.  And healthy organ donations are uncommon.

So, why not let one AIDS victim benefit another with a healthy, if infected, kidney?  Unlike the situation where someone inadvertently receives an organ from someone who has cancer, or an undetected infection, both donor and recipient share the same infection, are volunteers, and no disease will be transmitted from one to the other.

The report on this appeared in the New England Journal of Medicine this week.  See the USA Today (June 17) article here.

For the record the US has been doing transplants between donors and recipients who have hepatitis C.

But, unlike with Hep C, there are strains of HIV that are more resistant than others, and predicting resistance is not an exact science.  What if the donor organ comes from an individual with a resistant strain of the virus, and is given to someone whose disease is non-resistant?  Will it adversely impact the course of the recipient's illness?  Maybe...even probably.

To simply say that this factor precludes doing such transplants between HIV sufferers is too simple.  The alternative is to watch the potential recipient die.  In South Africa, resources are extremely limited.  Dialysis is relatively non-existent.

The conundrum in this situation is one that was recognized centuries ago.  The phrase, "First, do no harm"  is taught from Day One in medical school, and remains in the forefront of everything doctors do.  But when the alternative to doing a potentially harmful thing is doing nothing, and that "nothing" is potentially even more harmful (dying), it gets...well...complicated.

I've never found a specific guideline for this.  Each case has to be weighed individually.

The only general guideline that applies is more of a caution:  never let our technology get ahead of our ability to decide right and wrong.

Doc D

How Do We Merge Thousands Of Bits Of Health Advice Into Meaningful Action?

Eat brown rice, do this, don't do that...does all of it really matter?

I decided to write this post, despite my aversion to giving health advice.  If you need that, see your doctor, or there are thousands of books and websites that will advise you on everything from dating to constipation.

Nostrums was created to look beyond this superficial and puerile level of information on research and health policy.

I'll set the stage by this paragraph from the NY Times Health Blog (June 15):
"Now a new study from researchers at Harvard reports that Americans who eat two or more servings of brown rice a week reduce their risk of developing Type 2 diabetes by about 10 percent compared to people who eat it less than once a month. And those who eat white rice on a regular basis — five or more times a week — are almost 20 percent more likely to develop Type 2 diabetes than those who eat it less than once a month."
Brown rice is just white rice without the bran layer stripped off.  As you might imagine, leaving bran in the product--which is fiber--does all the good things bran does, including an improvement in blood sugar regulation.  That makes this study not all that revealing.  So, do what you want about brown rice.

What's more interesting, and the point of this post, is the cumulative effect of thousands of these articles each year reporting research on health benefits and risks.

Do they add up to anything, really?  Each "effect," described by the research studies is an isolated finding.  In order to show that the effect, beneficial or harmful, is actually occurring behind the scenes, all other effects, or variables, had to be excluded ("controlled for" in the jargon).  That's the way science works, generally.  There are some tools for handling more than one variable at a time (I'll continue to use that word instead of "potential effect"), but it gets terribly complicated very quickly as the number of variables rises, and the likelihood that anything will surface from the complex mish-mash goes way down.

Bear with me here.  Take a step back from cloning in on something like brown rice and its influence on our health, and ask whether in the context of a thousand other everyday things that could have an impact on our blood sugar regulation (and the disorder associated with it, diabetes), are we talking about something that's really of benefit?  If you are inactive, have a family history of diabetes, are overweight, taking any one of a dozen medications that effect blood sugar (the list goes on forever), how likely is it that you can change your diet from white to brown rice and expect anything to happen?

Very few of the media reports ever admit to this in their reporting of the Latest Great Discovery, because it undercuts the impression they're trying to create.  If you knew it probably doesn't do squat to eat brown rice in "real" life, then the article is a waste.

We're assaulted with thousands of these bits and pieces of advice over time.  Put them all together and the "new" content, stuff that's really helpful, beyond what common sense would tell you, is practically nil.  There are very few that are strikingly prescriptive (usually a "don't ever do this"), but it's been my experience that a lot of those come from an unregulated alternative medicine market (remember Laetrile, from peach pits?)

My advice is to throw most health advice into a big bag in your head under the label of General Info For Validation By Common Sense, and take it all with a grain of...well...rice.

Doc D

Thursday, June 17, 2010

Medical Quote Of The Day - 17 June 10

"I never read a patent medicine advertisement without being impelled to the conclusion that I am suffering from the particular disease therein dealt with in its most virulent form."

--Three Men in a Boat, by Jerome K. Jerome [1859 - 1927]

San Fran Requires Stores To Post Cell Phone "Radiation" Levels

You can always rely on San Francisco to be way out in front of reality.

Stores have to display data on Specific Absorption Rate (SAR), which is alleged to be a measure of how much of the cell phone's radio waves are absorbed into a person's tissues.

As the Wall Street Journal's Health Blog (June 16) says,
"it’s not at all clear what people are supposed to do with this information — there’s no conclusive evidence that cellphones do (or don’t) cause any type of cancer, let alone that one SAR level is safer than another."
Well, that sounds REALLY useful.  How about passing a law that says each public bathroom has to display data on how many trees each toilet paper company cuts down to make their product?  I'm REAL interested in that, too.

Despite the quoted statement above (which is true), organizations are already putting out lists of "safer" phones with lower SAR's.  Here's one example from some people who call themselves The Environmental Working Group (they "bring to light unsettling facts that you have a right to know"--that is, a New Age lobbying group).

Just to repeat, SAR is not a standard; it's not accepted by any scientific organization as a measure of human exposure to radiation; it doesn't imply anything about harm or safety.   It's just something that you can measure like the "lumens" that your lightbulb puts out.

So go ahead, spend a lot of your time and money on something that's...made up.  When I'm in the mood for fantasy I usually head for the Brothers Grimm.

Doc D

Wednesday, June 16, 2010

Obama "Asks" US Surgeon General Not To Attend AMA Meeting

The Obama administration apparently thinks the Surgeon General could commit some faux pas, possibly not "calibrating her words" correctly.

For the record, as MedPage Today reports (June 15), Dr. Regina Benjamin
"has served as the chairwoman of the AMA's Council on Ethical and Judicial Affairs. In 1995, she became the first physician under 40 and the first black woman to be elected to the AMA's board of trustees."
As the Administration is pushing to convince a public opposed to the HCR law that it's "a good thing,"  it would be inconvenient for her to be identified in public as a member of her profession, and to meet her professional responsibilities.

Politics, politics, politics...

Doc D

Hey, AMA. Where Is Your Head?

The AMA's House of Delegates showcases their responsible approach to the future of American medicine by supporting legislation to require porn actors to wear condoms.

Yep, the delegates had their meeting this week.  Apparently they think this will be "an act of role modeling" for the rest of the nation in condom use.


There are several hundred medical issues on the table concerning cost, access, quality and insurance coverage facing the American public, but the AMA's most important task is to make sure that citizens are positively influenced by the socially responsible actions of porn actors.

Unbeknownst to me, I have been transported to another where everybody is insane.

How do I get back to the Universe of Common Sense?  Beam me up, maybe?

In another earth-shattering policy battle, the Delegates decided that adolescent sleepiness is a public health issue.  A major rift among the delegates occurred over whether the magnitude of the problem warranted determining it was a "major" public health problem.  After much wrangling, the word "major" was dropped.

Whew.  I was worried there for a second.  We are extremely fortunate that these experts are on the job, targeting vital medical issues for the nation.

Sarcasm aside, I am reminded of the first chapter of Dickens' comic novel The Pickwick Papers.  It's the nearest thing to actually attending the House of Delegates meeting without actually being present.  From the Transactions of the Pickwick Club, it is resolved
'That this Association has heard read, with feelings of unmingled satisfaction, and unqualified approval, the paper communicated by Samuel Pickwick, Esq., G.C.M.P.C. [General Chairman—Member Pickwick Club], entitled "Speculations on the Source of the Hampstead Ponds, with some Observations on the Theory of Tittlebats;" and that this Association does hereby return its warmest thanks to the said Samuel Pickwick, Esq., G.C.M.P.C., for the same."
To the AMA's modern version of the Pickwick Club, I say...jolly good show, jolly good show.

Doc D

Medical Quote Of The Day - 16 June 10

"The basic mistake we're making with our health-care system now is that we regard it as just another business. And it's clearly not just another business. Patients, sick patients and worried patients, are not like ordinary consumers."

--Arnold Relman, MD, Professor Emeritus, Harvard Medical School, former editor New England Journal of Medicine.

For The Record: Medical Reality TV Shows Have Nothing To Do With Reality

I confess:  I watched Dr. Kildare as a kid, and loved it.  But I knew at the time it was entertainment.

My family knows that when House, MD or ER comes on, I have to leave the room.  They drive me nuts.

And while most people recognize intelllectually that these programs have nothing to do with the reality of how medical care occurs, I believe that they secretly imagine it to be so.

But it aint.  That includes St. Elsewhere, Scrubs, HawthoRNe, Gray's Anatomy, Marcus Welby, M*A*S*H, Quincy, Doogie Howser, Northern Exposure, Nip/Tuck, Royal Pains, and Nurse Jackie.

[I found a list of 55 medical shows that have appeared on US TV.  The public's fascination with this soap opera stuff is really amazing.]

Even worse, are the "documentary" shows that follow real patients, selectively, as they move through the medical system.  While ostensibly featuring real situations, they are all extremes (the boring and mundane parts--i.e., those parts that won't make money for the media--get edited out) that tease the viewer with a little blood-and-guts, but not too much, and create an artificial atmosphere of drama, during a time when serious work is needed.

To any of you doctors and nurses who engage in this stuff, shame on you for being narcissistic attention-seekers, and using the confusion and desperaton of suffering patients (who are not really competent to consent at that time) to highlight your "wonderfulness."  It's unseemly at best.

Worst of all, I have deep concerns about the invasion of privacy, and the willingness to shed patient confidentiality with a consent form, an issue discussed by bioethicists:
“People don’t expect to be filmed when they go to the hospital,’’ says George Annas, author of “The Rights of Patients’’ and a professor of health law and bioethics at Boston University. “You didn’t come there to get filmed. You came there to get your illness or injury treated, and they’re taking pictures of you and making them public.’’

Arthur L. Caplan, who heads the Center for Bioethics at the University of Pennsylvania, says there is “a certain degree of inevitable exploitation when you’ve got somebody who has just been through a traumatic and unexpected event and you’re there taping.’’
And finally, these filmmakers are making tons of money as the public watches the pain and suffering of others.

Why don't we just film people torturing pets or getting hit by trains...oh, wait...we do that.

Doc D


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