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

Sunday, February 27, 2011

At Last! Ice Cream From Breast Milk

Just what the world has been waiting answer to all our problems.

Go to the BBC News blog (Feb 24).  For those who can't pass up the nouveau sensation, stop by the Icecreamists restaurant in London.

Imagine you are an anthropologist some five hundred years in the future, and you come across a weathered and scored advertisement for ice cream made from human breast milk.

At the same time you see evidence of poverty, illness, crime and all the other ills that societies have attempted to address throughout the ages.

How would you put it all together?  Will they call this the Post-Modern-Post-Rational Age?

Doc D

Thursday, February 24, 2011

Survey: Half The Country Thinks Health Care Reform Was Repealed

It's enough to make you wonder whether democracy can work.

The news headline at the Wall Street Journal health blog (Feb 24) actually did say "almost half" think the law was repealed, but here's the real quotation:
"Previous polls by the Kaiser Family Foundation have consistently demonstrated that the country is deeply divided on the health-care overhaul law. But according to the group’s latest poll, almost half of those surveyed either believed the health law had been outright repealed (22%) or didn’t know enough to answer one way or the other (26%)."
One in four think it was repealed.  Amazing.

If you're interested in more on whether it's possible for a representative democracy to make good decisions, I recommend The Myth of the Rational Voter, by Bryan Caplan.  It's a semi-academic book, but there's a short, article-length version here.

In Caplan's view democracies make bad decisions because voters don't vote from knowledge of the issue.  Clearly if one fourth of us think the law was repealed, he's on to something.

Doc D

Wednesday, February 23, 2011

Doctors Handing Out Work Excuses To Support Political Protest

A long-standing practice becomes openly political.

Surely many of you have sought a doctor's excuse from work.  Plenty of my patients asked for one.  This has been going on for a long time, and most doctors I know don't really make an assessment of what the patient can and can't do, balance that against the type of work performed, and make a decision about physical capacity for work.

It's usually just an administrative pain in the neck that most docs just pencil-whip whenever asked.   If you've ever tried to argue someone out of needing one, they get mad, and then you just want to go on to the next patient.

So, now we allegedly have accusations of unethical behavior for writing multiple work excuses, sought by those who don't need it, so they can leave work to protest politically...and still get paid  See the Milwaukee Sentinel Journal, Feb 21)

Although there's a lot of hoopla on the airwaves and blogs, it's not clear what's being done.

If someone gets an appointment to see a doctor for a medical problem, and a doctor's work excuse results, I can't second-guess how it came about.   What happens in the examining room is confidential.

If people are just calling to say they want an excuse, or doctors are handing them out without seeing the patient, that's another matter...

I doubt that many doctors are doing it as an act of political protest.   Doctors don't care that much about labor laws.  A career without unions or defined working hours doesn't lend itself to sympathy over union contracts.

To the extent that doctors are pencil-whipping excuses for non-patients, or persons without a medical problem, there is an ethical issue.  Do you really want your doctor to accomodate you for convenience?   It may be to your benefit this time, but what about the next time, when the convenience benefits him/her rather than you?  If they are willing to bend for the former, they will do so for the latter.  Trust is undermined.

The ideal system for work excuses requires a doctor visit and evaluation, and a specification of what the person can't do (sit, stand, jump, lift, or they are dehydrated, etc).  If a person can sit but not lift, and sits at a desk all day, it seems silly to say they can't work.

There's nothing in the Hippocratic Oath about supporting political causes.

Doc D

Tuesday, February 22, 2011

STUDY: People Who Eat High Fiber Diets Live Longer, Or Vice Versa

This is one of those "associations" in science where you can't tell cause and effect.

Here's a quotation from the media's article on the research that appeared in the Archives of Internal Medicine."  (Miami Herald Health, Feb 22)
Researchers used data from the National Institutes of Health-AARP Diet and Health study that asked people ages 50 to 71 what they ate for the last year and how often they ate it. Researchers followed the participants for an average nine years, in which time 20,126 and 11,330 women died.  Those who consumed diets higher in fiber had a lower risk of death. The 20 percent of men and women who ate the most fiber (29.4 grams per day for men and 25.8 grams for women) had a 22 percent lower risk of dying compared with those who ate the least amount (12.6 grams per day for men and 10.8 for women).
The title of the news article was "Study links high-fiber diet to longer life."  Parse the words carefully...the media was careful not to explicitly state that eating high fiber will tend to make you live longer.  They just said there's a "link."
The link could be that healthier people who would naturally live longer happen to eat more fiber.
So, where's the beef?
Doc D

Sunday, February 20, 2011

Study On Heart Health: Nobody's Good Enough

We all get a failing grade in heart health.

I read the following title in Science Daily (Feb 18):

"Only One Person out of Over 1,900 Met AHA's Definition of Ideal Heart Health, Study Finds"

The AHA is the American Heart Association.  The article went on to list the multiple criteria that must be met to achieve ideal heart health.   It's the usual things:  weight, diet, exercise, blood pressure, cholesterol, etc.

Here's what got to me:  the assumption that this means we're all not doing our job.

But, if the standards (or "ideal") are almost never met, haven't we set the standard too high?  And whose business is it, anyway?

I was reminded of the following quotation from a book I'm reading called "The Servile Mind" by Kenneth Minogue.  His book is about political science--or, rather, government.  But you can see the analogue to "governing" our bodies:
[It is a] remarkable fact that 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 riding to hounds, or drinking too much...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 [emphasis mine].

It won't be long before the American Heart Association gets exasperated with us all.

But, I'm getting tired of being preached to.

So, here's an answer to the AHA:  buzz off.

Doc D

I Have A Cold, And I'm A Wimp

Another of the joys of caring for grandchildren.

Coinicidentally, I saw that Dr. Steven Novella had written a very nice post on Science-Based Medicine about treating the common cold.

I agree with the substance of his article.  Put simply, save your money; nothing much does a lot of good.  Most have some favorite anodyne, and if it does no harm and you believe in it...go ahead.  Witness the long list of comments to his post.

Non-steroidal anti-inflammatory drugs (NSAIDS like ibuprofen) are probably the best bet, with the caveat that I'm referrring to adults, and some people can't or shouldn't be taking them, due to other medical issues.

Go read his article, for a common sense and science-based review.

I want to make a pitch for the issue of "getting" the common cold.

I still run across patients who have some odd notions about contagion and prevention.

You probably saw the news reports about taking zinc in the first day of a cold, but for my money the science isn't convincing.

With regard to contagion, those who think that airborne transmission is the primary method (i.e., being coughed or sneezed on)--not true.

In fact, most transmission probably comes from immediate contact with contaminated surfaces.  This makes it very hard to be perfectly sanitary.

Squeeze that tomato in the grocery store? Grab that rail at church?  Lean on that counter in the bathroom?  The list of possibilities is endless.

BUT, handwashing can reduce the exposure greatly.  Just make sure you don't bite your nails, rub your eyes, etc, in between. 

And, while the hand cleansers are useful, I think about half the protection they provide comes from just being mindful of the cleanliness of your hands.   Plus, it's harder to disinfect all the surfaces of your hands in the same way washing with soap does, and it costs more.

In the end, don't wig out.  There are hundreds of these viruses out there; you can't keep dodging forever. 


Doc D

Thursday, February 17, 2011

Total Legal Challenges To HCR Law: Twenty-Five (Wow)

Pretty stunning numbers.

You can go here (Wash Post, Jan 31) for a detailed list of who, what, where, and when for each of the cases.  A good chart.  In typical fashion, the media includes which US President appointed the judge in the case.

Of the twenty five (25) suits currently underway that question the constitutionality of the health care reform law, only 8 or 9 have had some kind of preliminary ruling so far.  Note that some suits are large groups--like the 26-state suit--others are small, involving a special interest group (Secure Arkansas?).

Most of the judges that dismiss their case have done so on the basis that the plaintiffs do not have "standing" to sue.  To a non-lawyer like me this means that the people who sued can't establish that they have a legitimate injury to claim...or they don't yet.  My guess is that these probably won't go further.

Two (I think) of the dismissals were rulings on the actual constitutionality.

There are two that ruled for the plaintiffs that the law is unconstitutional.

We can expect the ones in these last two groups to be appealed.

[Caveat:  the situation is fluid.  I think I've got the numbers right.]

Doc D

Wednesday, February 16, 2011

STUDY: Great News. Ecstasy Use Doesn't Cause Cognitive Impairment (It's A Pre-Requisite)

Your tax dollars at work.  New evidence, contrary to previous studies, shows that ecstasy doesn't mess up your ability to think.

OK, they did a better study than before.  Previous efforts didn't control for other factors, like the use of other drugs at the same time.

But, removing the confounding factors from the eligible population of about 1500 left only 52 who could be compared to 59 controls.  Kinda' small numbers.  The study was published in the journal Addiction (Feb 11, 2011).

So, is it OK to use the drug?  According to lead author John Halpern,
"No. Ecstasy consumption is dangerous: illegally-made pills can contain harmful contaminants, there are no warning labels, there is no medical supervision, and in rare cases people are physically harmed and even die from overdosing."
Oh...the taxpayer funded part:  this was a grant from the National Institute on Drug Abuse.

I always thought "cognitive impairment" was what led to people using things like ecstasy.

Doc D

Tuesday, February 15, 2011

STUDY: Medical Devices That Are Approved Quickly Are More Likely To Be Recalled

A lot of finger pointing about recalled medical devices being more frequently a result of the accelerated approval process.

No duh.

See the Los Angeles Times Health Blog, Feb 15.

The FDA says the producers have been trying to get quick approval by claiming the new products are very similar to older, safe no big review or evaluation was needed.  The FDA gets beat up all the time for delaying approval of desperately needed treatment.

You can't have it both ways.   People want safe medicines and devices; this takes, on average, about ten years to accomplish (lab studies, animal studies, phase I, II, III trials, population studies)

On the other hand, people want advances in now.

So, under pressure, the companies AND the FDA try to thread the needle of getting more good stuff out quicker (for different motives).  Therefore, more problems surface.

Is this rocket science?

Or just politics?

Doc D

Monday, February 14, 2011

Slacking Off On Blog Posts

So, yeah, we've been taking care of grandkids.  A 2yr old and a 4yr old.

All the jumping, screaming, hitting, fighting, "I don't wanna...", "I don't like...,"  blah, blah, blah.

You know the drill.

But yesterday one of them got mad that her brother took her ball, and kicked the water line to the toilet.  When it began to gush water, she was afraid to tell us.   An hour later there was two inches of water in both bathrooms, into the bedrooms, etc.

So we spent most of the day vacuuming water and drying carpets.

I don't think we're going to need a contractor.

Tomorrow, we get paroled.  I'll taper off on the Valium, and see you then.

Doc D

Saturday, February 12, 2011

Friday, February 11, 2011

Utilitarian Health Care: The Best For The Most, Except For The Rest

I've been reviewing some of the literature on "outcomes-based" health care.  So far, a lot of promises, but not a lot of concrete evidence to show it works to improve care or costs.

Along the way, I came across a commentary in the Journal of the American Medical Association that addressed how another country is looking at an outcome-type system.  The article began with the following:
"The core purpose of a health system should be to maximize the health of the population. When the main challenge is managing long-term conditions, maintaining health rather than delivering health care per se should be the goal. "
--Toward an Outcomes-Based Health Care System: A View From the United Kingdom. JAMA. 2010;304(21):2407-2408. James Mountford, MD, MPH; Charlie Davie, MD
They lost me right there.

This is utilitarian thinking, the greatest benefit for the greatest number.  It works in the "macro" perspective, and can be argued effectively when you're talking about population vaccination rates.

But, it ignores the fate of those who don't benefit, just because most others do.  And I think, philosophically, that is an unethical approach to patient care (at the "micro" level).

I"m not talking about "death panels."  Where this would work to your harm is when you need a type of care that has been judged not to "maximize the health of the population."  You just have to "give it up" for the team, whether it's cancer chemo or an expensive type of surgery.

I don't think of myself as a population.  I think I'm pretty unique.

Doc D

Few Sign Up For High-Risk Pools Under HCR.

Predictions are political, of course.

The government predicted that 375,000 people would have signed up by the end of last year.

The number is currently at 12,000.

Recall that the high-risk pools were a safety net for all those people who were being denied coverage due to pre-existing conditions, and the Administration wanted to push this feature out early in order to generate support for their unpopular law.

Some other enrollment stats:

Washington, DC - 10
Maryland - 145
Virginia - 204

The problem is, just because you can get coverage doesn't mean you can afford it.  And that's one of things Congress failed to address successfully:  ever-rising costs.

Let's see if both parties get serious about constructing a sustainable plan.

Doc D

Thursday, February 10, 2011

Medical Cartoonville - 10 Feb 11

Justice is a heavy burden.

Doc D

Wednesday, February 9, 2011

Harvard Prof To Explain HCR In A Comic Book...Huh?

Everybody's having a lot of fun with a Harvard economics professor's announcement that he will write a comic book about health care reform.

We called them comic books.  I guess the politically correct term is "graphic novel."

You can go here (Assoc Press, Feb 9) and read some of the humor/sarcasm.

Everything from "Now even the dummies can understand how good it is" from supporters, to "Now even little kids can see how bad it is" from critics.

Is this what we get from our premier institution of higher learning?

Doc D

Tuesday, February 8, 2011

Survey: What Patients And Doctors Want From Each Other

And whether they're getting it. 

Consumer Reports published a survey, but you can see the gist of it from the Wall Street Journal health blog (Feb 8).

For doctors:  Only a third of patients thought their doctor was "very effective" at relieving pain and discomfort associated with their illness.

For patients:  One third of doctors said their biggest complaint was that patients didn't follow the treatment plan, which affected the outcome "a lot."

The rest of the survey had the usual stuff about communication and respect, nothing very startling.

But I have one pet peeve.  I have a tough time with patients who research the internet and come in with a stack of stuff and a diagnosis, expecting me to sign off on their efforts.  They are commonly very bright people who don't realize that we all have blind spots in our thinking.  Among them are the need to believe what we want to believe and disregard evidence that we don't like.

I do it, too.   And I've confessed to it in my own care...where I led myself astray.

Dealing with a pre-determined internet-based evaluation takes time.  I need to find out what the patient is seeing, and why, evaluate their reasons for thinking so (never forgetting they are sometimes right on), then ease into a new starting point to investigate the original problem if the case they make doesn't stand up. 

All in a twenty-minute appointment.  It doesn't seem fair to either of us...or those in the waiting room.

I'm willing to make a contract with a patient that I won't disregard or denigrate any firm conviction they have, as long as they will open up to my need to consider the issue afresh.

That's a healthy doctor-patient relationship.

Doc D

Monday, February 7, 2011

We Don't Need No Stinking Health Care Mandate

We've all been hearing about the constitutionality of the individual mandate in Health Care Reform.  NPR asks a few experts whether it's really necessary. (NPR Shots, Feb 7)

The government made the case that without the mandate, reform could not be sustained.   The uninsured would be freeloaders on the rest of the country, and premiums from the large group of the young and healthy were essential to pay for the care of the critically or chronically ill. 

The assumption of necessity was never openly questioned, although I've written a few things that suggest it isn't necessary, and so have some others.

NPR, from it's Lefty-but-painfully-trying-to-be-neutral stance, presents alternatives that all sound pretty cruel.  Suggestions that those who choose to opt-out of insurance would have to wait for the next round to enroll, or pay an extra amount for being delinquent.  It's all built around coercion as an ideological  and compulsory punishment for not falling into line.

But there are non-coercive ways to afford health care reform without punishing choice, or overcharging those who are ill and can't afford coverage.

Take a look at what NPR discusses and then I'll show some different alternatives.  Maybe a combination of policies from both groups makes most sense.

What an accomodation could do is keep us from a Consitutional battle that will either expand--in an unprecedented way--the power of government to direct our lives, or abandon health care for all. as unaffordable.

NPR (experts Jamie Court, Paul Starr, and Len Nichols):
 "You could offer discounts to people who sign up early. You could increase premiums for those who delay," he says. "Medicare actually does this."

"...if they choose to remain uninsured, he says, "you won't be eligible to opt back in and get any of the benefit of the subsidies or use new health insurance exchanges or buy without pre-existing conditions exclusions."
"...if people don't buy insurance when it is first available, "if you ever try to buy insurance again, you'll have to pay three times the market price, and we will put a gold sticker on your forehead and say to all hospitals, 'You do not have to treat this person; this person has forfeited their right to uncompensated care.' "

"Make the states do the hard work. Lawmakers could withhold federal funding in the health law unless states require people to have health insurance.
Just like the penalty under the mandate, these all punish people for choice.
By contrast see these suggestions:

Eliminate the employer-based tax deduction, and the individual health tax deduction.  At first, you might think this raises taxes on the worker.  No.  It gives the worker wages that the employer was keeping from them to pay the government.  Also, we have a progressive tax system; without a deduction, the wealthy will pay more.  Estimates are that this will generate several hundred billion dollars in revenue, while giving employees more income to spend for themselves (or on health care).

Put pressure on insurance rates to stay competitive by opening up the market, as it now is for car insurance.  This will eliminate New Yorkers paying 3-4 times as much for the same coverage as a resident of Columbus, Ohio, pays.

Pre-fund Medicare (as in pay ahead) and reset the age.  Quit expanding the entitlement through printing money.  Medicare was designed back when the average life expectancy was 62.  It's now 78.  Pass a law that says Congress can't raid the Medicare fund for pork and other earmarks.   Then we can live within the budget.  Right now our young adults are paying for the old folks, and the river will run dry.

Never curtail innovation by setting cost/benefit limits.  Reward innovation.  Other countries have stumbled by denying new care that has cost thousands of lives.  They only started paying for treatments after citizen protests.  How many died in Canada, New Zealand, and GB because these countries said that Herceptin for non-metastatic breast cancer was too unproven to justify the $55,000 cost of treatment?  Patients' needs are unique, not consistent with a computed average benefit.  In summary, get the government--who sets reimbursement rates--out of the business of deciding what care is best.

I won't go over tort reform, Medicare fraud, and all the other things you've heard about.  Those are sources of funding that can contribute to covering us all.  Tort reform works in my state, and no patients are harmed without plentiful compensation.  We just don't waste resources on frivolous suits.

The governments with big, coercive systems are running out of money.  They don't get as good care (despire arguments to the contrary:  yes, they get great care for common ailments, but their cancer survival rates are poorer).

So which approach sounds better?

And we don't need an individual mandate for either approach...or a combination of both.

Doc D

Medical Cartoonville - 7 Feb 11

Most health care people hate HIPAA.  This is the Health Insurance Portability and Accountability Act.  A Frankenstein monster.

Some pharmacies were selling customers names to drug companies.  It need to be stopped.  Instead of addressing that focused issue, Congress wrote an all-encompassing Privacy Act.   Bureaucrats then expanded on the regulatory power.

Now, I can't discuss a case with another doctor in the hallway, or link an identifying name or number to a case in an email.  Technically, those chart boxes on the wall in your doctor's clinic that have your record in them, so she can look at it before entering to see you, are questionable....they're exposed.

Along with boxing in any freedom of consultation and discussion to further healthcare quality, the law and policy-writers put in requirements that you document every time you discuss something with another professional.  There's a form to fill out.   And you have to post HIPAA regulations, and get people sign that they understand them (Did you understand all that legal jargon when you were standing sick, at the window?)

Absolute madness.  If you get upset that you can't get an appointment, it may be because I'm filling out forms (about 15% of most doctors time).

So, I think we are not far away from the following:

Doc D

Sunday, February 6, 2011

De-Bulk Your Super Bowl Calorie Festival

This is advice, of which I try not to do a lot.  I want readers to look at all the facts and make decisions for themselves.

But I ran across this on the USA Today Fitness and Food blog (Feb 5):
"imagine a typical Super Bowl party where over a three- to four-hour game, you eat four slices of pepperoni pizza (1135 calories), grab a beer (150 calories), eat six chicken wings (400 calories), then grab a couple dozen tortilla chips with some cheese salsa (600 calories). The total for just that short time: 2,285 calories."
You can have a rip-roaring time without that huge calorie load.

Enjoy the game, not the oral intake.

Doc D

Saturday, February 5, 2011

Medical Quote Of The Day - 5 Feb 11

The conundrum of demand for medical care versus the supply available.

"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 (Johns Hopkins Press, 2006)

Doc D

Friday, February 4, 2011

Keeping Up With The Woo: Medical Intuitionists

Medical intuition.  If only I'd known; it would have saved me ten years of rigorous and exhausting training.

The International Association of Medical Intuitionists is a real organization. You can bone up on their approach here.  They promise not to poke or prod you in the course of diagnosis, or cause any discomfort...heaven forbid.

Just Google medical intuition to find out how fast this is exploding.

My understanding of intuition is "a belief characterized by immediacy and founded on prior experience."  Philosophers have been arguing about this forever.  But, at one extreme it means knowledge without effort (it just "comes to you").  At the other extreme, it's something we all do:  when not everything adds up, we are bothered, and seek further.  That happens all the time when I see patients.  But it's not intuition in the former sense, it's just that subconsciously I'm not perceiving evidence fully or in perspective, and I need to gather more data.

The first extreme is hooey.  The second is an integral part of analytic thinking.  See where you think inituitionists fit.

There's a spiritual thread that runs through the methods (unexplained) and goals of the movement.

Here's what a Medical Intuition can do (from their website above):
--Provide specific information regarding the function of the organs and glands as well as the many different body systems.
[That's pretty cool.  I usually have to use all my senses, evidence, test results, and thinking skills to be successful.  Why have I been doing it the hard way?]

--Offer exclusive information regarding the function of the energetic body, thus revealing mental, emotional and spiritual issues that may surround your health concern.
[I think those issues have always surrounded your concerns, else you would be seeing a physician instead.]

--Reveal health issues that may go undetected when utilizing standard medical test 
[I can't argue with that.  These unsubstantiated approaches always seem to find something that can't be identified or investigated by any other means.]

--Offer you with a second opinion of your current health concerns.
[Definitely it will be.]

The referenced articles that allegedly support medical intuition are mostly by four people.  Titles like "Finding Your Authentic Space."

Here's the thing.  The claims are all purposefully broad and semantically ambiguous.  If the goal is to get you to think about your overall health, well and good.   But the description fails to lay a foundation for "how it all works" that can be validated.   And it ain't no substitute for breast cancer chemotherapy.

Maybe they can do some good, but I sure hope they know when to punt.

Doc D

Thursday, February 3, 2011

Your Government At Work. I Could Have Been Killed

We're weathered in, pretty much, but I had to run to the store.  It's heartwarming to know the government is there to protect me from respiratory and carcinogenic hazards.

This is the first time I've seen this warning on a product.

If you can't read the picture this is what it says: 
"CALIFORNIA PROPOSITION 65 WARNING:  Combustion of this manufactured product results in the emissions of carbon monoxide, soot and other combustion by-products which are known by the State of California to cause cancer, birth defects, or reproductive harm."
I'm eternally grateful for the huge mistake I could have made.  Those "emissions" sound horrible, and it gives me shivers to think how close I came to cancer...or reproductive harm (at my age).

Take a look at this dastardly hazard:

But it's cold, and I needed to light the fireplace.  So, to heck with it.

Now that I've had my little joke...the story's true...consider for a moment:

1.  California proposed a law or regulation that covered this product.  They probably spent several million dollars putting together the list of hazardous items.
2.  They hired people to write the regulation, which probably took a couple of years.  Let's say 10 people at $50,000 a year.
3.  The policy document went through an extensive review up and down, through the state agencies and political organizations, was revised several times, and eventually approved.
4.  A contract was let to produce the sticker for this product, containing all the correct words:  "warning," "emissions," "known," "cause."  (Imagine the fiery committee meetings where bureaucrats violently disagreed over whether it should say "causes" or "is associated with".  This is the stuff of legend)
5.  The industry, anticipating that if they didn't get the sticker on each box prior to the point when fines would begin--and force them to pull all their product off the shelves--rushed to get ahead of the state.

So, what did this cost the bankrupt state of California to let me know that matches catch fire and give off smoke...and that I shouldn't breathe it instead of atmospheric air?

For those that say, "OK, this was overkill, but we need to be safe,"  here's a quotation from The Bed of Procrustes, a recently published book of aphorisms:
"Don't talk about "progress" in terms of longevity, safety, or comfort before comparing zoo animals to those in the wilderness."
--Nassim Nicholas Taleb

For those that say it is a moral imperative that we protect our fellow man, here's one from T. S. Eliot:
"Half the harm that is done in this world is due to people who want to feel important.  They don't mean to do harm--but the harm does not interest them.  Or they do not see it, or they justify it because they are absorbed in the endless struggle to think well of themselves."
 If this sounds too libertarian, fine.  But there needs to be a balance between care for our fellow man (which doesn't include using public funds to tell me about matches), and responsible self management.

Rant over.

Doc D

Wednesday, February 2, 2011

Fears Of Radiation From Electric Utility "Smart Meters." You Have Just Entered The Twilight Zone

A boring day for medical items.  But if you want a hoot, check out the Orange County Register for wacky pseudo-science.

Apparently, the OC Register reports, (Feb 2) the San Clemente Council can't decide whether to put in "smart" utility meters that transmit their readings using radiofrequency.  This would allow meter reading from a distance, saving time, and labor.

But some citizens, and a couple of doctors, insist that their medical condition, electrohypersensitivity, exposes them to harm from the meters.

Here's the problem:

The meters do the same thing your TV remote does.


There's no such thing as electohypersensitivity.

The woo is taking over.

Doc D

Tuesday, February 1, 2011

Judge Rules Health Care Reform Unconstitutional In Its Entirety

What's shocking to a simple medic like me is how a single word in the legal system can have titanic implications.

The verdict wasn't unexpected, although some were shocked that the judge ruled the whole thing unconstitutional.  I've discussed that before:  Congress was too stupid to put in a sentence that said, "If one part doesn't survive, the rest can go forward."

Here's the shocking part.   The government claims that Congress can regulate interstate commerce under the Constitution.  And they can.  The courts have given great latitude, calling almost anything "interstate commerce."  For instance, if you plant tomato seeds from your last year's garden, you are engaging in "interstate" commerce because the spade you use could have come from somewhere else.  Nuts, huh?

But now, the common sense definition of commerce is under review.  Does the Constitution permit regulation of economic "activity" or economic "decisions?"

One single word.  The former means you have to be buying something before Congress can get involved.  The latter means any decision, even a decision not to engage in commerce is fair game.  This means Congress could regulate your decision to not buy a car, or which car you can or can't buy.

The plaintiffs argued that a decision to not buy health insurance was not commerce, because no commerce activity was involved.

And the judge agreed with the plaintiffs in a 78 page opinion that to an amateur like me, is fairly well written.

Along the way, the judge agreed with all the other judges that the government can't claim the insurance mandate is a tax at this late date, since Congress went out of their way to insist it was a penalty or fee if you didn't buy insurance.  That was just too egregious for any judge to buy.  There were other issues addressed that thrill legal theorists, but you can read them elsewhere.

This is the big 26-state suit.  The government has said they'll appeal.  So on we go to the next step.  The judge didn't issue a stay order, but he might.   The next court could either affirm, or set aside his ruling. 

Let the fun begin.  All unnecessary if we had a Congress that knew what it was doing.

Doc D

If Your Doctor Is "In It For The Money" And You're Getting Great Care, Where's The Beef?

Pay for Performance to improve health care quality is on a roll.  Maybe the assumptions are wrong.

A few days ago I submitted a post on Nostrums about a large-scale study done in the United Kingdom looking at a different way to pay physicians for providing health care.

As I explained, payment reform that emphasizes “outcomes” rather than services performed ( the old “fee for service”)—called “outcomes-based,” or in this case “Pay for Performance”-- has been touted as a way to improve quality in health care.  But it's also claimed `that it would act as a brake on costs, because physicians would no longer be motivated to do more than was needed.

In the US, believers in Pay for Performance (PfP) have gained control of the policy-making and are busily spending huge sums to implement outcomes-based payment. All of which assumes that there will be a positive impact on quality and cost. The study I described addressed that primary assumption that quality will improve when we incentivize payment toward results.

While no single study--no matter how good--can be definitive, there was little to criticize in the method. The study showed that if you look at the management of high blood pressure, both before and after a scheme for outcomes-based payment to providers and then looked at the quality of care the patients received, PfP made no difference in (1) how well the patients were monitored, (2) whether their blood pressure was controlled, and (3) the rate of complications that occurred in the population (strokes and heart attacks).

I thought at the time…and still do…that's enough of an input to cause us in the United States to pause as we're looking at reforming physician payment. That's not to say that reform of the payment system is not necessary, it's just that maybe this particular way of going about it is not the best, and doesn't incorporate other aspects of the delivery of healthcare that that need to be considered. See that post for more on the elements involved.

Coincidentally, I was rereading parts of a book I had read last year, Medicine and the Market: Equity v. Choice, by Daniel Callahan and Angela A. Wasunna. This valuable book avoids the politics and attempts to address the sometimes competing issues of equity and choice in the healthcare system. I found where I had highlighted a couple of quotes. This is the first.
Should I really care if my doctor is in it only for the money as long as he respects my dignity, treats me with empathy, answers my phone calls promptly, and provides me with high-quality care?
You frequently hear patients say, “He’s only in it for the money.” And certainly there are people who had the discipline and tenacity to endure 10 years of training for the primary purpose of making a great living or becoming wealthy. Too often it’s assumed that their motives corrupt their ability to provide the best care. But there’s no evidence of that. As in any career, there are scurrilous knaves, but almost all are not. The assumption that income has a corrosive affect on performance is false, because it conceals an underlying Romantic notion of perfect benevolence as a pre-requisite for good medical care.

However ethicists and policy makers have recognized for a long time that benevolence (not just empathy, but subordination of all other motives to doing good) is not achievable. To document this, the authors go back to Adam Smith (you remember The Wealth of Nations and the” invisible hand” of the marketplace from college, right?)
[Adam] Smith’s claim, as the historian Jerry Z. Muller has aptly put it, “is that an economic system cannot be based on benevolence, which is a limited sentiment not easily extended beyond those one knows.” ( from The Mind and Market: Capitalism in Modern European Thought, p 62). The great challenge, Smith believed, was to understand how to develop the potential social benefits of our propensity to self-love and self-interest. The market provides a way of increasing wealth while, at the same time, fostering social cooperation and valuable moral traits. Among those traits are discipline, delay of gratification, self-command, and prudence.
There's been a lot of interest in Adam Smith's work recently. Some experts are asking whether his formulation of self-interest could act in health care delivery as a social good. Referencing the quotation above, if your Dr. provides you with high quality care what difference does it make if she or he may be motivated by income?

On the other hand, if you insist that benevolence trump self-interest, other problems arise. Forcing benevolence in a global sense routinely collapses under the weight of coercion, patient dissatisfaction and regulatory interference.

If there was some way to say that good could come even in the absence of benevolence--leaving empathy in place, which all doctors are trained to evaluate and consider—and the result is high-quality medical care, what should it matter about payment?  Empathy is essential, see here for more.

I think this is a point that's worth considering, at least in the context of quality of care, particularly since it’s not clear that reform of payment using performance or outcomes will give us what we want..except more government agencies we don't want.

On the other hand, this says nothing about how physicians’ income motives can affect overall health care costs. That should be addressed. Solving the cost problem of ever-increasing demand will continue to be a challenge.
Many journalists and commenters want to demonize one or more segments of the health care system as a means of controlling costs: it’s the rapacious doctors, the evil insurance companies, the money-grubbing pharmaceutical companies, or the over-charging hospitals. All of this is useless class warfare, and is used cynically by politicians (who are pandering to ignorance, and know full well this is not the underlying cost problem.)

For those of you who subscribe to an “income disparity” view of the world, consider this: one economist said if we tax 99% of the income of the top 10% of the wealthy in this country, the money collected wouldn’t make a noticeable dent in the annual budget deficit.

Taxing the rich and cutting payments (or any type of price control) is ineffective. Most economists will agree that price-controls, price-capping and payment-reductions almost never result in a long-term cost reduction.

[SUPPLEMENT: I don't want to get into the psychology of how people make decisions about costs. Whether it’s buying a car or payment for medical services. This has been studied by psychologists for a long time. It's fairly clear that as human beings we are vulnerable to the influence of assuming that high-cost means high quality. And that's clearly not the case. Fixing our false tendency to think, if something costs more it’s worth more, is a seaparate problem, one that stems from defects in our reasoning, not problems in healthcare.]

When I step out of my doctor role, and enter the patient role, I look for competence and meticulous attention to detail in my doctor. If she/he wants me to come in for an appointment (for which they get paid) rather than prescribe over the phone (for which they don't), I’m OK with that. Their request accords with quality medical care; inconvenient for me, but they won’t overlook something by sliding on the need for a face-to-face assessment, no matter how simple or straightforward I think it is.

I won’t launch into my vision of healthcare cost, and payment reform in this post. I’ll save it for later. For the moment I’ll just assert that contrary to popular opinion, the government is the primary driver of cost increases, and that we do not have a market system for healthcare in this country. Au contraire, it’s one of the most highly regulated service systems we have.

Also, I won’t talk about the unintended consequences of performance based incentives at this point. There will be negative consequences: where there is a standard for care, but the patient doesn’t fit that standard, denial of payment will distort the incentive.  Again, for another post.

[BTW: what insurer has the highest percentage of claims denied? Nope, not a commercial insurer, it’s Medicare (over 6% denial rate; the commercial industry averages half of that…check it out.]

For now, we need to reign in the political warfare and fully investigate what will, and will not, work, before lurching down an unproven makeover of the huge and complex system we call US Healthcare.

Doc D


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