NOSTRUMS...by Doc D

Notice To Readers

2011-05-10T10:37:00.000-05:00

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

Medical Quotes v2 - 9 May

2011-05-09T11:54:00.000-05:00

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

2011-05-09T10:37:00.000-05:00

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

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

2011-05-06T10:47:00.001-05:00

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

Medical Quotes v2 - 4 May

2011-05-04T09:32:00.000-05:00

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?

2011-05-04T09:06:00.000-05:00

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

STUDY: Obese People Not Getting Sexually Satisfied

2011-05-02T09:00:00.000-05:00

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

Medical Quotes v2 - 1 May

2011-05-01T12:19:00.000-05:00

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

2011-05-01T11:58:00.000-05:00

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

Growth In Health Care Cost Not Controlled By Universal Care

2011-04-30T14:44:00.000-05:00

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

2011-04-30T14:24:00.000-05:00

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

Medical Quotes v2 - 29 Apr

2011-04-29T13:04:00.001-05:00

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

Medical Quotes v2 - 27 Apr

2011-04-27T08:12:00.000-05:00

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

2011-04-27T08:11:00.001-05:00

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.

STUDY: Medical Student Interest In Primary Care Continues To Plummet

2011-04-26T11:16:00.000-05:00

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

Medical Quotes v2 - 25 Apr

2011-04-25T13:05:00.000-05:00

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

2011-04-25T08:32:00.000-05:00

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

Medical Quotes v2 - 23 Apr

2011-04-23T10:25:00.000-05:00

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?"

2011-04-23T10:15:00.002-05:00

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

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

2011-04-22T11:31:00.000-05:00

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

Medical Quotes v2 - 21 Apr

2011-04-21T13:09:00.000-05:00

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

2011-04-21T11:08:00.000-05:00

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

2011-04-21T09:35:00.001-05:00

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

Hannibal Lechter Implements Health Care Reform...The Movie

2011-04-20T11:45:00.000-05:00

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

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

2011-04-19T10:41:00.000-05:00

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

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

2011-04-17T10:24:00.000-05:00

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

Cure For Everything Discovered

2011-04-15T09:35:00.000-05:00

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

Smokers Think "Slims" Are Less Harmful

2011-04-14T09:29:00.000-05:00

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

STUDY: Doctors Choose Riskier Treatment For Themselves Than For Patients

2011-04-12T10:31:00.000-05:00

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

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

2011-04-10T09:02:00.000-05:00

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

Government Shutdown? No. Elf Ears? Maybe

2011-04-09T12:12:00.000-05:00

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.

Training Doctors: More Rested, But Less Experienced?

2011-04-07T11:27:00.000-05:00

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

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

2011-04-06T12:11:00.000-05:00

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

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

2011-04-05T10:24:00.000-05:00

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 areimplicated 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

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

2011-04-04T09:23:00.001-05:00

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

Using Soy To Increase Radiation Therapy Effectiveness For Cancer

2011-04-03T12:05:00.000-05:00

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

Way Cool Radiation Dose Chart

2011-04-02T17:05:00.000-05:00

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

2011-04-02T11:15:00.000-05:00

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.

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

2011-04-01T09:05:00.000-05:00

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

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

2011-03-31T14:43:00.000-05:00

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

Accountable Care: Another Performance-Based Flop

2011-03-29T09:38:00.000-05:00

Accountable Care Organizations (ACOs), the latest brain child to improve quality and lower cost, fail at both.

A short time back I wrote about a large scale study in Great Britain that looked at whether switching to a Pay For Performance (PFP) method of reimbursing health care would be an incentive for doctors and other providers to give better care in treating people with high blood pressure.

Economists are always trying to work incentives. In this case it's simple: your patients do better and you get paid; if they don't, you receive a bite out of your wallet. The GB study looked at 500,000 patients over a six-year period: three years before PFP, then three years after PFP.

PFP had no impact on how well blood pressure was controlled or whether the patients had complications of the disease. Not a bad study, and a real kick in the rear for those who think quality can be engineered by dangling payment or not-payment as an incentive.

The study looked only at whether PFP had an impact on the quality of health care, not cost....the other Great Benefit that performance and outcome-based payment systems are supposed to bring about.

Now comes an analysis of cost in a similar setup, resulting from the PPACA (Patient Protection and Affordable Care Act)--i.e., the health care reform law, or Obamacare, take your pick.

The government selected a group of large, well-financed practice groups--Physician Group Practices, or PGPs)--to test the ACO concept (ones that could absorb a loss and still look OK). The group practices were offered standard Medicare rates, plus the chance to earn more by meeting certain performance standards. These extra payments were referred to as Shared Savings.

Writing in the New England Journal of Medicine (Mar 23), the authors looked at whether the selected groups were able to recover the initial investment in an ACO (~$1.7M on avg) over the first three years.

The answer was NO.

"The available data indicate that 8 of the 10 PGPs in the demonstration did not receive any shared savings payments in year 1. In the second year, 6 of the 10 practices did not receive such payments, and in the third year, half the participants were still not eligible for any shared savings to offset their initial investment. Given that the percentage of shared savings in the first 3 years was so low for experienced, integrated physician practices, it seems highly unlikely that newly established, independent practices would be able to average the necessary 20% return on their investment."

Both your clinics and mine, plus the insurance industry, are looking closely at moving toward such methods for improving health care quality and reducing cost. Billions are being spent pushing the idea by thinktanks and the government. The authors make a great point about testing assumptions FIRST, before adopting policy changes that implement them.

"For policymakers, the urge to do something must be tempered by the risk of disrupting the entire value-based–purchasing movement. We are concerned that physicians and providers may unwittingly undermine future value-based–purchasing efforts if the ACO model fails to live up to the high expectations that do not comport with the data."

This is another pernicious result of Health Care Reform, not unexpected under a major overhaul that was rushed through by incompetents to score an ideological victory. See my Poison Pill series for more examples.

The politicians get re-elected, the government bureaucrats find more make-work for themselves, costs continue to climb, and care doesn't get any better.

What more could the sick and injured ask for?

Doc D

Antibiotics For Cough And Phlegm

2011-03-28T09:34:00.000-05:00

A European study says that patients who come in with a cough and phlegm from a "lower respiratory" illness don't do any better with antibiotics.

But medical practitioners typically give antibiotics for yellow or green phlegm. The thinking has been that if there is a purulent (pus-like) phlegm then the disease is bacterial. Ergo, you give antibiotics. Many health care providers think that clear or white phlegm is due to allergy or viruses...for which antibiotics are useless, and if prescribed, risk adverse reactions. For a news article, go here.

If I remember the research from decades ago, the theory that the character of the phlegm provides treatment guidance was shown to be false. That is, coughing up a gross-looking phlegm could still be viral...or represent bacterial colonization that wasn't related to the illness.

However, it's not as easy (particularly in the US) to convince patients that without any treatment they are going to get well just as fast. Psychologically, people want an "action taken," and it's hard to make the case that doing nothing is best.

The researchers say that the severity and duration of symptoms doesn't change when antibiotics are used.

For Onion Peelers,
Patients producing discoloured sputum were prescribed antibiotics more frequently than those not producing sputum (OR: 3.2, 95% CI: [2.1, 5.0]), unlike those producing clear/white sputum (OR: 0.95, 95% CI: [0.61,1.48]). Antibiotic prescribing was not associated with greater rate or magnitude of symptoms score resolution among those who: produced yellow (Coefficient: 0.00, p-value: 0.68) or green sputum (Coefficient: −0.01, p-value: 0.11); reported any of three categories of feeling unwell; produced discoloured sputum and felt generally unwell (Coefficient: −0.01, p-value: 0.19).

It's hard to tell how the patients were selected and the study abstract doesn't say what kind of "lower respiratory" diseases were present. Clearly, some cases of severe pneumonia or chronic bronchitis require antibiotic treatment, or these patients could succumb.

So it's hard to validate their conclusion without access to the raw data and methods. We haven't heard the end of this.

While we need to reduce unnecessary drug prescribing in this country, I don't think it's going to change providers' treatment preferences...or patient's expectations.

Doc D

STUDY: Cruise Ship Virus, Passengers Got It But The Crew Didn't

2011-03-25T10:36:00.000-05:00

Interesting piece of research that looked at a norovirus outbreak from a cruise ship in 2009.

This was an epidemiologic study (Clinical Infectious Diseases, Mar 22). The researchers sent a survey to passengers who had been on board during the outbreak. They got a great response: 83% returned the survey.

Of those who returned the survey, 15% were classified as meeting the diagnosis for norovirus. There were 1842 people on board, so guesstimating about those who didn't return the survey that's about 250 total cases.

Some of the findings were what you would expect from a highly contagious disease in a confined population: greater likelihood of illness if a cabin mate was sick, increased risk from being berthed on the same deck where the outbreak began, etc

But a couple of interesting things:

--There was increased risk of disease if berthed or dining in proximity to a vomiting incident that occurred during boarding. I assume this constituted the index case, from which the outbreak spread. It's hard to see how this would occur: was everyone standing around when somebody threw up? was the clean-up not sanitizing? How did oral transmission occur at that point...from helping the ill individual?

--Crewmembers were much less likely to get ill: less than 1% as opposed to the 15% of passengers. The authors speculate that separate berthing, dining, and passageways for crew could explain it....or the crew was more likely to be immune from previous illness with the virus.

This disease, and others like it, spreads so rapidly that increased sanitary measures once the outbreak is identified are not often effective. It's too late to start frequent hand-washing and avoiding ill persons once things have gotten rolling.

There's just no substitute for good sanitation and hygiene as a lifelong habit.

Doc D

Dr. Oz Stirs The Radiation Hysteria Pot

2011-03-25T09:53:00.000-05:00

One last stab at dealing with radiation hysteria.

I hope you're as bored as I am at this point with all the news media attention to "detecting" radiation at various points around the globe.

Friends and family have been writing me. One of these was to inquire about Dr. Oz. I don't watch these shows, but apparently, the Great and Powerful Oz had a segment on x-rays and increasing risk of thyroid cancer. There's a shield for the thyroid (like the lead apron) so that the neck is covered during an x-ray. You can request its use, but a lot of dentists don't use it all the time, only when the patient requests it.

Here's why. If you want a thyroid shield for a dental x-ray, you should wear the shield when you go to the beach for the day, or when you fly in an airliner. The radiation dose is about the same. And it's "cumulative lifetime radiation exposure" that is the real measure of cancer risk. So if you get 0.001 millisieverts of exposure from a dental x-ray, but your routine background exposure from just living on the planet is 2.4 millisieverts per year (on avg), you can see that the dose is trivial: the radiation you experience everyday for a year is 2000 times what the dental film delivers.

There's a great Op/Ed piece from yesterday at Forbes.com (here) by climatologist Patrick Michaels. A couple of quotes:

People stay up at night worrying about the 5% increase in sunburn-causing radiation as a result of stratospheric ozone depletion, and the next morning go to the beach and expose 95% of their skin to the same rays.

and, in regard to the model of exponential decay with distance from an environmental exposure (radiation or pollution, take your pick),

At a 2 mile radius, there's only one-fourth of the concentration there is at one mile. At 10 miles, a hundredth; at a thousand, a millionth--all of which simply proves that there will never be a health effect from Fukushima found in California.

I'm not sure how much more income the news networks can milk out of this false issue, but they'll keep trying as long as people tune in.

Doc D

SUPREME COURT: Cold Remedy Liable For Not Reporting Unproven Adverse Reaction

2011-03-23T15:55:00.001-05:00

Once again we see a problem arise from categorizing Complementary and Alternative Medications (CAM) as not requiring FDA approval before marketing.

Most people know that Congress gave makers of herbs and complementary medicines a free ticket to market their stuff. They don't have to go through the drug approval process that every pharmaceutical must weather. The only way a harmful CAM product can be restricted is when enough anecdotal reports of injury or death surfaces by word of mouth. Then, the FDA can take action.

So when the makers of Zicam, an over-the-counter (OTC) cold remedy that's marketed as a "homeopathic" medicine, learned through customers that a few patients experienced anosmia after using the nasal spray, they were under no regulatory requirement to identify the problem. Anosmia is the term for losing your sense of smell; something you don't think of as very important until you don't have it.

[BTW, if you used Zicam (no longer sold), know that homeopathic "remedies" consist of serial dilutions of the active ingredient to the point where no, or almost no, molecules of the substance is still present...in this case zinc. Wikipedia says that "Some of the homeopathic ingredients used in the preparation of Zicam are galphimia glauca, histamine dihydrochloride (homeopathic name, histaminum hydrochloricum), luffa operculata and sulfur. I haven't a clue what any of these would do to your nose.]

The number of anosmia reports was few and in the opinion of the manufacturer, Matrixx Initiatives, not "statistically significant."

The Supreme Court said (NY Times Health blog, Mar 22) that a lack of statistical significance doesn't let you off the hook as far as liability. Unusually, the justices were unanimous.

I have mixed feelings about this. Statistical significance, if properly measured, is very important to determining whether an effect is real...or just a coincidence.

However, I'm not impressed with manufacturers who are not regulated deciding for themselves how and when statistical significance is reached.

There's this big book--so big it's almost unusable--that all doctors have, called the PDR...which stands for Physicians Desk Reference. It includes every possible side effect and adverse reaction for every pharmaceutical that's marketed in the US. If it was a list of only those things that are connected to taking the medicine, then it would be useful. However, drug manufacturers use it as a CYA (cover your you-know-what) document, and include every single thing that any patient has ever reported.

So the book ends up having a list of adverse reactions a mile long for the most innocuous drugs. Most of the reactions don't have anything to do with the drug, but the manufacturer--if he's ever sued--can say, "It's in the PDR and your doctor was informed."

For an (exaggerated) example, it's important to know that blood pressure medicine X can cause low blood pressure when taken with certain other medications. But if somebody reports getting belly button lint after taking it...it will be listed in the PDR. We just ignore most of the junk like this.

The funny thing about this Supreme Court case is that the anecdotal reports of anosmia surfaced, and patients were warned about it. The plaintiff in the case is not a patient, but an investor who lost money when the warning about anosmia was issued, and lost money. The plaintiff filed suit not for product safety, but for securities fraud. Crazy in America.

Justice Sotomayor wrote

“Given that medical professionals and regulators act on the basis of evidence of causation that is not statistically significant...it stands to reason that in certain cases reasonable investors would as well.”

So Matrixx Initiatives, who alleged that since the reports of anosmia--which they had known about but not revealed--were not significant, they weren't obligated by law to report them, took it in the shorts.

If Complementary and Alternatives Medicines (CAM) had a regulatory process parallel to pharmaceuticals and medical devices, none of this--neither securities fraud nor product safety issues--would have arisen.

Another Poison Pill from our country's approach to CAM.

Doc D

Comparing Health Risks Requires Understanding Of Biology

2011-03-21T12:54:00.001-05:00

This is a Food-For-Thought post about judging potentially harmful health effects.

Suppose I tell you that exposure to something carries a negligible risk of serious harm, one in a million, say. Now I tell you that 100 million people are going to be exposed to that risk. Does it make a difference to our perception of risk--that is, do we take action to prevent it--because now there are, on average, 100 people in that 100 million who will experience that harm?

If you look at the question from the point of view of yourself, as an individual, and realize that there are thousands of things you are routinely exposed to every day with orders of magnitude greater risk (1 in 100,00 for instance...which is close to the risk of a dying in a car accident), the risk is non-existent because it's so small...to yourself...and in the larger scheme of total risk.

If you look at the big picture of those 100 in the total of 100 million and think, "This is a measurable level of risk to individuals that is morally wrong to tolerate," and assuming that something can be done to remediate it, you would want to eliminate the risk.

What makes one person see a given risk as not worth considering, and another person as a risk to correct?

Before concluding that this is an unrealistic hypothetical, consider that the body scanner at the airport delivers a very small dose of ionizing radiation. The measure used is "sieverts" (the parallel of "meters" for length and "grams" for weight). Radiation exposure is a lifelong cumulative risk; a single exposure isn't a causative event, it's the total amount you recieve over a lifetime that increases the risk. You receive about 0.0001 millisieverts from a body scanner (one ten-thousandth of a millisievert)

--You receive about the same dose from flying at 30,000 feet in an airplane for two minutes.

--You receive about 2.4 millisieverts a year, just from living on the planet due to bombardment of the earth with radiation...called background radiation. This can vary from 1 to 10 millisieverts a year depending on where you live. Background radiation alone will cause 1 in 100 to dies of cancer (the cumulative effect of going to the beach, flying, and just being on the earth) according to one expert. See here for a discussion.

--You receive about 10 millisieverts from a CT scan to detect cancer.

--People living in Tokyo are being exposed to 0.001 millisieverts. That's one-thousandth of a millisievert, again, for clarity). Note that this is 150 miles away from the affected reactors.

Now, back to my hypothetical. The risk of cancer from an airport body scanner is about 1 in 80 million...even lower than my example of 100 in 100 million. Given the magnitude of routine exposures above, and the cumulative nature of radiation exposure risk, does an airport scan worry you?

Yep, it adds a miniscule amount to the lifetime total. But you could get body scanned a hundred times and not reach the dose obtained by a day at the beach. A CT scan is the equivalent of four days living on the earth.

[By the way, there are alternative airport scanners that use millimeter wave scanners--using radio waves--to scan the body instead of ionizing radiation. The two types of scanners cost about the same]

To carry this further, are you worried about radiation from Japan? By the way, the half-life of radioactive iodine is about eight days. Most of what leaked from the core container has already decayed.

My theory is that so few people understand the biology of how radiation affects our bodies that it becomes a boogey man, something to panic over. The less we understand, the greater our belief that it's deadly. The philosopher Montaigne once said,

"Nothing is so firmly believed as that about which we know the least."

Radiation is a real hazard, but only if you're standing near the leaking core container in Japan. Conflating that hazard with radiation hazard from medical treatments and airport scanners is comparing (in size) a grain of sand to Mt Everest.

Doc D

Medical Quotes Of The Day - 19 Mar 11

2011-03-19T08:29:00.000-05:00

Here's a few of those "A _____(fill in the blank) a day, ...." sayings:

--A pill a day keeps the stork away.

--If a smile a day will keep the doctor away... Here`s Mine!

--A condom a day keeps AIDS away.

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

Doc D

Idiotically Unnecessary Guidance: WHO Says People Arriving From Japan Are Not A Radiation Risk To Others

2011-03-18T09:04:00.000-05:00

I started to write a short note on just how weird and panicked you have to be to think that someone who has been in Japan would bring back some radiation that could affect their neighbors. See here.

Where would it come from? Their luggage? On their breath? In their pocket?

Anyway, I'm speechless. So, I'll let it go at that.

Doc D

Media Goes Nuts Over "Pear" Versus "Apple" Body Fat

2011-03-18T08:51:00.001-05:00

Almost every news outlet today is breathlessly touting a study that just appeared showing that it doesn't make any difference whether your body is apple-shaped or pear-shaped in regard to risk of heart disease.

This flies in the face of years of studies that showed, if you're apple-shaped--body fat centering in the abdomen instead of the thighs--you're toast. See here for a news article that's typical of the now-contested guidance.

Remember the Peter, Paul, and Mary song, A'Soaling?

Apple, a pear, a plum, a cherry
Any good thing to make us all merry.

So, they were wrong. Fruits, at least in regard to their shape, don't make us merry.

Now I'm confused and it really puts a wrinkle in my efforts to transfer my abdominal...uh...girth...to my thighs. I've been massaging downward for years (to little effect, I might add).

What does the actual study (The Lancet, Mar 11) say? First of all, they controlled for a lot of other variables like age, sex, smoking status, high blood pressure, diabetes, high cholesterol.

For Onion peelers,
Serial adiposity assessments were made in up to 63,821 people (mean interval 5·7 years [SD 3·9])...Addition of information on BMI, waist circumference, or waist-to-hip ratio to a cardiovascular disease risk prediction model containing conventional risk factors did not importantly improve risk discrimination (C-index changes of −0·0001, −0·0001, and 0·0008, respectively), nor classification of participants to categories of predicted 10-year risk (net reclassification improvement −0·19%, −0·05%, and −0·05%, respectively).

That's a lot of measurements in a lot of people, and not one jot of difference. But this won't settle the question; one study does not the truth make.

For now, though, I'm pushing "fat location" to the back of my risk-filled dinner plate...so to speak.

Doc D

Record-breaking Longevity In The US. 78 Years And 2 Months

2011-03-17T10:54:00.001-05:00

Great news, if you were born last year.

Lots of news stories today about the CDC's just-released report on life expectancy in the US. Most articles mention that the new record for average length of life applies only to those born in 2009.

Be that as it may, there is a gold mine of information in the preliminary report. For instance:

1. The usual gender and ethnic gaps are still there: you still have an advantage if female and white.

2. Suicide made it into the Top Ten causes of death, which aced out septicemia for the 10th spot. Living longer, but not happier, I guess.

3. Death rates for 10 of the top 15 causes dropped. The biggest decreases were in heart, lung, and stroke.

4. Fewer overall deaths by 2.2%, but fewer births overall by 3.1%. As an exercise, figure out why this alone doesn't mean that population growth will slow.

5. Infant death rates from maternal complications and accidents went down, 7.5% and 8.5% respectively. The overall infant death rate has fluctuated over the last 10 years. The top three causes remain the same: malformations, prematurity, and SIDS.

None of this data takes into consideration innovation or breakthroughs in treatment or prevention.

Just imagine what could happen if the following developments--already in the works--should prove effective: a vaccine for all strains of influenza (#8 cause of death), pancreatic stem cell replacement for diabetics (#6), a gene therapy that reverses the symptoms of Parkinson's disease (#14).

The planet's gonna get awful crowded.

Doc D

Are Americans Getting Fatter Or Not?

2011-03-16T12:04:00.000-05:00

Well, yes and no. This is confusing.

My Just-Arrived-In-The-Mail issue of the New England Journal of Medicine has a commentary on what's going on with obesity in this country (not yet available online).

Consider the following quotations from that article:

"state-and national-level data from the 2009 Behavioral Risk Factor Surveillance System...showed increases between 2007 and 2009 in the reported prevalence of obesity among adults--a 1.1% increase nationally, or an additional 2.4 million or so obese adults."

"Results from the CDC's 2007-2008 National Health and Nutrition Examination Survey suggest that the prevalence of obesity among women (35.5%) and children 2 to 19 years of age (16.9%) has remained stable over the past 10 years and that the prevalence among men (32.2%) has not changed significantly since 2003."

You can see the confusion. I've written before that maybe we've "peaked out" on weight gain in those who are susceptible, or that the obese are getting more obese, but those who are not susceptible are keeping weight gain in check...but it's just speculation.

While the authors mention this, there are other likely explanations. Some are methodological: one set of results is from measurements (the second) and the other is from self-reporting (the first). Self-reporting is frequently distorted, particularly if some opprobrium attaches to a positive self-assessment. Some are congratulatory: our efforts to reduce obesity are having some impact. I don't believe it.

Apparently it's not in doubt that the obese are getting "up there." The fraction of obese people who are grossly so--350 pounds and up--is growing.

We don't need to get distracted by seemingly contradictory data reporting. The fact is, this is a critical public health problem and we don't have a good way to address it. I've written that IMO, dietary laws are futile (here, here, and here).

From a preventive medicine specialist's perspective it's the most frustrating problem of all. There's no pill to take (there are some, but I dispute the wisdom of these treatments), the surgeries work for only a while (same dispute with the wisdom).

And there ain't no vaccine.

Doc D

Peope In CA Taking Potassium Iodide To Prevent Radioactive Iodine-Induced Cancer From Japanese Nuclear Accident

2011-03-16T11:04:00.000-05:00

You've GOT to be kidding. How many thousands of miles is it to Japan?

At first, I thought this was a joke, but then I saw an article on Kevin MD from Kevin himself. He reports that pharmacies in California are running out of potassium iodide pills.

Guess what? The kind of radioactive particles that leak from reactors don't zap with the speed of light into the far reaches of the galaxy instantaneously. They mostly fall to earth near by.

Worse, the media has jumped on the Panic Bandwagon and USA Today is telling people that they have to begin taking iodine several weeks before exposure to radioactive iodine in order for the radiation-induced cancer to be prevented.

I'm still astonished at the degree to which we--as a species--panic about things.

Let's review our past. Some of these things seem laughable now.

1. In the Fifties, families dug atomic bomb shelters in their back yard and stocked them with months supply of food.

2. After the Three Mile Island reactor leak, measurements were taken of radioactive material in the vicinity of the reactor. Only trace--and harmless--readings could be detected within a quarter-mile radius of the faciilty.

3. In the early years of AIDS, an orthopedic surgeon was quoted as saying, "It's not a question of IF I get the disease, it's WHEN I will get it," predicting that everyone who touches someone with the disease would contract it.

4. In the 1970's after several decades of a reversal of global warming, scientists were speculating that we were entering a new Ice Age. It only took 30 years for them to "do a one-eighty."

5. When Saddam lit the oil fires during Desert Storm, predictions were that the enormous smoke cloud would drift over Europe and change the climate for decades. By the following year, there was no trace that the fires had ever occurred.

6. When five people were killed in an anthrax attack some years ago--carried through the mail and confined to a single chain of mail handling--tens of thousands of people across the country wanted their doctors to prescribe the antibiotic Cipro, so they could take it...just in case.

7. When the Gulf Oil Spill occurred last year, experts predicted untold damage to the ocean environment, until researchers discovered a bacteria in the depths of the sea that eats oil. Oh yeah, we forgot that oil has been spilling into the ocean for hundreds of millions of years from earthquakes and the like.

There are many more. The book to read is, Extraordinary Popular Delusions & the Madness of Crowds, by Charles Mackay, first published in 1841.

And, by the way, if I see another news story in the media explaining reactors and radiation effects, I'm going to commit seppuku.

Let's all take a deep breath, calm down, and use common sense. The Japanese people have a definite public health problem to prepare for. But we here in the US should probably spend our time looking at OUR reactors near the coast line (if we have them) for vulnerability to damage. That would be more helpful than wasting money on iodine.

And, as the Kevin MD article says about taking potassium iodide without a clinical need, "there are side effects as well, including inflammation of the salivary gland, allergic reactions, and gastrointestinal side effects."

So, if you're worried about radiation effects, and want to take a pill, don't take iodine, take a Valium.*

Doc D

*Note. For the litigious: this is not a medical recommendation...it's sarcasm.

CITATION: Some "Healthy" Foods Aren't

2011-03-15T09:36:00.000-05:00

This is just a quick note referencing another article on how we develop a false black-or-white view of nutrition.

Some foods are bad for you; some are good. But mostly they all have their good and bad points. The OC Register Healthy Living blog (Mar 15) talks about some of the ones we think are healthy...and for which we need an attitude adjustment.

Please go here and read the article for explanations. But these are the "5 healthy foods (and a water) that aren’t so healthy."

1. veggie chips
2. granola cereal
3. turkey hot dogs
4. vitamin-infused waters
5. wrapped sandwiches
6. couscous

The original source for the nutritional information is Consumer Reports.

You can eat these things and it's not going to kill you. The "killer" is a fanatic belief in the virtue of any rigid approach to nutrition.

Doc D

Why People Disbelieve The Science...Often Strongly So.

2011-03-14T12:25:00.000-05:00

Beliefs about issues like vaccination are driven by cultural values not scientific evidence.

Such is the theory of risk proposed by researchers like Dan M. Kahan, of Yale Law School, who has written on the conflict that develops when all the scientific experts agree but some members of the public do not (and vehemently so).

This came up in an article in the Wall Street Journal Health Blog two days ago (Mar 12). The original article concerned the "clash" between patients and scientists over a suspected viral cause for chronic fatigue syndrome (CFS). Almost everyone has heard of CFS: a debilitating and chronic syndrome, the etiology for which doctors and scientists have been speculating and experimenting for decades. The literature, advocacy groups, and blogs are littered with ideas, allegations, hypotheses, and claims.

Desperate for a cause and a treatment, patients have alleged conspiracies to cover up evidence that the syndrome is a definable disease with a specific cause, and at the same time have suffered the ignominy of disbelief and disparagement by the public...and sometimes, doctors.

Along the way, quacks with remedies and healthy people who want to jump on the bandwagon to explain their life stress have muddied the waters and confused patients and public alike.

Desperate people are the most vulnerable to quackery.

The fact that XMRV--the suspected virus--has only been associated with CFS in one or two small studies, but other investigators have not been able to reproduce those results, drives the desperate to want an answer NOW. Scientists, knowing that initial studies are often a red herring, want to be deliberate and systematic.

See the blog for more detail on CFS. At one point the article branches off into why people sometimes strongly disbelieve the empirical data (as in the autism-vaccine debacle). One theory, and a good one to explore, is that people develop belief that accords with their values over the evidence. From one of Kahan's papers (on the controversy over requiring adolescents to take the Human Papilloma Virus--HPV--vaccine) found here (on SSRN):

"The cultural theory of risk asserts that individuals selectively attend to risks and related facts in a way that reflects and reinforces their "cultural worldviews," or preferences about how society should be organized (citations). If this process is at work in the HPV vaccine debate, those on both sides are advancing the positions that they honestly believe promote the health of girls and young women. Yet the reason that they hold those particular beliefs is the congeniality of one or another set of risk perceptions to their preferred vision of the good society."

The science is clear that HPV vaccine is safe and effective against several strains of the virus that can lead to cervical cancer, that HPV infection is spread as an STD, and that the vaccine can interrupt the chain of transmission in many cases.

Kahan relates the HPV story to other controversies such as gun control, and links the resulting conflicts to the cultural theory of risk.

Both the blog article and the paper referenced are recommended reading.

Doc D

Taking Meds For Hair Loss And Feeling Limp?

2011-03-13T11:26:00.000-05:00

A quick note for males in the audience.

I noticed this article in USA Today"s Health blog (Mar 12).

Avodart, Proscar, and Propecia are drugs in a single group called 5-alpha reductase inhibitors. They are used to treat difficulty urinating due to prostate enlargement....and hair loss.

The review referred to in the blog article can be found here. The pertinent result (quotation is from the blog link above) was:

"About 8% of men taking the drugs reported erectile dysfunction, and 4.2% reported reduced libido, they found, compared with 4% and 1.8% of men receiving placebo, respectively. Reduced ejaculation and semen volume and depression were also reported by some men, the researchers note."

The point is, there are almost no beneficial medications that do not have other, often unwanted effects.

Therapy, particularly for esthetic reasons--like hair loss--should be approached with caution (see my post on the German celebrity who died from her sixth breast augmentation.)

Sometimes accepting nature's cruel blow is the better course.

Doc D

Who's In Charge In Congress? The Staffers?

2011-03-13T11:09:00.000-05:00

The media reports that a Congressional staffer who was a major player in drafting the health care law has admitted privately that the law was not what the Senator (Kennedy) wanted, but "what I wanted."

I doubt most voters know that the staff frequently does what THEY want, not necessarily what their boss, or the people who elected her/him, want. For the reporting that alleges the claim above see Politico here ("Orrin Hatch: Ted Kennedy wouldn't have wanted health care law")

I remember studying this in my MPH masters program. There's a great book called The Dance of Legislation: An Insider's Account of the Workings of the United States Senate , by Eric Redman, now considered a classic. Redman served on the staff of Senator Magnusson (WA) several decades ago. His book focuses on a single piece of legislation, the 1970 National Health Service Bill (ironically a health care reform effort), and tells the story of

"the maneuvers, plots, counterplots, frustrations, triumphs, and sheer work and dedication involved. He provides a vivid picture of the bureaucratic infighting, political prerogatives, and Congressional courtesies necessary to make something happen on Capitol Hill" (publisher blurb).

If you watched the ugly process we observed in 2009 (the Cornhusker Kickback, and the Louisiana Purchase to mention only two of hundreds), and wondered how all this stuff goes on, this is the book to read. It's hard to make legislating read like a thriller, but this comes close.

What struck me the hardest in the book is the primary role that the Congressional staff plays. They do the work of interacting with special interests and lobbyists, negotiate with other members' staff, direct or perform the actual writing of the legislation, and promote the product to the elected member.

It's almost like they are the legislators...and the Congressional members are "front men" (and women) that are the political and vocal "face"... but not the substance of what gets done.

Shocking, really. The book is still available from online retailers.

It helps to know that staffers begin their career (generally) as young college graduates with little to no experience of the subjects they are charged with managing (taxes, welfare, health care, agriculture, etc). They usually have a poli sci degree. The senior staff who've been around for 10 years or more have soaked up knowledge, but what knowledge they have is all linked to the political process they have lived every day.

[A personal anecdote of working with Congressional staffers. I was involved with physician manning for the military back in the 90's. We explained to the staff that we were short of orthopedic surgeons. One young, pimply-faced staffer said, "The answer is simple; we just make all medical graduates go into orthopedic surgery." This is the quality of thinking that's typical.]

And this partially explains why our government adopts such incompetent policies.

Doc D

Medical Cartoonville - 11 Mar 2011

2011-03-11T10:54:00.000-06:00

One of Dr. Val's great cartoons.

Doc D

The Health Care Reform Waiver Lottery: Now Entire States Enter The Game

2011-03-10T09:56:00.000-06:00

The state of Maine received a waiver from a key provision of the HCR law. Other states have similar requests in the pipeline.

I read in The Hill yesterday that as of last week the Department of Health and Human Services (HHS) has granted 1040 waivers to organizations that say they are unable to meet the minimum coverage requirements. By contrast only about 50 waiver requests have been denied. This is another effort to postpone the toxic effects of the law; the last several months have seen numerous efforts to delay requirements until after the 2012 elections to minimize disruption that could cost an election. See here on the delay in W-2 reporting that was required in the law; and recall the delay announced in shrinking Medicare Advantage programs and HSA accounts.

Maine received a waiver from the requirement that insurers spend almost all their revenue for actual health care services (as opposed to running the business, administrative costs, and--presumably--executive bonuses).

Allegations are that some of the waivers are politically motivated. That is, the Administration is favoring unions and other political supporters. I haven't seen any data that supports that yet; although one report said that Service Employees International Union (SEIU) received one of these waivers. HHS claims that the waivers are primarily going to small insurers, but SEIU is one of the biggest unions in the country.

Recall that SEIU and others who have so-called "Cadillac" health care plans received an exemption under the law (until 2018?) from paying the tax on high-end, covering-everything type plans.

Political maneuvering that favors some groups over others just fuels further disgust with the whole process, and sustains the high disapproval ratings that pollsters continue to see when surveying health care reform.

I read elsewhere today that the number of doctors who are opting out of Medicare in my state (TX) is continuing to grow. Maybe I should put a couple of counters on the website, so readers can monitor the growth of things like waivers and opt-outs. I'll think about it.

The other states seeking a minimum coverage waiver are Kentucky, New Hampshire, and Nevada (isn't that Harry Reid's state?)

Doc D

The Mediterranean Diet Works, Of Course...Because There's Nothing New In It

2011-03-09T09:46:00.001-06:00

A meta-analysis of the health effects of the Mediterranean Diet shows benefit, but that's what we would expect from a collection of common sense advice that we've known for decades.

People talk about the Mediterranean Diet (aka THE DIET) as if there's some magic ingredient, or specialized technique.

Read this description from Science Daily (Mar 7):

The Mediterranean diet is a dietary pattern characterized by high consumption of monounsaturated fatty acids, primarily from olives and olive oils; daily consumption of fruits, vegetables, whole grain cereals, and low-fat dairy products; weekly consumption of fish, poultry, tree nuts, and legumes; a relatively low consumption of red meat; and a moderate daily consumption of alcohol, normally with meals.

Anything you haven't heard about before? When you take each part of the diet and consider the advice, it's all stuff we've known for a long time.

So why does this diet have a special name? Or a sacred status:

The Mediterranean Diet is more than a diet. It is a lifelong living style. You have to adopt it, as a religion. Decades ago, it was the natural way of life of many people around the Mediterranean Basin, especially in Spain, Italy and Greece (from Mediterranean Diet.com).

I've got it. I can be rich and famous by putting together a bunch of common sense and giving it a name. Here's the Doc D Automotive Safety Prescription: make sure the key is turned on, establish that there's a brake pedal, glance at the tires to make sure they're inflated, and never try to drive from the back seat.

Do you think it'll become "lifelong living style" in driving safety?

Anyway, what got me started on this rant, was the Science Daily article referred to above. So I went to the research at the Journal of the American College of Cardiology (current issue dated Mar 15). The meta-analysis took 50 previous studies and combined all the data. This included statistics on approx 500K participants. The focus of the review was to measure the impact of THE DIET on metabolic syndrome, the quick and dirty definition of which is: heart risk due to a combination of insulin resistance, high blood pressure, obesity, clotting factor abnormalities, and predisposition to inflammation. That's very inexact, so you can go here to read more about it. It's growing in prevalence.

So they found that THE DIET reduced the risk of metabolic syndrome (MS).

For Onion Peelers,
...Adherence to the Mediterranean diet was associatedwith reduced risk of MS (log hazard ratio: –0.69, 95%confidence interval [CI]: –1.24 to –1.16). Additionally,results from clinical studies (mean difference, 95% CI) revealedthe protective role of the Mediterranean diet on componentsof MS, like waist circumference (–0.42 cm, 95% CI: –0.82to –0.02), high-density lipoprotein cholesterol (1.17mg/dl, 95% CI: 0.38 to 1.96), triglycerides (–6.14 mg/dl,95% CI: –10.35 to –1.93), systolic (–2.35mm Hg, 95% CI: –3.51 to –1.18) and diastolic bloodpressure (–1.58 mm Hg, 95% CI: –2.02 to –1.13),and glucose (–3.89 mg/dl, 95% CI:–5.84 to –1.95)

If you look at the statistics closely you can see that the individual differences are not that great, and the confidence intervals are large, but taken together the health impact can be substantive.

That's all for today. I have to go work on my DRIVING SAFETY program.

Doc D

STUDY: Nicotine Measured From Toenail Clippings Predicts Risk Of Lung Cancer

2011-03-08T08:40:00.000-06:00

Wouldn't it be easier just to ask whether a person smokes, how much, and for long?

This dubious research was done at the Univ of San Diego (see here for the media report). I hope we taxpayers didn't fund it.

What could possibly have led these scientists to analyze toenails for nicotine?

One comment in the media article said that some of the men with the highest levels of nicotine in their toenails were non-smokers, and speculated that they were exposed to second-hand smoke. Does that make sense? That some people are nicotine magnets?

On the contrary, such a finding would make me question whether the measurement was accurate or meaningful.

Doc D

STUDY: Psychosis Symptoms More Likely In Marijuana Users

2011-03-06T17:40:00.000-06:00

Two studies this year showed increased risk of symptoms of psychosis after adolescent marijuana use. The most recent was a better study, but not definitive.

Although the legalization crowd will criticize the studies, and their opponents will trumpet them, we haven't heard the last word on whether marijuana use among teenagers has anything to do with mental health, except as an "association" between two variables. Previous studies, showing increased rates of schizophrenia and other mental health issues, have been criticized for being poorly controlled.

This week's study, appearing in the British Medical Journal, enrolled subjects age 14-24 who had not used marijuana before (first caveat: "self-reported" non-use), and followed them for 10 years. Those who subsequently became users had higher incidence of psychotic symptoms. [see here for an editorial on recent studies.]

As Nostrums readers know, the association of an exposure (marijuana) and symptoms (psychosis-type) doesn't mean that one caused the other. It could just as likely be explained by an unknown variable shared by those at risk, or simply that people who are likely to develop psychotic symptoms are more likely to start using marijuana.

In designing the experiment, it was left up to enrolled subjects whether they initiated substance use or not. From the perspective of experimental design, clearly this isn't random, or blinded. And I can't think of a way to make it so.

That the risk of symptoms of psychosis increased the longer the person smoked is interesting, but doesn't necessarily imply a dose-effect (i.e., the more you inhale the worse you get).

But you have to give the researchers some credit. They compared users and non-users for differences in gender, socio-economic group, age, other drugs, and other health problems. No differences were found. This means the higher risk of symptoms of psychosis can't be explained by being poor, or male/female, or older, etc., the usual confounding variables.

I'm not a fan of substance use of any kind. And smoking any plant probably entails similar lung risks (I'm not aware of any useful research that looks at lung cancer or emphysema risk in marijuana smokers). But the science isn't complete.

The fur will fly over this research, and we are marginally closer to defining harmful effects, but the fat lady hasn't sung.

Doc D

HCR Expert Says, "Yeah, You Have To Buy Broccoli"

2011-03-04T10:53:00.000-06:00

According to Harvard professor and HCR supporter, the Constitution does allow the government to make you buy broccoli.

There were a lot of horse laughs at Judge Vinson's comparison between the individual mandate under the new health care reform law and the government forcing you to buy broccoli. Recall that this is the judge in the 26-state suit claiming that the requirement to buy health insurance is unconstitutional. Vinson said, "Yep, it's unconstitutional," and wrote a long opinion as to why. In that opinion he made the statement that if not buying something comes under the government's power to control or coerce, then you could be forced to buy this tasteless vegetable.

I think the judge chose broccoli as a humorous exaggeration...not many people eat broccoli. But some tried to ridicule the comparison by taking it seriously.

Now, former Solicitor General and Harvard professor Charles Fried, one of the experts testifying before Congress that the mandate is constitutional, admitted that...well, yes...the government could force you to buy broccoli. See here.

All this talk of broccoli is beside the point.

I think what's at stake here is whether Congress has the authority to pass laws that compel persons to purchase a specific product.

A more realistic example would be for the government to compel purchasing an American-made product because a large company that makes that product is failing, and people would be laid off. One example others have used is automobiles. Suppose a US car company is about to go under, unable to compete with foreign makers or with their competitors in the US. Interpreting Professor Fried, the Congress could compel you to purchase one of their cars, as being in the best interest of the country. Note that I don't mean compelling people who are already in the market for a new car, but people who don't want a new car.

I think Congress would have been better advised to write the law in such a way that defined health care as a special case. That is, it's not like any other industry. This would have carved out a limitation: that is, the government can make you get health care insurance, but they can't make you buy other things you don't want.

Had they done that, there wouldn't be a "slippery slope" argument that risks the Supreme Court saying, "The government did not define a constitutional limit on what it can compel citizens to purchase, a vagueness that we are unable to rule in favor of."

But they didn't choose this route. That would have started a different legal battle, but it's one that doesn't involve expanding the scope of the US constitution in an unprecedented manner. Even the judges who have ruled the mandate constitutional (so far) have admitted that their interpretation of a decision not to buy something as "economic activity" and, therefore, covered by the Commerce clause of the Constitution, has no legal precedence.

In any case, Congress decided to write the law in such a way that "mental activity" (the thinking you do about whether to buy something) is "economic" and therefore, commerce.

Go figure.

Doc D

Supreme Court Rules "No Suits Against Vaccine Makers"

2011-03-03T12:36:00.000-06:00

The decision wasn't even close (6-2). For some, this result doesn't make sense...but it does.

Here's how the Des Moines Register (Mar 2) described the case:

"Last month the U.S. Supreme Court sent a message to American parents: If you think a vaccine harmed your child, don't turn to the local courthouse. In a 6-2 ruling, the court affirmed federal law that prevents vaccine makers from being sued in state courts and protects them from civil liability in "damages arising from a vaccine-related injury or death."

Before we hear from those who would argue for the parents and their children, consider this:

1. The vaccines in question have been approved safe and effective by the FDA. We're not talking about experiemental or unlicensed use.
2. Back when vaccine makers feared constant lawsuits over their products, the industry was bailing out of making them. This created several crises, resulting in vaccine shortages.
3. As a result, Congress set up a vaccine court to hear all cases of harm to children, a "no fault" alternative to suing companies who make quality products, but can't guarantee that no one will have a reaction to the vaccine. Even the safest of our vaccines, while saving millions of lives, cause adverse reactions to somebody.

The vaccine court's responsibility is to establish whether the vaccine caused the harm, then award compensation from a federal fund established for that purpose. Establishing cause and effect allows the science to eliminate the litigous, ambulance chasers, and those whose claim is without merit (there are a lot of these).

[This Supreme Court case was one of the latter. There was no link between the injury and vaccine, so the parents and their lawyers went after the company.]

The National Vaccine Compensation Program (that set up the vaccine court) has been a success. Vaccine companies have continued to, and in some cases re-started, making vaccines, and those who are innocently harmed have an avenue to seek redress.

Had the Supreme Court ruled otherwise, vaccine makers would have to increase the cost to cover liability, and lawyers would have a deep pocket to bring cases against. Parents who misapprehend what caused their child's problem would have had a way to pursue a baseless claim to jurors who might be swayed by the tragedy alone.

As the world's leader in lawsuits, the US doesn't need to fabricate more.

Doc D

CIty Funds Brain Cancer Scans For The Healthy

2011-03-02T11:14:00.000-06:00

Unnecessary screening leads to unnecessary treatment.

I ran across this article in the Wall Street Journal Health blog (Mar 2):

"NYC City Council Funds Unproven Cancer-Screening Program"

Apparently the city funds a scanner to the tune of about $2 million to go around the city scanning normal people for brain cancer.

The article rightly points out that there are situations where screening is at least prudent (both your parents are diabetic, and you get a fasting blood sugar). But this is one of those situations where it's not.

Brain cancer is very uncommon. I'm not sure how many people you have to screen to find a "real" brain cancer, but I bet it's in the thousands. From that same population you will find hundreds with other "findings" that may suggest they need to be treated, but more likely you're better off without treating...and without knowing.

The prostate cancer blood test, prostate specific antigen (PSA), is a case in point:

"The PSA test, the benefits of which still aren’t clear, has become the poster child for this controversy. (One analysis found that for every life saved by the PSA, 47 men received unnecessary treatment and risked side effects like incontinence.)"

Epidemiologic data, the sensitivity and specificity of the screening test, and (most importantly) the risk factors of the patient, need to be guiding factors in screening for medical diagnoses.

There's an old saying among doctors, "Test enough and you'll find something."

That's not preventive health care, it's fishing.

Doc D

Ethics... And Evaluating New Treatments For Serious Diseases

2011-03-01T08:48:00.000-06:00

A new approach to gene therapy for AIDS is promising, but...

We've known for decades that a few people are resistant to HIV--on the order of 1 in 100. They can be shown to be infected, but don't get sick (so far) and don't need to take medicine.

There's a receptor (CCR5) on the surface of the immune cells that HIV attaches to, in order to infect the cell. These rare individuals seem to lack that receptor, and the gene that produces it. No receptor, no virus attachment, no infection of the cell....get on with your life.

Researchers have discovered a way to take immune cells from someone who has the disease and snip out the genetic code repsonsible for this receptor, then grow a whole bunch of these cells and give them back to the patient. For a decent summary of the research go here (Assoc Press, Feb 28).

The modified cells appear to survive when put back in the host. The hypothesis is that they are resistant to infection with the virus and can continue to do their job in the immune system.

It's exciting, but reading the news article, I asked myself why we have this receptor, and what does it mean if we don't have it? We don't know. The reseachers realize this, and know that before we go modifying every patient's cells, we need to understand the function of this gene.

The few people who have been treated so far with modified cells have shown some improvement, but it's not a cure.

Ethical question for the day: How do you balance our limited knowledge of the safety of a new treatment against the harmful effects of not giving the treatment? Assume that three years from now, we can't find any reason to justify not removing this CCR5 receptor from the immune cells of patients who are ill with HIV, and on several medicines a day to keep the disease at bay. What if you could read the future and knew that it would take us 20 years to find out that CCR5 becomes essential to the immune system later in life? Treatment with treated cells would help now, but create a new problem later. If long-term studies show that people treated with the modified cells are harmed by the treatment, even though they benefited in the short run, can they sue?

Far-f;etched? A little, but this happened with the early hearrt valves. Until the first artificial valves were invented most people died of their leaky valves. After getting a new lease on life for 20-30 years, the valves began to crack from the constant pounding they took from pulsating blood flow.

The patients sued: defective product.

I don't have a good answer to questions like these. I suspect that all new treatments and devices are vulnerable. Political pressure will be put on the FDA to approve quickly, and then they will be criticized later if long-term studies show problems that could have been avoided if there had been more research.

We saw this last week, when it was reported that medical devices approved quickly were recalled more often. I doubt that this occurred because the devices were shoddy workmanship. More likely the devices needed more time to be studied before approval. This is the Monday Morning Quarterback phenomenon: "We shoulda known..."

For something like HIV, any investigational therapy will undergo the same push to get it out quickly. Particularly if the media hails it as a "breakthrough" even while the therapy is still in the developmental stages.

How many times have we heard about breakthroughs? Some recent research suggests that most of these new and exciting ideas never see the light of day because the research was faulty or we find a problem ("the operation was a success but the patient died").

Experience suggests that almost all "breakthroughs" never break through.

Doc D

At Last! Ice Cream From Breast Milk

2011-02-27T11:26:00.000-06:00

Just what the world has been waiting for...an 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

Survey: Half The Country Thinks Health Care Reform Was Repealed

2011-02-24T13:29:00.000-06:00

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

Doctors Handing Out Work Excuses To Support Political Protest

2011-02-23T12:01:00.000-06:00

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

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

2011-02-22T12:42:00.000-06:00

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

Study On Heart Health: Nobody's Good Enough

2011-02-20T13:59:00.000-06:00

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

2011-02-20T12:24:00.000-06:00

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.

Achoo.

Doc D

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

2011-02-17T10:10:00.000-06:00

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

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

2011-02-16T13:23:00.000-06:00

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

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

2011-02-15T11:41:00.000-06:00

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 products...so 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 treatment...like...right 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

Slacking Off On Blog Posts

2011-02-14T09:00:00.000-06:00

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

Special Message To Those Who Are Discussing Whether Hilary Used Botox

2011-02-12T11:41:00.000-06:00

(link)

Get a life.

Doc D

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

2011-02-11T11:04:00.000-06:00

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.

2011-02-11T10:50:00.000-06:00

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

Medical Cartoonville - 10 Feb 11

2011-02-10T17:03:00.000-06:00

Justice is a heavy burden.

Doc D

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

2011-02-09T11:13:00.001-06:00

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

Survey: What Patients And Doctors Want From Each Other

2011-02-08T11:30:00.001-06:00

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

We Don't Need No Stinking Health Care Mandate

2011-02-07T15:27:00.001-06:00

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

2011-02-07T13:05:00.000-06:00

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

De-Bulk Your Super Bowl Calorie Festival

2011-02-06T08:09:00.000-06:00

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

Medical Quote Of The Day - 5 Feb 11

2011-02-05T10:07:00.000-06:00

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

Keeping Up With The Woo: Medical Intuitionists

2011-02-04T11:02:00.000-06:00

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

Your Government At Work. I Could Have Been Killed

2011-02-03T11:02:00.000-06:00

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

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

2011-02-02T11:29:00.000-06:00

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.

and....

There's no such thing as electohypersensitivity.

The woo is taking over.

Doc D

Judge Rules Health Care Reform Unconstitutional In Its Entirety

2011-02-01T15:20:00.000-06:00

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?

2011-02-01T14:36:00.000-06:00

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

Breast Reduction Surgery For Men On The Rise

2011-01-31T11:19:00.000-06:00

Largely ascribed to the collision between obesity and body scuplting, but there are other causes.

According to the BBC News (Jan 30), male breast reduction surgery rose by 28% last year in the UK.

There's a lot of discussion in the article about obesity as a cause. Many of the men who request the surgery are advised to do diet and exercise instead. But the pressure to give the appearance of a "male" chest, is clearly behind most of the requests.

And, while overweight and obesity are a large part of the problem, there are a couple of things you may not know about.

Some of the substances to which we expose our bodies contain compounds that have "estrogenic" activity. That is, they act like estrogen, the hormone that is critical in women's reproductive and sex characteristic expression.

Men's bodies can be sensitive to those estrogen-like effects.

Here are a couple of things that can contribute to Man Breasts:

1. Saw Palmetto, the herbal product taken by some for "prostate health" (whatever that means)

and...you guessed it,

2. Marijuana

There are probably a lot more herbals that have estrogen-like activity, and then there's the estrogen that's present in the environment --rom human use. We don't have a clue yet just how pervasive this all is, or how influential, when it is absorbed internally.

Which is not an endorsement of free-range chickens and such. I've raised chickens; their eggs are natural ,but they taste the same to me, and you have to wash off the fecal smears just like the commercial farms do.

Doc D

Who's An MD And Who's Not...And Does It Matter.

2011-01-30T11:11:00.000-06:00

A survey by the AMA shows that people are pretty confused.

The American Medical Assocation released a survey this week; the survey asked people whether certain professionals were MD's or not. It's amusing, really, but not that helpful. The AMA was trying to use the survey to show that people really prefer MD's, but I don't think it's very persuasive about that. Yes, some people do, but others have great trust and benefit from other healthcare providers. I will concur, however, that some of the non-MD's have years of training that qualifies them, and some do not. That should be the distinguishing feature: skills and knowledge.

But, back to the funny part. Here's my mini-version of the test. Make your choices and don't cheat...answers below. Which of these is an MD?
1. Podiatrist
2. Orthopedist
3. Chiropractor
4. Gynecologist

5. Anesthetist
6. Psychiatrist
7. Audiologist
8. Dermatologist
9. Nurse Practitioner
10. Otolaryngologist
11. Midwife
12. Ophthalmologist
13. Dentist

Answers: All the even numbered are MD's. The others aren't. Some are pretty obvious to most of you, I'm sure. But here's some amusing percentages:

Despite the title "nurse practitioner," 1 out of 4 thought they were MD's.

70% thought that dentists were MD's.

88% were sure that orthopedists were MD's, but that's down from 94% two years ago. Huh?

The AMA didn't ask about anesthetists, I just threw that in. CRNA's (certified registered nurse anesthetists) are nurses with special training in anesthesia, and very capable at what they do (see my post here on whether they should always be supervised by an MD). Anesthesiologists are MD's.

Don't get me wrong. I'm not being derogatory of the critical role in health care all of these experts play--except chiropractry, which is quackery IMO. However, they do not spend from 8-12 years training for the job. Midwives just deliver babies, audiologists manage hearing, podiatrists deal with feet, etc....but they don't have to go 4 years to medical school first.

The other parts of the AMA survey are interesting, but phrased in ways to get the answer they want ("Do you think somebody that amputates a foot should be an MD?"). They could have asked more neutral questions IMO.

One last survey result: People were evenly split on whether they could easily tell who was an MD and who was not from "services offered," "credentials displayed," and "marketing materials." 51% said "No."

The charts are entertaining. See how you match up. You can find the results here.

Doc D

Medical Quote Of The Day - 29 Jan 11

2011-01-29T12:02:00.000-06:00

This is a long quote. And it's not a funny one.

I've struggled with a vision of health care reform throughout the three years I've been writing here. I know the Big Four issues: Coverage, Access, Cost, Quality. I know they are inextricably linked such that attention to less than all at once will fail. I don't want a slogan...maybe later. I've used the phrase "Patient-Directed Care" to express my frustration with the "patient-centered" approach that's being touted by policy wonks. I'll keep working on the vision.

But the following, by a practicing physician, published in the New England Journal of Medicine (Sep 10, 2009) captures the perspective that I see for doctors and the patients they serve.

It is a tired and cynical cadre of physicians who will implement health care reforms. Yet few published perspectives include the view from the factory floor. The usual platitudes about changing financial incentives, increasing efficiency, and delivering high-quality care sound naïve to clinicians who deal with the imperfections of human nature and the messy effects of illness on patients. Doctors are already, by training, sophisticated decision-making machines, capable of achieving extreme efficiency through the use of heuristics and experience.

The main problems that clinicians face in achieving efficiency and reducing costs are, first, a perceived need for certainty in diagnosis and treatment — a need driven by secular expectations and malpractice concerns; second, gross inefficiency created by obligatory documentation to satisfy billing requirements that have little value for clinical care; and third, restrictions on the use of clinical judgment that could avoid excessive testing. None of these problems, whose solutions would save money and time, have been incorporated into the national discussion about reform.

One change that would augment the role of clinical judgment would be for the health care system to resist the temptation to require adoption of often-elusive “best practices.” There has been an assumption by analysts that published clinical trials provide a sound guide for therapy, but all reputable studies report odds, hazard ratios, and effect sizes, almost all of which are small or modest. Absolutes are discordant with the realities of sickness and health. There may be guidelines and measurable outcomes for mundane problems, but for the vast majority of daily doctor's visits and hospital decisions, incremental or recursive approaches to diagnosis and treatment are more effective and efficient.

--Allan H. Ropper, MD

This is very Kantian. Persons are ends in themselves...and unique. Large-scale social planning in an area like health care places other priorities in conflict with the interests of persons.

Doc D

Tone Down The Rhetoric On Reports Of Cancer In Breast Implants

2011-01-29T11:35:00.000-06:00

The FDA is looking at a handful of reports of lymphoma around breast implants. But it's in the scar tissue from surgery, and unrelated to silicone.

The reporting on this (Boston Herald, Jan 26) is surprisingly balanced...for the media. Except for the linked article title: "FDA sees possible cancer risk with breast implants." We're talking 60 reports out of 10 million implants.

The FDA doesn't "see" anything yet. The reports of this are so rare that it reaches the limits of what can be studied with any assurance of a definitive answer. Looking at how common implants are, and how few of these cases, and how mnay years it takes for problems to occur, I guess that it will take almost a million women to be followed for over 10 years...and even then there may not be a clear-cut result.

Before you think breast implants may be a risk, consider the following:
1. Lymphomas can occur in scars of any type, like a cut on your arm...rarely. It may be that--if it exists--the risk is the same as with any scar tissue, and has nothing to do with implants.
2. The few cases don't show any predilection for one type of implant over another (silicone versus saline). This is minor support for item #1 above.
3. Even if some researchers were able to corral this many women with implants for long enough, the risk may turn out to be in the "one in a million range." This is right at the limit of the abilities of the scientific method to discern differences under controlled circumstances. In scientific slang this is called the "One In a Million" rule.

So, bottom line, in 20 years we may know that's not a problem, or at worst, a miniscule problem.

Our dietary habits are a thousand times more risky.

Doc D

Study Undermines Assumption That Payment Reform Can Improve Quality

2011-01-27T10:52:00.001-06:00

Another assumption of health care reform rebutted: that quality of care will improve if doctors get paid for what they accomplish, rather than what they do.

This is the so called "outcomes-based" or "pay for performance" proposal. The quality solution to the nefarious "fee for service" system we currently have.

Pay for Performance (PfP) carries the kind of simplistic logic that avoids getting into the details of the complex interactions in health care delivery. The premise is that (1) doctors get paid to do stuff, (2) doctors want to get paid more, (3) doctors will do more stuff to get paid more. This will result in unnecessary and potentially harmful tests, surgeries, and treatments. So quality will suffer.

Despite refuting false claims about health care quality being poor in the US (see my posts here and here), the media and activists have been largely successful in portraying the US health care system as giving poorer results than abroad. In fact, longevity and infant mortality, two of the most common comparisons, are better.

But given that most people now assume the critics are right, it makes things easier for them to propose changes that have the appearance of being "a good idea," when they may not be.

Enter Pay for Performance (PfP): to reverse the incentives to perform too much, and potentially harmful, care; to change the payment system--pay only for results, or "outcomes."

Take the example of high blood pressure (hypertension). Pay for Performance would reward physicians if they met certain standards for whether a patient's blood pressure is checked regularly and is controlled, whether they follow standard protocols for what drugs are used to control the pressure, and whether they reduce the number of complications in the patients they are taking care of (strokes, heart attacks, etc).

As I say, it all sounds very straightforward. The incentives are shifted from income to outcome: keeps doctors focused where they should be, eliminating care that's not needed.

There've been a few limited experiments that show quality improvement under such a scheme, but they've all been criticized on the basis of the Hawthorne effect, small study size, and other issues.

Now, there's a large scale research project out of the UK, looking at hypertension, where Pay for Performance resulted in no improvement in quality. The authors conclude,

"Governments and private insurers throughout the world are likely wasting many billions on policies that assume that all you have to do is pay doctors to improve quality of medical care," says senior author Stephen Soumerai, professor in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute. "Based on our study of almost 500,000 patients over seven years, that assumption is questionable at best." (Science Daily, Jan 25)

Note the scale and duration of the study (available here, BMJ Jan 25). They looked at over half a million patients from 2000 to 2007 not only to have a large denominator, but also to ensure a comparison to the non-PfP results prior to implementing the scheme in 2004. The date range included data for three years prior to implementing PfP, and three years after, for comparison. There was no change in blood pressure control or in complications from the disease.

For Onion Peelers,
After accounting for secular trends, no changes in blood pressure monitoring (level change 0.85, 95% confidence interval −3.04 to 4.74, P=0.669 and trend change −0.01, −0.24 to 0.21, P=0.615), control (−1.19, −2.06 to 1.09, P=0.109 and −0.01, −0.06 to 0.03, P=0.569), or treatment intensity (0.67, −1.27 to 2.81, P=0.412 and 0.02, −0.23 to 0.19, P=0.706) were attributable to pay for performance. Pay for performance had no effect on the cumulative incidence of stroke, myocardial infarction, renal failure, heart failure, or all cause mortality in both treatment experienced and newly treated subgroups.

The separate question, whether it saved money, is not addressed. But even so, PfP is being sold as a correction to poor quality...which didn't occur.

As another author put it, in the same Science Daily piece,

"Doctor performance is based on many factors besides money that were not addressed in this program: patient behavior, continuing MD training, shared responsibility and teamwork with pharmacists, nurses and other health professionals. These are factors that reach far beyond simple monetary incentives."

Quality improvement is a critical effort. Lobbyists, politicians, and advocates for PfP are diligently implementing expensive programs as we speak.

Wouldn't it be better to validate the concept first? Maybe look at some of the other contributions to quality that interact with payment?

Doc D

UPDATE: Omitted a duplicated paragraph.

BOOK: "Overdiagnosed" Generalizes Too Much--And Another Personal Story

2011-01-25T11:13:00.001-06:00

A new book called "Overdiagnosed" got me to thinking about treating health issues when the patient feels well.

The authors make a point about looking for diagnoses when there are no symptoms, and someone feels healthy. Most doctors would agree that if you do enough lab tests, you'll find an abnormal value that's a red herring.

But this is different. The authors, of "Overdiagnosed," H. Gilbert Welch, Lisa Schwartz, and Steven Woloshin, make their point in this way:

"Overdiagnosis occurs when physicians make a diagnosis in an individual who would never go on to develop symptoms or die from the condition. It happens when we try to make diagnoses too early, in people who don’t have symptoms. I’m not saying we should never do that, but members of the general public have gotten the message that early diagnosis is always in your best interest, that it’s always good to look harder and find more. But the reality now is that we can find abnormalities in just about everyone and that can start a whole train of harmful events. So we all need to adopt a more balanced approach." (WSJ Health Blog, Jan 20)

Problems:
1. Often people have no symptoms when a serious illness is in its early stages. Breast cancer, borderline heart failure, diabetes, and the like. There are standards for when people are most prone to develop certain serious problems, and screening tests are used to discover them. There aint no such thing as "too early" a diagnosis here.

2. There's some research that says better control of some borderline conditions improves the long-term prognosis. Welch and his co-authors give the example of borderline high blood pressure (hypertension) as an overdiagnosis. However, we have some data to show that if you control borderline hypertension, or get even better control of some one who already is under treatment for hypertension, you reduce the risk of heart attack and stroke further.

Here's a personal story (my other personal stories are here and here). I have hypertension. It's not that bad. At first, 6 years ago, I would have a borderline reading at the doctor's office; but not always. So, I asked for a 24-hour blood pressure (BP) monitoring. It showed that while my BP didn't often get high (while resting) during the day, at night there wasn't the normal fall in pressure that occurs with sleep. This is a sign of developing hypertension.

For me, this was enough. I was having trouble exercising to control BP and weight, due to back problems. I knew that the damage from high BP comes from many years of being high, during which I would feel fine (no symptoms). But after 20 years of this, there will be risks: heart attack, stroke, kidney damage, vascular trauma, circulation issues, etc.

So, I went on medication. It brought down the pressure, but not to what it was when I was 20 years old. For example, if without treatment I averaged 145/92, under treatment I would be 135/80. But back when I was younger and running every day, the average was about 118/68. Initially, my doctor--and I--was happy to get below the 140/90 threshold.

But later, large-scale reviews began to show that if you could normalize the pressure even more, the risk would fall even further. There's a counter-balancing risk, however; if you over correct, people can get syncopal--their blood pressure can be that low under normal circumstances, but when they stand up quickly, or get a little dehydrated, they can feel faint.

In any case, I asked for more aggressive treatment. It brought down my BP. In the meantime, I had back surgery (I posted that personal story, too), allowing more physical exercise. Admittedly, there were a few times when, working out in the heat of the summer, I got a little woozy and had to sit down for a minute. So, we re-adjusted the medications.

Having this condition--hypertension--is like having diabetes, you have to monitor things. Not all the time, but every few months or so. I lost weight exercising, and my need for medicine went down, so another adjustment was needed. These days, I range about 128/75, which is safe and probably an improvement over my initial therapy.

But I'm still watching the research on this, because science is always being modified by new results. Should the benefits of "optimizing" blood pressure, as opposed to "lowering" BP turn out to be minimal, then I'll re-look at the strategy. That's the way it works.

The authors' example of borderline cholesterol results can be argued similarly.

But unlike my story about getting a spinal fusion, I've tried to avoid being Dr. Know-it-all, and work with my doctor to obtain the best solution. When I try to run my own medical care, I'm just as stupid (if not more so--a little knowledge is dangerous) as anybody else. None of the above should be undertaken on your own, and it may be that your condition is not amenable to this kind of management. Or you may decide, with the authors, that living your life unburdened by early diagnosis is happier. (BIG DISCLAIMER).

So back to the book "Overdiagnosed." I can't agree with the underlying premise that accidental health issues, uncovered by routine exam or testing, which are asymptomatic--and the patient is feeling well--should be unexplored.

There are many health issues that benefit from being discovered early. And, in particular, there are conditions where fully treated borderline, or partially corrected, problems can make a difference to long-term health.

We're all unique. Generalizing about "over"-diagnosis makes the mistake of "over"-looking that fact.

Doc D

Semi-Vegetarian Tacos

2011-01-25T10:09:00.000-06:00

Somebody figured out that Taco Bell's meat filling is not all beef, and they're suing.

But, take a lot at what is alleged to be added to your "beef" taco.

"water, ‘Isolated Oat Product,’ wheat oats, soy lecithin, maltodrextrin, anti-dusting agent, autolyzed yeast extract, modified corn starch and sodium phosphate.."

Sounds like to me they reduced the percentage of the "bad," unhealthy beef...and added in vegetable products that are more healthy. See the OC Register, Jan 24, for more.

Not only that, they put in all that tasteless, healthy veggie stuff and kept the taste that people want.

Oats, soy, yeast, corn. This could be a health food store supplement. Water? Sodium phosphate? These are added to many foods.

So, what's your reward for stealthily reducing red meat in the American diet (and saving money, since it's cheaper)?

Sued for false advertising. Only in America.

Considering the investment in four years of law school, you have to do something to support 25% of the world's lawyers.

Doc D

Jack LaLanne Mini-Euology

2011-01-24T11:38:00.000-06:00

Mr. LaLanne was a daily feature of my early childhood. His TV show was a breakthrough at a time when exercise was un-feminine and weightlifting was frowned upon.

You have to remember that when I watched his show, it was on a huge wooden box with a tiny black and white screen. And if you didn't tweak the antenna "rabbit-ears" just right there was poor reception.

Amazing man. Upbeat and energetic, he lived the life he encouraged every day. I'm not sure many of us can say we walk the walk all the time.

He was first to show that you don't need any equipment to do a good workout, and the first to propose that inactivity is our own worst enemy. His advice was always simple and never strayed from common sense. He didn't care what you did to exercise as long as it was moving and using your body.

So different from all the extreme self-help gurus of today.

Clips from some of his 50's TV shows are available on YouTube.

The news reports (OC Register, Jan 24)say he died of pneumonia. He'd had a heart valve replacement sometime in the last 2 years, I think.

But he put everything into his 96 years.

Doc D

HHS Collects Some Chump Change From Medicare Fraud

2011-01-24T11:17:00.000-06:00

The Secretary of Health and Human Services (a political appointee with no experience in health care) announces that they recouped 4.0 billion dollars in Medicare fraud last year...about 4% of the total fraud.

Great job. This puts us up from 1% in the past. See here for the positive spin from USA Today (Jan 24).

Now if we could just get back the other 96% of the approximately $100 billion in Medicare fraud each year.

You've heard the stories about how easy it is for criminals to defraud the government's program. Organized crime is finding it a lot safer than drugs or prostitution. There was the pizza parlor in Florida that was getting paid for AIDS transfusions. And the dentist in New York who was filing claims for almost 300 patient procedures a day.

And the answer to why all this money down the drain? "We don't have the resources to investigate." Well, if we had that 100 billion we wouldn't have needed any funds for Health Care Reform. Can't you figure a way to get in the game?

But, thanks, Madame Secretary, for putting your heart and soul into this determined effort in the cause of justice...that gave us very little.

Doc D

NOSTRUMS...by Doc D

Notice To Readers

Medical Quotes v2 - 9 May

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

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

Medical Quotes v2 - 4 May

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

STUDY: Obese People Not Getting Sexually Satisfied

Medical Quotes v2 - 1 May

Dr. Mercola Warned By The FDA About Unwarranted Claims

Growth In Health Care Cost Not Controlled By Universal Care

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

Medical Quotes v2 - 29 Apr

Medical Quotes v2 - 27 Apr

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

STUDY: Medical Student Interest In Primary Care Continues To Plummet

Medical Quotes v2 - 25 Apr

Shiny Happy People Holding Hands...And Committing Suicide

Medical Quotes v2 - 23 Apr

Health Care Incentives: Are We "Consumers?"

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

Medical Quotes v2 - 21 Apr

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

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

Hannibal Lechter Implements Health Care Reform...The Movie

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

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

Cure For Everything Discovered

Smokers Think "Slims" Are Less Harmful

STUDY: Doctors Choose Riskier Treatment For Themselves Than For Patients

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

Government Shutdown? No. Elf Ears? Maybe

Training Doctors: More Rested, But Less Experienced?

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

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

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

Using Soy To Increase Radiation Therapy Effectiveness For Cancer

Way Cool Radiation Dose Chart

Ruby Does Reiki, And Demonstrates Human Vulnerability To Quackery

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

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

Accountable Care: Another Performance-Based Flop

Antibiotics For Cough And Phlegm

STUDY: Cruise Ship Virus, Passengers Got It But The Crew Didn't

Dr. Oz Stirs The Radiation Hysteria Pot

SUPREME COURT: Cold Remedy Liable For Not Reporting Unproven Adverse Reaction

Comparing Health Risks Requires Understanding Of Biology

Medical Quotes Of The Day - 19 Mar 11

Idiotically Unnecessary Guidance: WHO Says People Arriving From Japan Are Not A Radiation Risk To Others

Media Goes Nuts Over "Pear" Versus "Apple" Body Fat

Record-breaking Longevity In The US. 78 Years And 2 Months

Are Americans Getting Fatter Or Not?

Peope In CA Taking Potassium Iodide To Prevent Radioactive Iodine-Induced Cancer From Japanese Nuclear Accident

CITATION: Some "Healthy" Foods Aren't

Top Five Posts - March Edition

Why People Disbelieve The Science...Often Strongly So.

Taking Meds For Hair Loss And Feeling Limp?

Who's In Charge In Congress? The Staffers?

Medical Cartoonville - 11 Mar 2011

The Health Care Reform Waiver Lottery: Now Entire States Enter The Game

The Mediterranean Diet Works, Of Course...Because There's Nothing New In It

STUDY: Nicotine Measured From Toenail Clippings Predicts Risk Of Lung Cancer

STUDY: Psychosis Symptoms More Likely In Marijuana Users

HCR Expert Says, "Yeah, You Have To Buy Broccoli"

Supreme Court Rules "No Suits Against Vaccine Makers"

CIty Funds Brain Cancer Scans For The Healthy

"NYC City Council Funds Unproven Cancer-Screening Program"

Ethics... And Evaluating New Treatments For Serious Diseases

At Last! Ice Cream From Breast Milk

Survey: Half The Country Thinks Health Care Reform Was Repealed

Doctors Handing Out Work Excuses To Support Political Protest

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

Study On Heart Health: Nobody's Good Enough

I Have A Cold, And I'm A Wimp

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

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

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

Slacking Off On Blog Posts

Special Message To Those Who Are Discussing Whether Hilary Used Botox

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