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

Tuesday, May 10, 2011

Notice To Readers

 
My posts to this blog will slow down.  At approximately one month from this date, it will no longer be available on the Kindle as a subscription.

After almost 1000 posts over a three year period, I will be moving on to other projects.  The blog website will stay up and I may publish to it on occasion.  As the sole author, I find the other things I'm doing are making it harder to maintain the flow.  It's unfair to subscribers, who expect a product on a regular basis.

For website subscribers and followers, there are no consequences.  For Kindle subscribers, you will see the number of posts get less over the next few weeks.  This will give you adequate time to unsubscribe.  At $0.99 a month the financial change will be minimal.  Amazon will keep posts available which you have already received, in case you want to re-download something (if I understand all the legalese correctly).

On the whole, it's been fun, and a learning experience.  In addition, it has kept me "up to date" on the literature, and the media's frequent mis-reading of it.

Health care reform is a mess, the media still plays on fears and hopes by hype and distortion, and even the science will frequently prove to be wrong.  So, nothing has changed, and won't...unless you do the work of finding out for yourself.

Thanks for reading.

Best wishes,

James J Dougherty, MD, MPH, FACPM
Brigadier General, USAF (ret)

AKA Doc D
 

Monday, May 9, 2011

Medical Quotes v2 - 9 May

 What is--and is not--a disease?
 
"The history of medicine is filled with examples of new drugs and technologies functioning to change popular and professional thinking about what counts as a disease or a health care problem....Neither baldness nor erectile dysfunction in aging men nor a less-than-desirable nose shape was considered a medical problem--until medicine found a way to do something about them."
--Medicine and the Market, by Daniel Callahan and Angela A. Wasunna (Johns Hopkins Univ Press, 2006)

Is mortality a disease?  How about poor decision-making...a disease?

Doc D
 
 

STUDY: Cancer Rates By Sexual Orientation. A Waste Of Research Funds

 
The last several days have been very boring...medically speaking.

If I see another bin Laden story, I'll lose control.

[Maybe there's a connection.  Maybe bad news (in the sense of "unworthy") crowds out the good (in the sense of "valuable information").]

So, all I've been reading are the usual highly technical journal articles, like this:
"Ranibizumab and Bevacizumab for Neovascular Age-Related Macular Degeneration"  (NEJM, Apr 28)
It's an important study, but has no appeal unless you're treating patients.

The rest of what the media is publishing hovers around ground-breakingly empty stories about how pets can improve health or 10 new healthy recipes for okra, and the like.

If I'm not interested in that fluff, then I assume you won't be.

But this one caught my eye, if only to condemn this kind of reporting
"Gay men 'report higher cancer rate than straight men'" (BBC News, 9 May, but also reported in other media.  The original study is in the journal Cancer)
Apparently women don't exhibit a parallel rate difference.

Studies like this come from the category of research--epidemiologic studies--that are least valuable, most often wrong, and most vulnerable to bias and confounding factors.

This will almost certainly turn out to be (1) an unverifiable result, (2) subject to selection bias, or (3) due to an unidentified, third variable that distinguishes the two groups (like age, education, income, and a whole laundry list of other inconsequential things).

What's its NOT, is any indication that sexual preference determines getting cancer.  

So, you have to ask why they even wasted the research funds.

Doc D
 
 

Friday, May 6, 2011

Measles Continues To Spread. Thanks, Wakefield, McCarthy, and...Oprah

 
Just Google the word "measles" to find that the US is not the only country experiencing a big increase in cases, all due to vulnerable unvaccinated children.

This follows in the immediate wake of increased cases of pertussis...for the same reasons.

I blame the people above, among others.  Andrew Wakefield published fraudulent research linking autism to vaccines.  Jenny McCarthy is still convinced (and will be, no matter what) that vaccines caused her child's autism, and Oprah has given McCarthy and others an open forum to reach millions with their scare tactics.

All this, in the face of repeated well-conducted, large-scale, controlled studies that show there is no such link to vaccines.

Someone said that the success of vaccines is the source of their downfall.  As the diseases--which ran rampant--began to disappear, people began to adopt New Age fears about things that are not "natural" or "organic."  (vaccines are organic, of course, but they're invasive...you have to stick somebody).

I saw a case of measles in medical school, but none since.  I guess I'll have to go back to the textbooks to re-learn the diagnosis and therapy now that people are too stupid to protect their children. 

In my childhood, it was just expected that you caught chicken pox, measles, mumps, and rubella.  I got 'em all.  A few kids died.  It was part of life.  There were also about 100,000 cases of polio every summer, and parents feared greatly.  The vision of rooms full of iron lungs, breathing for children whose respiratory muscles had been paralyzed by the polio virus, was horrifying.

All that's gone now, but it's return was probably inevitable.  An irresponsible media and a handful of wacky advocates were enough to overcome people's ability to reason and to prey on their fears.  We deride primitive man for his irrational fears, and bizarre explanations for what happens to us (demons, witches, curses, etc).

But we're no different, just more technological.

I posted on the vaccine life cycle a long time ago.  The vaccination--disease disappearance--decreased vaccination--disease reappearance process has been recognized for decades.  See that post here.

As one distressed mother told a reporter, she had heard all the warnings about vaccines and thought that childhood illnesses were all pretty benign, anyway.  She didn't have her child vaccinated, and after the child's death, could only say, "I had no idea these illnesses were such a potentially deadly threat."

A tragic way to learn.

Doc D

Wednesday, May 4, 2011

Medical Quotes v2 - 4 May

 
Talking about how medical research is vetted by reviewers before publication:

"When, as a test, 211 of the British Medical Journal's frequent referees were sent an article purposely tainted with eight presumably detectable problems, the reviewers managed to catch an average of two.  More than half the time, peer reviewers don't even agree on publication worthiness, according to one study of a range of journals; reviewers for the New England Journal of Medicine, for example, see eye to eye only one-fourth of the time."
--Wrong:  Why experts keep failing us..., by David H. Freedman (Little, Brown, & Co, 2010)

Doesn't give you great confidence that the process weeds out poor or inaccurate work, does it?

Doc D
 
 

Europe Ahead Of US In Regulating Herbals. A Good First Step, Why Not Here?

 
There's an article in Science-Based Medicine (4 May) that discusses Europe's new regulatory requirement to demonstrate safety of herbal products.

It's about time.  Now if the US would just wake up to the harmful consequences of some of these often adulterated products.

For those who think herbal "medicines" can only be good for you, we have multiple instances of common ingredients--found in a range of these products--that damage the kidneys (aristolochia) and the liver (kava).  The worst case reported to date was ephedra (known as ma huang in Chinese medicine, used for asthma, colds, and weight loss).  From Wikipedia,
"Ephedra-containing dietary supplements have been linked to a high rate of serious side effects and a number of deaths, leading to concern from the U.S. Food and Drug Administration (FDA), the National Center for Complementary and Alternative Medicine, and the medical community.  However, initial efforts to test and regulate ephedra were defeated by lobbying and political pressure from the dietary supplement industry.  Ultimately, in response to accumulating evidence of adverse effects and deaths related to ephedra, the FDA banned the sale of ephedra-containing supplements on April 12, 2004."
How many people were harmed while lobbyists for the herbal manufacturers stymied efforts to restrict its use?  Even the Natl Center for CAM was worried.

In this country no herbal regulations exist.  You can take a plant, grind it up, and say it cures almost anything.  No proof required.  Your only problem, after you make millions off the gullible, is if enough people keel over dead that somebody notices they were all taking your product.  Pretty cool deal, huh?  Then you can flee the US and live handsomely in a non-extradition country.

As you might imagine European herbal manufacturers are screaming that this is a "ban" on herbals.  It's actually very simple, and not very stringent:  they have to be licensed by showing some evidence of safety.  That's minimal compared to what pharmaceuticals have to prove.

Some of my friends say, "Well the herbals are much cheaper, and I can better afford them."  This logic defies common sense.  Of course they're cheaper:  the makers don't have to spend money purifying the product and can leave in all the adulterants and other compounds for which we have no data on safety, and they don't have to do any research to establish that it works.  So, of course it costs less to make, and costs less to sell.  Not rocket science. 

To those who worry about the cost of effective drugs, save all your money and don't spend it on poor quality, adulterated products.

More importantly, all the large scale studies of most of these things--that people shell out 5-10 dollars for--have been shown to be ineffective.  So, doing nothing will leave you even more financially well off.

If your goal is to save money rather than get well.

Now that REALLY makes sense. 

Doc D
 
 

Monday, May 2, 2011

STUDY: Obese People Not Getting Sexually Satisfied

 
A survey-based study published in the Journal of Sex and Marital Therapy shows that "obese men's satisfaction scores fell between the cancer survivors and the general population, while obese women scored lower than both groups."

Well...duh.

The research (reported in USA Today Your Life blog, 1 May) alleges that as body mass index increases men and women report decreased "functioning only for arousal and behavior."

Is there something else that this is "only?"  There must be other categories like performance, and attitude, or channeling, maybe.  After some consideration, I confess to being clinically illiterate in the jargon of the sexual literature.

But out of curiosity I went to the journal's website.  I'd never heard of it.  There were articles on erotic stories as sexual adjuvants, a proposed "Hypoactive Desire" registry,  the democratizing of transgenderism (what?), and pregnancy sex in Turkey.

It's been a while since I've had as much fun with nonsense.  I hope my tax bill didn't fund any of this.

IMO, this journal falls somewhere between the New England Journal and Hustler Magazine.

Doc D
 
 

Sunday, May 1, 2011

Medical Quotes v2 - 1 May

 
When I first bought a personal computer it was very expensive.  As technology got better, the price went way down.  Why has health care done the opposite? 

Everybody has an opinion.  Here's a refreshing perspective about spending that doesn't come directly out of your own pocket.

"On the whole, advancing medical technology, unlike agriculture or telecommunications, has been accompanied by exploding costs.  Why is health care the exception?  The reason is simple:  Americans do not pay directly for physicians or hospitals or other health providers.  A third party makes the vast majority of payments in the United States.  And as Prof. Friedman has observed, nobody spends somebody else's money as wisely as he spends his own."
--The Cure:  How Capitalism Can Save American Health Care, by Dr. David Gratzer (2006)

For those who say that market-based health care has failed, that's not the case.  To praphrase G. K. Chesterton on Christianity, it's not that market-based care has been tried and failed, it's that it's been found hard, and not been tried. 

The last time we had market-based care in this country was prior to World War II, when employers began to offer health insurance as an inducement, under wartime wage caps that made it hard to attract employees.  Since then, health care has become the most highly regulated segment of our economy.

Doc D
 
 

Dr. Mercola Warned By The FDA About Unwarranted Claims

 
Proof that in the Information Age popularity is a credential that fosters belief.

Dr. Mercola is one of those notorious alternative health gurus who make a lot of unverified claims about the therapeutic benefit of nutritional and other substances.  People who believe his claims point to his popularity as a reason to believe what he says; "he can't be wrong if he's so popular."  "He's appeared on Dr. Oz's show more than once."  Really?

When did popular hysteria become a valid form of reasoning?
And readers know my opinion of the supernatural stuff that Dr. Oz promotes.

In this country, anyone is free to make a claim about things that can't be confirmed or verified, like energy healing, homeopathy, and naturopathy.  No oversight is possible because the foundation of these claims can't be addressed; they all rely on invisible and undetectable forces that only an adept or person with special knowledge (unavailable to normal humans) can identify and exploit.

Conversely, in this country, you can't claim an FDA-approved medical device has capabilities that are beyond those for which the device was approved.  And Dr. M crossed that line.

Dr. Mercola's website claims that his Meditherm camera can diagnose or screen for diseases of the breast, and is more sensitive than mammography.  This is false, and I hope women won't be fooled into avoiding mammography.  The FDA has sent a warning to Dr. Mercola (see here) to stop making this claim, and to withdraw several other statements about his Meditherm camera.

From the FDA letter:
"Your website promotes the Meditherm Med2000 Telethermographic camera for uses for which you have not obtained marketing approval or clearance, which is a violation of the law....The FDA requests that you immediately cease making claims, identical or similar to those described above, for this product. You should take prompt action to correct these violations. Failure to correct these violations promptly may result in the initiation of regulatory action by the Food and Drug Administration without further notice. These actions include, but are not limited to seizure, injunction, and/or civil money penalties."
For the record, the device under consideration merely measures skin temperature over a specified surface area.  Skin temperature fluctuates greatly as the surrounding air temperature changes, basal metabolic rate increases or decreases, with fever, and when substances are in contact with the skin (chemicals, but also clothing).  As such, it is an imprecise measure of temperature at the surface, much less of what's going on below the skin.


The FDA originally approved the Meditherm camera for "viewing and digitally storing thermal patterns generated by the human body..."  Nothing was stated or implied that it was approved for screening, diagnosis, or treatment.

Apparently the good doctor has decided to defy the FDA (Chicago Tribune, 26 Apr).  This is going to be interesting.  It will put him in the same category as Dr. Wakefield, the anti-vaccine "fraudster" who lost his medical license.

In my opinion, some recognized, expert agency needs to exercise oversight of all alternative and complementary substances and devices.  They are sometimes harmful, but we have no way to know until they cause enough harm to surface through anecdotes.  The only reason Dr. M is being stopped is because he's using a medical device that comes under the purview of the FDA.  We need the same regulatory safety for herbals, supplements, and wacky therapies that don't make sense.
Finally, it's OK if you watch Dr. Oz, or read Dr. Mercola's newsletter...as long as it's for the entertainment value and not real health advice.

Doc D
 
 

Saturday, April 30, 2011

Growth In Health Care Cost Not Controlled By Universal Care

 
An interesting graph of cost increases per person in Switzerland, UK, US, and Canada.

During the health care reform debate, rising costs in the US were a big selling point; we need to change the system in order to reduce inefficiencies and unnecessary care, making health care cheaper for us all....and universal care with regulatory oversight by the government would accomplish that.

So, it's interesting that when you look at cost increases in other countries that manage their health care system, you see the same increases, and more volatility.



Caveat:  this is not total cost per person.  We still lead the pack there.

Switzerland has some element of market-based care, Canada is experimenting with a few market-based initiatives, and the UK has essentially a government-run system.  So, this represents a decent cross-section of different systems.

And cost fluctuates in them all.  The difference is that in the US costs are addressed by controlling demand (hence the popularity of catastrophic insurance coverage:  you pay cash unless something big happens) while the others control costs by reducing supply (increased waiting times for expensive care, controlling whether expensive therapies are covered, postponing certain services).

I can only conclude that the promise to lower costs in this country was...speaking diplomatically...misleading.

Doc D
 
 

Jury Says No To Hospitals Who Sue Tobacco Companies For Unpaid Bills By Uninsured

 
These hospitals get the Nice Try Award for trying to shift the burden of uninsured care.

It's funny that I had to read about this court case in the British news (BBC News, 30 Apr).  It's not prominently covered here yet.

37 hospitals in Missouri decided they were taking it in the shorts, financially speaking, by taking care of uninsured people with illnesses related to tobacco use.  Since they can't turn them away by law, the hospitals have a lot of unpaid bills for emergency treatment and hospitalizations.

As I say, nice try.

At some point in this country we have to make people responsible for their harmful behavior.  We're long past the point where the individuals with smoking-related illness can claim they were misled.

We're so long past that point...actually it's been about 200 years that we've known that tobacco can kill you, in a number of ways...that I think the big tobacco award some decades ago was a wrong judgment.

If you recall, people claimed that the tobacco companies assured them that cigarettes were not harmful.

Yeah, and if I told you that Chevrolet's were safe and Ford's were unsafe would you believe that, too?

In any case, those folks who sued for damages, and were able to profit from ignoring common sense, have probably all died.  Good on them for being smart enough to have their cake and eat it, too.

So, in 2011, it's a little late to be blaming tobacco companies for unwise choices by individuals.

And the jury agreed.  Plus, when they looked at the balance sheets for those hospitals, they found that there was no hardship incurred, as the hospitals had claimed.

Sorry, no $455 million award.

But, I'm still in awe of the gall it took to try.

Doc D
 
 

Friday, April 29, 2011

Medical Quotes v2 - 29 Apr

 
 
A great book that tries to explain why we are so vulnerable to implausible fears:


Anecdotes and suppositions, no matter how right they feel, don't lead to universal truths; experiments that can be independently confirmed by impartial observers do.  Intuition leads to the flat earth society and bloodletting; experiments lead to men on the moon and microsurgery.
--The Panic Virus, by Seth Mnookin (2011)


Doc D
  
  
 


   
 


Wednesday, April 27, 2011

Medical Quotes v2 - 27 Apr

 
Today's quote from What I'm Reading:
"That governments give us good things is powerful rhetoric in the armory of rulers seeking power, and we have come to take for granted that it is the state that supplies good things such as medicine, education, and welfare subsidies.  It takes considerable simplicity of mind, however, to believe that such policies are straightforward gifts of the state, beause governments have nothing of their own to give:  all they can do is redistribute what some people have so that it may benefit others."

--The Servile Mind, by Kenneth Minogue (2010)


Doc D

FDA Sends Warning To Some Hand Cleansers...Discussion On Hand Cleansing

 
Hand cleansers are better than nothing, but still don't match hand washing.

I notice that the FDA has issued warnings to several companies who make hand cleansers.  The common thread to the warning is claims of preventing strep, MRSA, avian flu, etc.  See the article at the Miami Herald Health Wire (Apr 20), for more.

Most of the hand cleansers contain alcohol as their main ingredient.  You could just pour a bottle of alcohol over your hands and get the same effect.  Alcohol has anti-bacterial activity, but it's imperfect.  A small application to the hands will work for only a short time, and will fail to kill many germs.

[Factoid:  Wonder why they use that orange stuff called povidone (Betadine) in hospitals?  Because no bacterial resistance has ever developed]

Plus, I'm not aware of any studies that show adding a moisturizer to the cleanser doesn't undermine the product's benefit.

So claims to prevent disease are...well...let's call them misrepresentations.

[Note:  Here's my vote for Best Contagion Opportunity:  the key pad at your grocery store or ATM machine.]

By contrast, good handwashing, if you cover all surfaces of the hand, acts mechanically and chemically.  The soap combines with many chemicals, and the scrubbing washes off debris, dirt, dead skin (all of which provide nutrient for germs), and...yep...it washes away the bacteria. 

Many of you know the old guideline:  you should scrub for as long as it takes to sing "happy birthday to you," at least once.  Yes, it takes more time, but that's what it takes to be effective.  Your call.

Doc D
 
 
PS:  The subtitle says "better than nothing" because sometimes nothing else is available.

Tuesday, April 26, 2011

STUDY: Medical Student Interest In Primary Care Continues To Plummet

 
For some physicians it may be about the money.  For me it was about the job.

First, here's the data from the research that appeared in the Archives of Internal Medicine (Vol. 171 No. 8, April 25, 2011).

This was a review of two previous national surveys of over 2000 students between 1990-2007.  They focused on students who were planning to go into internal medicine.  The study looked at the number who were interested in "general" internal medicine (that is, including primary care) and those who were not.  The number who wanted to include primary care fell from 9% to 2%.  They also asked whether primary care was a reason they chose internal medicine:  the number who said "yes" fell from 57% to 33%.

So, over this period, students were running away from primary care.  Note that Obamacare's success is tied to access for the newly insured by encouraging primary care careers.  There aren't enough PC practitioners now, much less after we add 32 million people to the rolls.

And as I've written before, providing financial incentives for medical students to enter primary care has been tried before, and failed.  More about that below.

For Onion Peelers,
The total sample of 2421 students comprised 1244 at 16 schools in 1990 (response rate, 75%) and 1177 at 11 schools in 2007 (82%). ...Similar proportions of students planned IM careers (23% vs 24%), although plans to practice general IM dropped from 9% to 2% (P < .001). The appeal of primary care as an influence toward IM declined from 57% to 33% (P < .001).

This is not a bad study.  Response rates are high enough to preclude a situation where only students with certain plans would answer the survey.

OK, back to why medical students are trending away from what we so desperately need.  Most people who write about this are health policy mavens or economists.  They see financial incentives.  It's true that a gastroenterologist gets reimbursed handsomely for doing a colonoscopy, while a PC doc gets little, even if the treatment she provides is critical.

Here's the rub.  I haven't heard any of my classmates or colleagues over the years express those financial incentives as being an influence in choice of specialty.

What I have heard--and felt myself--is that the job of primary care is unrewarding.  I went into medicine to help people, but if I just wanted to do that there are a lot of other careers that fit that motive.  What I "needed" in a career was something that was very mentally challenging;  requiring mental focus, complex data analysis, rigorous thought processes, a mountain of knowledge retained, and frequent engagement of my best judgment for subtle differences in diagnosis and therapy.  That's the juice.

By contrast, primary care involves screening for rare abnormalities, from among common presentations of common things that (by most estimates) would have cured themselves about 2/3's of the time.

So, you see 10,000 cases of sore throat.  And over the years, among those patients I've seen a couple of retro-pharyngeal abscesses, a case of cancer, and several that were caused by an STD.  But this leaves about 9, 900 that were garden variety sore throats.

In a word, it's boring.

90% of the primary care job is a handful of illnesses, prominently respiratory illness, back pain, headache, and arthritis.  The substantive illnesses have been sucked up by the specialists.  What kind of professional challenge can this provide?  And don't tell me every patient is different; of course they are, and you consider that.  But most sore throats are just...sore throats.  And don't tell me that every now and then something rare shows up in one of these common cases;  of course it does, but it doesn't take much to keep that in mind and not overlook it.  And I did my duty, not shirking just because there wasn't the excitement of diagnosis and treatment:  the patients got good care.

Maybe some doctors see their training as something painful they had to go through to return to normal everyday life.   I loved it for how hard it was, and looked forward to new and different challenges throughout my subsequent career.  I finally found that, but it wasn't in primary care.

I didn't make that much, and after 10 years I'm still paying off college debt from our children.  The money was never that important.

If you offered me twice the income to move to a small town and be their family doctor, I wouldn't take it.  And almost none of my classmates--who did accept the deal--stayed with it.

Good luck, Obamacare.

Doc D
 
 

Monday, April 25, 2011

Medical Quotes v2 - 25 Apr

What do you think, are we fooling ourselves?
 

"Medical progress, as with most other forms of progress, is self-fueling:  the more of it one gets, the more one wants.  That progress breaks down any lingering fatalism about the inevitability of nature to do us in, seemingly open to any and all possibilities in the improvement of health."
--Medicine and the Market:  Equity v. Choice, by Daniel Callahan and Angela A. Wasunna (2006)


Doc D
   

Shiny Happy People Holding Hands...And Committing Suicide

 
Research study says if you live in  a place where people are more happy, there are higher suicide rates.

I struggle to make sense of superficial associations in the research literature...like this.  As usual the authors suggest some "the downtrodden need our help" reasoning, when there's nothing in the data to suggest that as a cause.

[The REM song referenced in the title was purportedly an ironic comment on Chinese propaganda at the time of the Tiananmen Square debacle.  But there's nothing in the lyrics to give you a clue.]

The association theresearchers  found between happiness (actually "well-being") and suicide is criticizable on so many grounds, it's not worth trying to explain them all.

Some examples:

--Hawaii ranks number 6 in happiness but 43 in suicide.

and conversely,

--New Mexico is 32 in happiness but 4 in happiness.

However, if you look down the list (you can find it printed here (Al.com, AP News, Apr 25), you'll find that a lot of states are in the middle of the pack on both happiness and suicide.  And there are exceptions where the "rule" is violated.  For instance, Colorado is 3 in happiness and 6 in suicide.

I have not doubt that when you apply statistical methods to the results there is a trend toward an inverse relationship.  But it seems to me that this is not about well-being and suicide, but rather a good lesson in how statistics can create an impression that's not useful, unless you look at the primary data yourself  (something I've encouraged readers to do from the beginning of this blog).

Good for a headline, but a tempest in a teapot.

Doc D
 
 

Saturday, April 23, 2011

Medical Quotes v2 - 23 Apr

 
A while back I read an article on science in the 20th C.  The author said something to the effect that, "In the past scientists would say 'here are the facts,' while nowadays scientists say 'here are the facts, and here's what we should do about it.'  I thought of that when I read the following:

"It may seem strange to say it, but experts are rarely interested in getting at the truth, whatever it may be.  What they want to do is prove that certain things are true.  Which things?  Well, whatever they happen to believe is true, for whatever reasons, or whatever will benefit their careers or status or funding the most.  Hawkers of diet plans need their gimmicks to help people lose weight...--if there's evidence that their advice doesn't in fact pay off, don't expect to learn it from them."
--Wrong:  Why experts* keep failing us, by David H. Freedman (2010)


Doc D
 
  

Health Care Incentives: Are We "Consumers?"

 
Argument among columnists and politicians:  are we "consumers" of health care that can make good choices or not?

Liberal economist Paul Krugman says (New York Times Op-Ed, Apr 21) we can't because it requires too much specialized knowledge for us to decide whether we really need health care or not.

Others say (WSJ Health Blog, Apr 22) that if we ask people to pay some of their own money for health care, it will make them more circumspect.  Conversely, where they pay nothing, there's no incentive to not abuse the system for unneeded care.

Both arguments have their points.  But I would tell Mr. Krugman that our health care decisions are already consumer-based.  We just have to consult someone...like a doctor we trust...to get the pertinent information to make that call.

We're not helpless because we aren't experts at everything.  We use experts to buy cars and other appliances (e.g., Consumer Reports), because we haven't studied refrigeration repair for several years.

And having to put in some of your blood and sweat usually makes you think before acting, at a minimum.

Those who can't afford much should pay little, that's just common sense.  But our system of government subsidies is abused.  Every doctor I know who sees Medicaid patients is aware that seem pretty well off (late model Cadillac Escalade, iPhone, expensive jewelry, etc) but see their free medical care as their right. Either they have other undeclared income, or somehow they've become qualified for the program.

Some of our other patients who are struggling to pay bills, but don't have as much material wealth, are very angry that they pay the taxes that get these folks their free care.

In any case, this is not about the broken system.  It's about personal freedom and responsibility.  I come down mostly against Mr. Krugman. 

My experience as an adult is that people value only what they earn, not what they are given.

Doc D
 

Friday, April 22, 2011

Oh Woe! What Shall We Do With Medicare/Medicaid?

 
Everybody agrees Medicare/Medicaid reform is essential to avoiding economic meltdown.  But how?

Human nature being what it is, the citizenry is showing great political will to place our financial house in order, and to do it by controlling spending...in particular, government spending.

As long as they personally aren't adversely affected.

Not possible.

Controlling federal spending is a tough thing to do when incentives to spend for one's constituency are combined with the power to print money.

For what it's worth, I found the table below that compares two different plans to bring down Medicare/Medicaid costs.  The descriptive information is pretty good, but the arguments for and against are incomplete and slanted.

If the graphic is not readable in this post, click here to go to the original.




From the New England Journal of Medicine, Apr 20, 2011

My complaints about the arguments for-and-against are the following:  (1) incentives to reduce cost lose effectiveness over time, (2) government is the main driver of health care costs not industry or providers, (3) competition (which we have not had in health care for decades) is an effective measure when implemented properly, (4) increased cost sometimes is a good thing--forcing people to prioritize health care appropriately to their situation, and (5) some people are disciplined enough to use health savings accounts others are not (usually because they expect somebody else to pick up the tab).  I could go on...

My advice to the government is to quit playing ideological games and try all these methods.

But let reforms prove themselves first.

Doc D
 
 


Thursday, April 21, 2011

Medical Quotes v2 - 21 Apr

 
Dr.  Groopman on choosing patient therapy.

"But today's rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.  Statistics cannot substitute for the human being before you; statistics embody averages, not individuals."
--How Doctors Think, by Jerome Groopman, MD (2007)


Which is why the government shouldn't be setting up "comparative effectiveness" efforts in concert with "payment advisory" boards.

Example:  If a new cancer therapy "only" extends life for three months "on average," and therfore is not approved for reimbursement, this means some people will live much longer, and some will live less long.  What if you are one of the ones who would do much better than average?

Doc D
 

The Return Of "Medical Quote Of The Day"...Sorta

 
In the past, I would post a historically famous medical quote.  But there are only a finite number available, so I quit.

I'm going to post quotations from current writings.  It won't be every day.

The goal will be to present thoughts from books and articles I'm reading that struck me as significant.  I may agree or disagree, but the point being made seems important, or witty.

The first will come later today.

Thanks for reading.

Doc D
 
 

The Best Seller List....Pharmaceutical, That Is

 
WHAT'S on the list is less interesting than the comparison between the "most prescribed" and the "most sales revenue" lists.

As usual, most of the most popular and expensive items are those you would expect from a modern, immensely prosperous society:  drugs to combat eating too much, being anxious, and suffering from various aches and pains.  You can see the most-prescribed list here, and the most-revenue list here.

----From the most prescribed list,

-Vicodin (#1), an opiod derivative for moderate to severe pain.  The marketing niche is (1) less nausea and stomach upset than codeine--from which it's derived, and (2) cough suppression.  Addiction is a hazard.

-Simvastatin (#2), lowers cholesterol, raises HDL.  A solid statin, that's generic and cheap.  As good as the high-priced spread...but suffers from not being the "designer" drug of choice.

-Azithromycin (#6) and amoxacillin (#7).  Antibiotics that cover most common infections, like strep throat, etc. cheap.

-In the top 25 most-prescribed, there are 4 pain pills, 7 blood pressure pills, and 4 psychiatric agents.

An addendum on blood pressure pills:  At #10 hydrochlorothiazide, old as the hills, dirt cheap, and the first choice for BP, is holding it's own in the middle of the pack.

The Weirdness Award goes to Prilosec (#6) for acid reflux.  It's estimated that over half the people taking it wouldn't need it if they didn't eat a bund of tacos or pizza within hours of bedtime...and lost a few pounds.  Nexium, the high-priced spread on the revenue list (#2), is for the same thing, and has no therapeutic advantage over Prilosec.

----From the best-seller list (by $$billions spent):

-Lipitor (#1) the high-priced spread for cholesterol  (#12 on the prescribed list above).  Lots of sex appeal.  $7.2B

-Crestor (#8), a newer and still expensive cholesterol drug, has jumped onto the list with almost 200% increase in revenue over the last five years.  Could be that Lipitor is losing it's sex appeal, according to columnist Matthew Herper.

-Three drugs for rheumatoid arthritis and other auto-immune problems:  Enbrel, Humira and Remicade (#12, 18, and 11, respectively).  Bio-engineered products, fusion protein or monoclonal antibody.  All together $9.5B

______

I would love to do a study on the psychosocial aspects of drug sales and prescribing.  How much of the drug use above is reasonable, giving the individual patient's needs?

Doc D

Wednesday, April 20, 2011

Hannibal Lechter Implements Health Care Reform...The Movie

 
It's hard to find anything encouraging in health care reform these days.  Most of the process comes out like Silence of the Lambs, Part 2.  (We're the lambs, of course).

As the country's financial situation slides, Standard & Poor's give the government a warning over possible loss of credit rating, and the President gives a passionate speech on his version of deficit reduction that goes over like a soggy French Fry (according to the polls. See here), the citizenry's anxiety level rises.

Meanwhile over at Health and Human Services, they are handing out waivers to the requirements of the health care reform law like lollipops at the doctor's office...and now giving bonuses to Medicare Advantage programs to keep them afloat.  Yes, these are the programs that are so wasteful the PACA phases them out and "saves" hundreds of billions that will be spent to cover the new 32 million covered patients.  This is more of the government's New Math, where we take away with one hand and give it back with the other...and no forward progress is made.

But if you think that's bad, listen to where we're headed.  In Great Britain's National Health Service, the model from which our Medicare director and Administration get their ideas for how national health reform should occur, a recent study by
"The Kings Fund says statistics for February show 15% of patients waited over 18 weeks for treatment, the longest time since April 2008...The official waiting figures are only part of the picture. As the BBC recently found, some parts of the NHS in England have introduced new restrictions on treatment or put routine operations on hold for several months. None of this appears in the [government's] statistics as it occurs before the clock starts." (BBC News Health blog, Apr 19)
What's going on there, and what we risk here, is a focus on social engineering to numeric standards...like waiting times.  Prior to this year, Britain's government pushed to track and keep the waiting period low, but found that hospitals were admitting the "quick turn around" cases preferentially to keep their waiting times down.  So this year, the government decided to let up on tasking hospitals to the 18-weeks.  Now the serious cancer cases are getting put in more quickly, but other less lethal, but needed, care goes into the "not-right-now" bin...and waiting times climb.

Either way, the result is pernicious.  The underlying problem is the attempt to cap cost by reducing care.

...Which we are rapidly implementing in the US, through the President's Independent Payment Advisory Board (IPAB), a 15-member, un-elected council appointed by the President who will advise him on policies to keep costs down.  The law forbids the Board from recommending most things.

"Since the board is not allowed by law to restrict treatments, ask seniors to pay more, or raise taxes or the retirement age, it can mean only one thing: arbitrarily paying less for the services seniors receive, via fiat pricing."
For more on the IPAB, see here (WSJ, Apr 20).  I thought we all decided (including most economists) back in the 70's that price controls never work in the long run.
"As a practical matter, the more likely outcome is the political rationing of care for the elderly, as now occurs in Britain, or else the board will drive prices so low that many doctors and hospitals drop out of Medicare. Either alternative would create the kind of two-tier system dividing the poor and affluent that Democrats claim is Mr. Ryan's mortal sin."
The evidence is getting so overwhelming that the government can't make this flawed reform work, that some  analysts supportive of HCR are throwing in the towel, saying, "Yes, rationing will occur, but you'll like it, and it will benefit the country if not you, personally."

As Sheriff Ed Tom Bell says in the movie No Country For Old Men, "If this isn't a mess, it'll do 'til the real mess comes along."

Doc D
 
 

Tuesday, April 19, 2011

Low Carb Diets Cause Weight Loss...Because They Restrict Calories...Duh

 
I've yet to find a miracle diet that is not a scam or doesn't rely on eating less calories to work.

USA Today Your Life blog (Apr 18) has an article on a couple of popular, and new, low-carbohydrate diet books.  The nutritionists they consulted weren't very impressed.

There are always some diet books on the best seller list.  The main draw is their title:  they promise either a substantial loss of weight, or results in a short period of time, or some improvement in body appearance...or any combination.

The latest fad is the low-carbohydrate diet, offered in a number of forms.

One very popular diet tries to make the case that rapid alterations in food categories will "confuse" your metabolism, a state called "metabolic confusion" (a term made up by the author).  I guess if your metabolism is confused, it won't know what to do with food. 

This is laughable.

I've yet to find one that, when you dig in to all the hand-waving about avoiding this food, or eating more of that one, doesn't come down to just a caloric restriction, below the daily requirement.

And no matter what you eat, if you eat less than your body needs...you will lose weight.

Voila!

Secret revealed.

Doc D
 
 

Sunday, April 17, 2011

STUDY: Increased Infant Head Trauma During The Recession...Not Yet Validated

 
Unfortunately, this is an unpublished study, and has not been peer-reviewed.  Also the numbers are small.

Researchers try to be alert to changing social and economic influences on health.  Sometimes a casual observation can lead to a formal assessment of a health risk.  On occasion, policies to mitigate or prevent harmful socioeconomic impacts can be implemented.

Since the recession began, there have been literally thousands of articles about rates of crime, abuse, drinking, overweight...you name it...all trying to show that when things are bad, bad things happen.  It sounds stupid, when you say it like that, but that's the underlying concern.  Most of these studies are rapidly performed and poorly controlled, so they don't help much.

But that doesn't slow down the media.  They report them all, breathlessly...as in this case (USA Today Your Life blog, Apr 16).

This study, performed by a third-year medical student is being presented at a scientific meeting.  But, since it has not been peer-reviewed or published, the results casn't be accepted uncritically.

We all remember the studies of crime back in the 90's that resulted in public demand for greater protection...only to learn that crime rates were already falling...and have continued to fall.

Also, recall the debacle back in the radical feminist heyday about spouse abuse during the Superbowl game.  It was widely circulated in the press and advocacy literature that a study had found that spouse abuse doubled during the timeframe that the Superbowl game was being played.  The unspoken assumption was that husbands and other males were beating up on women as a result of their violent tendencies.  This was a period when the "All men are rapists" theology was being preached.

And, come to find out, no such study existed.

So, here's what the med student found:
"A total of 43 cases of NAHT [non-accidental head trauma] occurred in the 31 months of the recession period (December 2007 through June 2010), compared with 50 cases during the 72 months of the non-recession period (December 2001 through November 2007), which represented a 101% increase."

No data on how the rates changed and when, exactly.  From 2001-2010 there were 93 cases of NAHT in infants under 2.  These are relatively small numbers.  No information is yet available on whether changes in diagnostic criteria or more accurate reporting could be ruled out.  While the results are alleged to be "significant"  the article doesn't say "statistically" significant, and gives no figures for that analysis.  Overall, trauma decreased during the recession, and accidental infant head trauma also went down, according the their data.

But, as usual, the press picks up on this preliminary progress report for its inflammatory value.

Studies like these are sometimes a valuable guide to prevnting harm due to socioeconomic changes.  Just as often they are a red herring (like the study of leukemia in children living close to electrical transformers...cherry-picked and biased data that took several years to de-bunk.).

Those who are predisposed to a belief that the recession can lead to greater intentional infant trauma will believe, despite the limitations.

The press can always jump the gun to sell the news, but the rest of us need to wait for the science to be validated.

Then we can talk about health policy.

Doc D
 
 

Friday, April 15, 2011

Cure For Everything Discovered

 
Obviously this is sarcasm.

I read dozens of news articles and research studies every day.  And every day there are at least a half dozen "breakthroughs."

Here are some from the last two days.  They all sound great, and the concept behind the proposed therapy--or cure--is novel or intriguing.

--Gene Therapy for Pain

--Pancreatic Cancer Vaccine Trialled

--Sensor Determines If Packaged Meat Has Spoiled  (it changes color in the package)

--Injectable Gel Could Spell Relief for Arthritis Sufferers  (it releases drug from the gel only when arthritis is acting up)

And, for a bit of humor,

--Human Factors/ergonomics Research Leads to Improved Bunk Bed Safety Standards

We've ALL been waiting for that one.

The problem is, historically, most of these won't pan out.  Human trials, and post-marketing research--even if the therapy gets that far--have been the downfall of most great ideas.

The gene therapy for pain will turn out to be placebo effect, the vaccine for pancreatic cancer will have some impact but cause creeping jungle rot (or something else), the gel will release too much or too little drug, and the sensor will "sorta" turn colors where you can't really tell whether it changed or not (like some of the early pregnancy tests).

So, they are fun to read about, but don't get real excited yet.

Doc D
 
 

Thursday, April 14, 2011

Smokers Think "Slims" Are Less Harmful

 
The power of words to alter or confirm belief.

I was trying to force myself to study a boring paper on comparative effectiveness research in medical therapeutics when I came across a reference (Science Daily, Apr 12) to one of those How-Can-People-Be-So-Stupid studies (Addiction, Apr 12):  a survey of cigarette smokers' beliefs about cigarettes.

Socialists re-branded themselves as Social Democrats, liberals want to be called "progressives."  The world is filled with people who are trying to use language to change perceptions.

In the US, companies may not, by law, use the words "light," "mild," or "low-tar," with reference to their tobacco products because they give the false impression that the cigarettes so labeled are less harmful.  Not every country prohibits this deceptive practice.

But in a country where 26% of adults surveyed think that health care reform was repealed, it's probably not surprising that smokers would come to have false beliefs about cigarettes.

This survey-based research found that one-fifth of people who smoke think that if the cigarette brand is labeled with the words "slims" or "golds" or "silver", then they are less harmful.

[Insert:  Other beliefs smokers delude themselves about are that "cigarettes with harsh taste are riskier to smoke than smooth-tasking cigarettes, filters reduce risk, and nicotine is responsible for most of the cancer caused by cigarettes." (from the Science Daily article]

Lest you think the situation can't be worse, the researchers who did the study advocate restricting advertising language further.

Chasing after adjectives is a losing proposition.  If you write a law against "slims" and "golds" then companies will just shift to another set:  "trims"  "low-cal" "organic" (how can fight that one?). 

Imagine "Marlboro Anti-Oxidants," or "Vita Kools."

I don't think these people are fooled by the words.  In fact, they know smoking is harmful and are desperate to find some mitigating or modifying feature in order to continue the habit.

It lessens the cognitive dissonance:  we form beliefs that are in line with our needs, and when conflicting evidence arises we modify the interpretation of the evidence in order to persist in our beliefs.   Standard human psychology.

So, the answer isn't more laws about language.  People will always find a way to believe what they want to believe.

There ain't no cure for human nature.

Doc D
 
 

Tuesday, April 12, 2011

STUDY: Doctors Choose Riskier Treatment For Themselves Than For Patients

 
Because I feel comfortable taking a chance for myself, but not for patients.  Is that surprising?

I saw an article by Assoc Press (Apr 11), that described a study of over 700 primary care doctors.  Given two scenarios in which an alternative treatment choice was available, and where the choice came down to a greater risk of death versus risk of long-lasting complications, doctors were more likely to go for the gold:  a higher risk of death in order to have lower risk of complications.  They recommended this option less often for their patients.

I don't find anything surprising here.  From day one, I was taught "do no harm."  In general, death was considered the greatest harm.

That's not always the case, of course, but it tends to be the standard against which alternatives get measured.  Yes, there is a "living death" that many would not prefer, and certainly some patients would also prefer to take their chances rather than suffer complications for a long time.

When there are treatment alternatives, there is an ethical imperative to present them both, giving your judgment as to the relative merits and dangers of each.  Almost every time this has happened to me, I have to give a summary and refer the patient to outside data (journals, etc) if they wish to check it out themselves (some people don't want to).

It's impossible to say everything.  And it's not possible to communicate eight years of training.  But you do your best.

The scenario in this study asks what physicians say if the patient, after all the explanation, says, "What would you do if it were you?"

The bottom line is, I will sometimes take more risks when I am risking myself.  I own this body, and can make those decisions.  I don't own the patient's...and will err (if there is any error) on the side of caution.

The scenarios used in the study were (1) a colon cancer treatment decision, and (2) treatment versus no treatment for influenza.  The choices were described in some detail.  The conditions were reasonable, and ones that could--and do--occur.  I recommend reading the details; you can find a fair description at Science Daily (Apr 11).

[The scenarios compared relatively small but real differences in risk. Most patients obtain a cure from colon cancer, and few patients die of the flu]


For Onion Peelers, the study is here  (Arch Int Med, 7 Apr):
"Among those asked to consider our colon cancer scenario (n = 242), 37.8% chose the treatment with a higher death rate for themselves but only 24.5% recommended this treatment to a hypothetical patient (21 = 4.67, P = .03). Among those receiving our avian influenza scenario (n = 698), 62.9% chose the outcome with the higher death rate for themselves but only 48.5% recommended this for patients (21 = 14.56, P < .001). "

Note that the cancer treatment scenario showed a trend, but didn't quite reach a p-value of 0.05.  With 700 study subjects, we should take this with a grain of salt.

I can only speculate that the differences between the results of flu versus cancer represents a psychological element:  i.e., a perceived difference in how serious the two diseases can be.

The lesson here is, if you ask your doctor how they would treat themselves, you should realize that this opens a door to a different set of values...theirs.


Doc D
 

Sunday, April 10, 2011

We Now Have A Budget, 6 Months Into The Year...With Health Care Riders

 
Health care implications of the budget compromise.

It's funny how no news outlet made the point that this budget deal is actually for the fiscal period that began last year, that we've been operating without a budget since October.  Normally Congress works the budget through the summer and passes it in September.  Democrats, sensing their big election losses, thought it would be to their advantage--in a year where the public wanted cuts--to avoid even beginning a budget, and leave newly elected Republicans the tough work of debt reduction.  Cowardly, but typical for Washington.

I haven't read any of the legislative language, and probably won't.  The media opinions are all over the map, with a big emphasis on discussing which party won or lost.

Who cares about that?  Unemployment, recession, debt, housing, unsustainable entitlements....and the press wants to talk about such childish stuff?

Some points I picked up:

--Planned Parenthood still gets their money for women's health, but Dems had to agree to vote on defunding it at a later date.

--Same thing with health care reform.  Not repealed, but the Senate had to agree to a vote in the future on repealing it.

--Then there is the death of a thousand cuts:  riders in the budget deal that force audits of health care waivers, studies of premium increases, and a number of other provisions aimed at exposing the "warts" in the reform law.

The budget battle goes to show that people are worried about the country's debt, but will fight tooth and nail to make sure it's only other people who will suffer from spending cuts...not themselves.

Now Congress begins "girding their loins" (did you know this phrase comes from the Bible and refers to tightening up your clothing to prepare for work?  I didn't) for the bigger battle of the upcoming budget for 2012, which is supposed to be passed before the fiscal year begins in Oct 2011.

Remember back when Congress used to budget in advance?

And don't forget the impending battle to raise the debt ceiling....again.

Doc D
 
 

Saturday, April 9, 2011

Government Shutdown? No. Elf Ears? Maybe

 
After all the inflammatory rhetoric about government shutdowns and setting back women's right 100 years*, I was curious to see what impact there would be.

Since anti-deficiency laws gives exemptions from a shutdown for police, fire, medical and military, it wasn't clear how much of a hit there would actually be.

In my area, reporters were desperate to find people who could be scared into crying on camera (a military spouse) or telling us how agonizing it is for the long line waiting to submit passport applications (like these people haven't putting it off, and suddenly had to scramble).

In any case, the shutdown hoopla sucked all the air out of the medical news, except for this tidbit.

"Elf-ear surgery: Trend, and sometimes hoax"  in the Orange County Register In Your Face blog (a "cosmetic medicine" site), Apr 8.

Surely people are not really doing this.  But from the comments section, I have to admit that wanting big round boobs at age 65 is not really any different.

There have been wackier things.  You can always find somebody who wants to undergo anything.

Here is an alleged post-surgical elf-ear:




Is it a hoax?

Doc D
 
 
*PS:  Money is fungible.  This means if you give federal money to an organization that does abortions, they just shift all their spending on women's health screening and counseling to the federal funds, freeing up the private money for more abortion spending.   Everybody who's done budgeting and planning knows how to do this.  Stupid allegations, meant to sway the uninformed.

Thursday, April 7, 2011

Training Doctors: More Rested, But Less Experienced?

 
It's accepted that limited work hours leaves doctors-in-training more rested (and alert?), but some research and anecdotal data suggests that patient safety hasn't improved and fewer hours means less experience.

A review of research on working hours versus patient outcomes, published in the British Medical Journal (Mar 22), put the good face on reduced hours by saying that reduced hours have not made patient safety worse.  Well thanks for the obvious, but our real question is why reduced hours haven't made patient outcomes any better?

And some research is surfacing that fewer hours disrupts continuity of patient care (patients get handed off several times to different doctors) and in some specialties doctors aren't seeing enough cases of uncommon diseases (so when those diseases occur later in their career they are less prepared to diagnose and manage the different presentation and course the diseases could take), nor doing enough surgical cases of each type of procedure to reach a good level of technical competence.  None of this was anticipated by the "Reduced Hours=Patient Safety" reformers.

The proponents of fewer working hours have been telling us for years not to worry about these issues.  The benefit in patient safety outweighs any such concern.  But now the data is starting to emerge that the promised benefit isn't surfacing.  See the editorial in the British Medical Journal that asks, "How come?"

But you tell me:  do you want your appendix taken out by a newly trained graduate in general surgery who has done 10 appendectomies, or by one who has done 50?  These numbers are illustrative and not from any data I possess, but you get the idea (see Archives of Surgery, Jun 2010, for survey results from reduced surgical training hours in Switzerland).

Doctors have strong feelings on both sides of this question, and argue with the same intransigence as the politicians do about the budget crisis.  Attitudes on both sides are sometimes silly ("If I did it, they can do it" is not a reasonable argument).

I confess to have done my training in an era when there were long working hours, and the culture insisted that any off-duty time was "as opportunity arose."  This meant 100-120 hour work weeks in the first years.  I sometimes did not leave the hospital for three days.  One rotation on the cardiovascular surgery ICU (60-bed) required that the resident stay in-house for two months.

And I was often tired.

Sounds insane.  But, on the other hand, I got to see ALL the patients, from start to finish.  Nobody sent me home in the middle of an operation because I had reach my work-hour limit (anecdotally, this is happening).  I did my own appendectomies, amputations, hernia repairs, breast biopsies, gall bladder surgeries, and assisted on major trauma....in the first year.  After the end of my first year, I had seen and learned more than I could have imagined possible, and performed procedures over-and-over again, fine tuning my skills.

But, "Safety!", you say.  What about the poor patients who had to suffer through me learning on them?

Here's how it worked.  I evaluated the patients first.  Behind me was a more senior resident who saw them again, and checked my work, gave me feedback or criticism.  Then there was a chief resident to oversee both of us, monitoring what we did and approving or modifying our plans.  Then behind all three of us was a staff physician, who was often an academic, who supervised and taught the whole team.  It was a step-wise increase in responsibility and authority, with oversight at every level.  We never hesitated to turn to the next in line when there was a difficult diagnosis or a question about what to do.  It wasn't perfect, nothing is.

But I sure would have had a good time working  a maximum of 48 hours a week.  Instead of having a "lost decade" from the first year of medical school to the last year of training, I could have seen a few movies, dined out occasionally...maybe a trip to the beach every once in a while.  To this day, I can't tell you what went on in the country during that decade...music, politics, movies....zilch.  Jimmy Carter was what?

My spouse worked and children didn't come along until late in the process.  That's the only reason relationship and family survived.

We've crossed the Rubicon on training hours, though.  Regulatory agencies have taken charge, and any violation of work-hour limits is punished by residency-credentialing authorities.

Either way--fewer hours/less experience versus longer hours/more experience--there are problems.  One benefit of fewer hours is clear:  trainees now have a more enjoyable life...and fewer breakdowns under pressure.  But guess what?  The pressure is life-long, not just during training.

Some insist that the answer is to lengthen the training.  But it already takes 7-12 years after college.  I earned my first paycheck, in my own practice, just shy of 30 years old.  I'm not sure that's the answer.

The answer remains elusive, but one thing is clear:  actions have consequences.

And reformers often turn a blind eye to the unintended consequences of their grand plans.

Doc D
 
 

Wednesday, April 6, 2011

Estrogen Replacement And Reduced Risk Of Breast Cancer. The Caveats.

 
Lots of news today about a large study showing reduced risk of breast cancer in hormone replacement therapy (HRT).  But most articles don't list all the limitations in the study.

We've heard scary stories about the use of hormone replacement, based on research done over the last twenty years.  More specifically, higher risk of breast cancer, heart disease, and stroke.  Combined estrogen-progestin was the main offender, but all replacement has been thought to confer some risk.

Now comes a large scale, government study (NIH, not industry) from the Women's Health Initiative (WHI).  The WHI was started twenty years ago and has followed a number of women's issues.  You can see one example of the news reporting here (Assoc Press, Apr 5).

The study showed a 23% reduction in breast cancer for those women taking conjugated estrogen versus placebo.  And no increased risk for a range of other conditions.  Mean estrogen use was 5.9 years; follow up was 10.7 years.

Everybody is surprised, and a few are questioning the results.

But if they knew the narrow focus, and specific conditions of the study, there would be less discussion.  Here are some:

1.  The conjugated estrogen taken by the subjects was equine in origin.  This leaves open the question of whether synthetic estrogens, now used by many women, may impose more or less risk.
2.  Only the women who took estrogen after hysterectomy had the reduced risk.  Taking estrogen-only for the two-thirds of women over 50 who haven't had hysterectomy is thought to increase risk, so they are prescribed combination estrogen-progestin--also a risk but less so, and only when symptoms are severe.
3.  The study participants took the estrogen only until 2004--when risk was thought to accompany any use of hormone replacement--but were followed subsequently--not taking estrogen--until 2009.  That is, the treatment group had not taken estrogen for five years.  Many women take Ogen or other products well after menopause symptoms have resolved.  This study doesn't address post-symptomatic, continued therapy.
4.  Further, the reduced risk may be due to stopping the estrogen after symptoms resolve.  In other words, using estrogen in the peri-menopausal hysterectomy patient, and then subsequently terminating the therapy, may all be necessary elements of the reduced risk. 
5.  The age range included in the study was 50-79 years.  There's some data to suggest that women who began HRT before 50 or who take it in the late 70's are at increased risk.  The study can't answer this.
6.  After the estrogen-takers stopped the drug in 2004, the (low) increased risk of stroke found at that time fell to the level of risk of women who had not taken HRT.  So the risk went away when the drug did.  Again, this applies to estrogen from horses only.
7.  Lastly, the risks we're addressing here are relatively small to begin with.

If that isn't overwhelming enough, here's the data analysis for Onion Peelers,
"The intervention phase was a double-blind, placebo-controlled, randomized clinical trial of 0.625 mg/d of CEE compared with placebo in 10 739 US postmenopausal women aged 50 to 79 years with prior hysterectomy. [...] Over the entire follow-up, lower breast cancer incidence in the CEE group persisted and was 0.27% compared with 0.35% in the placebo group (HR, 0.77; 95% CI, 0.62-0.95)."

I've omitted a lot of the other risk data (hip fracture, etc) for simplicity.  Please see the study if you're interested.

The good news from this study is not that estrogen is safe; it's that we can see more clearly that risk differs depending on clinical history and the life stage at which hormones are acting.   This research makes distinctions about which patients need what, and at what time.

And takes women's health out of the "One Size Fits All" mode of thinking.

Doc D
 
 

Tuesday, April 5, 2011

STUDY: Food Addiction Brain Response Similar To That With Drug Addiction. But...

 
A small study showed that anticipatory changes in the brain of food addicts are similar to those seen in drug addicts.  But this isn't to say that the two "addictive" behaviors are equivalent.

I've had my say in the past about how we medicalize all repetitive human behaviors that have negative consequences.  Addiction is one of those categories where the public and some mental health experts have expanded the definition to include almost anything:  TV-watching, shopping, exercise, web-surfing.  I'm not sure we've adequately distinguished addiction from poor choice of habit.  People argue about this endlessly.

In any case, this study showed that some women who experience an "addiction" to food have changes in their brain--as measured by MRI brain scans--when they think about delicious food that are very similar to those changes that occur when a drug addict craves the drug.

That's OK, as far as it goes, but the researchers say in conclusion:
"Similar patterns of neural activation are implicated in addictive-like eating behavior and substance dependence."
This is where ambiguity arises over the types of repetitive behavior that we class as addiction, abuse, and dependence.  The authors don't imply that brain activation makes for identical physiologic mechanisms, but the use of the word "dependence" may create a false impression that they are.

Definitions vary, but here is one way to distinguish addiction from dependence.

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry... characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviors and interpersonal relationships

When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped.

I interpret this to mean that addiction is a broad, inclusive term for a behavioral abnormality.  Dependence, while included in that definition, adds an element of tolerance and withdrawal.

To put it simply, food addiction is distinct from drug addiction due to dependence.  You don't have seizures and die during withdrawal from food addiction.  Further, there's an element of food consumption that's essential to life, not present in heroin consumption.

For Onion Peelers,
Food addiction scores (N = 39) correlated with greater activation in the anterior cingulate cortex, medial orbitofrontal cortex, and amygdala in response to anticipated receipt of food (P < .05, false discovery rate corrected for multiple comparisons in small volumes).

The authors recognize that the study was very small and confined to women, limiting its broader interpretation.  But this isn't good enough.  To show similar brain activity may indicate that our "craving" mechanism is universal, but doesn't mean food--as an addiction--is parallel to drug dependence.

Until we stop throwing every repetitive behavior into the "addiction" basket, and make causative distinctions, we won't design specific--and effective--remedies for such problems as obesity and drug abuse.

Doc D
 
 

Monday, April 4, 2011

2011 Pigasus Awards For Nonsense. Congratulations To Dr. Oz For His Second In A Row

 
The 2011 Pigasus Awards have been announced, recognizing the year's best in promoters of nonsense.

A hat tip to Dr Stephen Barrett at Quackwatch for spreading the news.

The James Randi Educational Foundation publishes the award.  See the full list of honorees here.  I won't spoil the suspense; go there to see the best in How to Thrive and Prosper by Promoting Drivel.

It's worth mentioning, after my criticism of Dr. Oz, that the good doctor has won his second prize in a row.  The first to be so recognized.  According to the JREF, in addition to his past promotion of  energy medicine, "tongue examination" diagnosis, and "John of God" the Brazilian faith healer, Dr Oz has surpassed his own record for silliness:
"This year, he really went off the deep end.  In March 2011, Dr. Oz endorsed "psychic" huckster and past Pigasus winner John Edward, who pretends to talk to dead people. Oz even suggested that bereaved families should visit psychic mediums to receive (faked) messages from their dead relatives as a form of grief counseling."
I don't know whether to laugh or cry:  laugh at the inventive wackiness of some people, or cry at human vulnerability.

Doc D
 

Sunday, April 3, 2011

Using Soy To Increase Radiation Therapy Effectiveness For Cancer

 
OK, soy improved cancer cell killing, but it also caused DNA damage.  Not a breakthrough, just a tiny step for mankind.

I was intrigued by an article in Science Daily that read "Soy Increases Radiation's Ability to Kill Lung Cancer Cells, Study Shows."  It doesn't take much to gather that while this sounds really great, the title of the article is clear that the study concerns cancer "cells" not cancer "patients."

And as expected, on reading the article, I found they were discussing cancer cells in culture in the lab, subjected to radiation, with or without a dollop of soy added.  More technically, the Human A549 non-small cell lung cancer cells were exposed to isoflavones found in soybeans.  Nostrums readers will know right away that what happens in the lab translates only occasionally into what happens in people.

Nobody involved in the study implied that eating soy would prevent cancer, or that eating soy while getting radiation therapy would help.  Rightly so.

Be that as it may, the missing piece of the story involves the implications of how isoflavones act.  Soy isoflavones act by blocking the DNA repair mechanism that cancer cells use to defeat the radiation therapy.

If you're really sharp, it may occur to you that if these isoflavones block DNA repair in the cancer cells, they may have an effect on normal cells.

And in fact that does occur.  The isoflavones caused DNA double-stranded breaks in the cancer cells (a good thing in this context).  They didn't have normal cells in the study, so we don't know what impact there would be on any normal cells.

However, the effect of blocking repair was greater than without the isoflavones.  Whether the damage caused would have any adverse consequences is well beyond what the study could assess.

What does all this data have to do with soy and getting cancer?  (1) For a long time, epidemiological studies have shown that Asians have lower rates of certain cancers (breast and prostate, but I'm not aware of any data on lung CA).  (2) They eat much more soy than Americans.  (3)  Isoflavones have anti-oxidant properties (a mixed blessing).  (4) And, at least one isoflavone has been shown to inhibit cancer cells (back to cells again, not people) and interfere with causing cancer in animals.

While this is interesting and worth exploring, it's not so QED that soy can prevent--or help cure--cancer in humans based on this alone.  Lots of work to do.

For Onion Peelers,
No data available.  The authors didn't record any quantitative results in the abstract.  A significantt gripe.  To the authors:  "lay it out, we're smart enough to wade through all the jargon" (Expressions of γ-H2AX, HIF-1α, and APE1/Ref-1 were assessed by Western blots. DNA-binding activities of HIF-1α and NF-κB transcription factors were analyzed by electrophoretic mobility shift assay.  Don't mean nuthin'.)

To the point, the news article sounds much more promising than what the science really shows.

But now you know.

Doc D
 
 

Saturday, April 2, 2011

Way Cool Radiation Dose Chart

 
For those of you who lie awake at night worrying about Japanese nuclear plant leakage...or medical X-rays.

A special thanks to the Randall Munroe.

Here's a smaller version of the chart.  For the mega version go here or click on the image.




Note that living within 50 miles of a nuclear plant for a year equals the same dose as eating one banana.

And flying coast to coast in an airliner is 8 times the dose of a dental or hand x-ray.

Doc D
 

Ruby Does Reiki, And Demonstrates Human Vulnerability To Quackery

 
I'm not a TV watcher, but my eye was caught by a TV "reality" show episode where the reiki nonsense played a part.

Most people have heard of the TV show Ruby.  An obese woman works to lose weight and we follow her through her travails.  It's the usual intersection of manufactured drama and reality...which media marketers refer to as "Reality TV."

I was reading, minding my own business, when I heard the word "reiki" from the episode playing in the background.  For those who have not been educated about reiki, it's a form of
...energy healing. These methods are based on the idea that the body is surrounded or permeated by an energy field that is not measurable by ordinary scientific instrumentation. The alleged force, said to support life, is known as ki in Japan, as chi or qi in China, and as prana in India. Reiki practitioners claim to facilitate healing by strengthening or "balancing" it. (adapted from Alternative Therapies, Mar/Apr 2003).
For a scientific assessment of reiki see Dr. Stephen Barrett's article on Quackwatch, or go to the research literature here (Intl Journal of Clinical Practice, June 2008), for a review of randomized clinical trials, where the kindest thing that could be said was
"In total, the trial data for any one condition are scarce and independent replications are not available for each condition. Most trials suffered from methodological flaws such as small sample size, inadequate study design and poor reporting."
It's amazing how often these nonsensical therapies are based on elements or forces that can't be felt, heard, seen, or measured by any methods known to science.  In fact, the proponents revel in the fact that they've discovered something that can't be verified  (that's why it's "special").   But notice that if something can't be verified or measured it's harder to debunk...which is to their benefit.

All dubious and implausible therapies rely on this.  And while it's true that "lack of evidence is not evidence of lack,"  we should not support claims that fly in the face of all we experience in the world.

Nevertheless, humans are extremely vulnerable--especially under the duress of pain and suffering--to suggestion and misinterpretation.

Back to Ruby.  According to a "close friend" (spouse, actually), Ruby has been inching her way to some sort of revelation that causes her to fail in her life, her obesity being the proximate result.  In this episode, well-meaning friends take her to see Gabriela, a Reiki Master (whatever that is...sort of like Glenda the Witch of the North, I guess).

Watching the session reminds me of hundreds of thousands of patients who'ved come to see me, troubled and confused, whose experience of the therapeutic session lets them open up to their distress.  Nothing to do with me or medicine...it's the setting.

Gabriela positions Ruby semi-supine and does some really comical hand waving and intense gestures, following by brushing hand movements (my wife asked me to quit laughing).  All without touching Ruby.

...who gets distressed and begins to cry, reacting defensively to a situation that's been manufactured by underlying problems and an expectation that something might actually happen.

Anyway, the session is a flop, and Gabriela is left standing there. Afterwards, her friends discuss the implications and everybody agrees that the Reiki Master "opened doors" to Ruby's feelings.  I agree that the setting was one where problems could surface.

One problem.  None of this has anything to do with reiki.  It's a consequence of setting and expectation.  Identical reactions occur in a doctor's office, with a psychotherapist, or in an intervention.   Or, frankly, in any situation in life where an event strikes a vulnerable chord.

Best of luck to Ruby, but I think the producers will continue to tease the viewers along, hinting around at a revelation to occur in the future.  What it will be is anybody's guess:  the stereotype for the Helping Culture is sexual abuse as a child.  But the specifics are unimportant.  The viewers are along for the ride, and the network will milk all the money out of it that people will tolerate...until they get bored with this fad and move on to the next.

I'm vulnerable to this stuff, too.  I don't think any of us are immune.  We are desperate for meaning and hope in life.  Immersion in stories like this is a form of virtual living.

And quackery like reiki steps right in to take advantage of that need.

Meanwhile, I need to get back to the planet Earth.

Doc D
 
 
Oh, BTW.  Don't write and tell this stuff helped you.  Of course it did, that's the point.
 
 


Friday, April 1, 2011

We're Still Too Ignorant To See How "Good" Health Care Reform Is

 
Happy Anniversary, Health Care Reform!  Most still don't want it.

There were a flurry of articles on the first anniversary of the HCR law's passage.  Even those who leaned toward hailing the achievement had to admit that it's not without flaws, and lacks support.  The meme is that people are still too stupid  to realize that it's a good thing.

So, just as a reminder, the most recent survey puts support for repealing the law at 58%, compared to 36% who oppose repeal.  Support for repeal has stayed strong at 50-63% for the last year (v. 36-42% opposed).

Americans trust Republicans slightly more than Democrats on health care:  46% to 42%.

About 4 out of 5 Americans are happy with their current health insurance (79%).  This has been stable for a long time.

So, here we are at one year.  Most of the big changes are still to come, but the Poison Pills in the law continue to grow.

Doc D
 
 

Thursday, March 31, 2011

Despite No Demonstrated Success We're Pressing Ahead With Accountable Care Organizations

 
The head of Medicare appears to say (IMO), "We're pushing ahead with Accountable Care Organizations (ACO) even if it costs more and doesn't improve quality."

Readers who looked closely at my posts on outcomes-oriented and performance-based approaches to health care have seen analyses and research studies that show they don't work...at least the way they are being implemented.

ACO's are another term for these efforts.  They wrap a health care team around financial incentives to be more efficient and reduce cost by paying more when certain standards of quality are met.  In other words, doctor groups that don't improve care or reduce cost will make less.  It's all about incentives...i.e., money.

Unfortunately, as I wrote, the government's demo of this concept under Obamacare provided too little in bonuses to pay for the initial investment over the first three years, and was unlikely to get better into the coming years.  All this, despite the fact that the Demonstration Project under HCR cherry-picked big, successful doctor groups to show how ACO's could work.

Dr Berwick, the President's recess appointment to run Medicare/Medicaid (remember?  it was feared his controversial beliefs would undermine Senate confirmation of the appointment) published a commentary in this week's New England Journal of Medicine (NEJM, Mar 31) that basically says, "Don't sweat the fact that the companies lost money:"
"What can we reasonably expect of the coming wave of ACOs? We know that not all previous efforts at developing a model of shared savings have met expectations."
But we're pressing ahead because it's the best "right" thing that we haven't figured out how to make work or achieve it's stated goals.

In the commentary, Dr. Berwick's nod to the demonstration product as having only achieved "modest" savings is Political Speak.  It means, "Yes, it didn't work, but we think it still will, despite the fact that we picked the doctor practices that we thought would surely succeed and even they can't recoup their investment in the ACO process."  For us simple folk, the businesses lost money.

I've written about Dr. Berwick's organization (The Institute for Healthcare Improvement) and it's Patient-Centered Care concept before.  See here for a criticism of what that means to the patient's ability to choose the care they need and want.

Several months after writing about it, I still think that Americans don't want Patient-Centered Care.  They want Patient-Directed Care.

Doc D
 

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