"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Lectured by Committees, preached at by chaplains, scowled on by treasurers and stewards, scolded by matrons, sworn at by surgeons, bullied by dressers, grumbled at and abused by patients, insulted if old and ill-favored, talked flippantly to if middle-aged and good humoured, seduced if young...
-Anonymous quote, 1857, on the lot of nurses
Moira Breen and Anne Wilson come to the defense of the nursing profession against Stanley Kurtz, who seems to think that nursing is a distinctly feminine field, and that it’s the femininists who are responsible for the nursing shortage. Au contraire, Mr.Kurtz. Anne Wilson does a wonderful job of disabusing him of that notion. Reading it reminded me of one of my favorite nurses. I say favorite, because this particular nurse is one of the best nurses I have ever dealt with: observant, conscientious, diligent, a true patient advocate, and a man. Not only is he a man, he’s about the least feminine and nuturing man I’ve ever met. He favors motorcycles and muscle shirts, he’s an unapologetic womanizer in his private life, and he has no interest in settling down with a wife and family. Yet, for all that, in his professional capacity as a nurse he’s beyond compare.
Nurses aren’t there to wipe a brow and hold a hand. They’re there to monitor the patient’s disease or post-op course, to interpret signs and symptoms and know when there’s a problem that needs attention, to make sure drugs are mixed and given properly, and to make sure wounds are dressed and healing properly. They can’t rely on goodness and mercy to do their job well, they have to have a good grounding in the basics of medicine. Anyone who doubts that only has to spend a few hours on a hospital floor and observe the difference between the nurse’s aide and the registered nurse. A nurse can recognize problems early on, the nurse’s aide isn’t likely to recognize them at all. Unfortunately, hospitals are hiring more aides and fewer nurses to cut costs, and therein lies the problem.
Besides, where is it written that nurturing is a specifically feminine virtue? posted by Sydney on
7/13/2002 08:10:00 PM
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Lies, Damned Lies, and Statistics: Ian Murray, at The Edge of England’s Sword is skeptical about the recent study of hormone replacement therapy. He also has this link to a critique of the statistics used in the study.
They’re both a little hard on the study and on the media. Most of the media reports I read were careful to say that the increase in cancer and heart disease in the users of estrogen were small, but significant. They were also careful to point out that the study only pertained to those using estrogen and progesterone. Still, there is a tendency, both in the media and in the medical community, to take this kind of data and communicate it in terms of relative risk, which always makes the danger seem much more ominous than it is. Physicians aren't any better at statistical analysis than the general public, so we get sucked into the exaggeration, too. It's quite conceivable that people, including doctors (and more ominously, malpractice lawyers), will interpret the findings to mean that no one should take estrogen replacement therapy. That would be wrong. (For the raw results of the study click here.)
The biggest issue here, is that patients need to be allowed more of a voice in selecting preventive treatments. By and large, women weren’t given much of a choice when it came to hormone replacement therapy. They may have been told of the potential risks and the benefits, but if the physician believed the benefits outweighed the risks, he would emphasize the benefits. In many cases, though, especially ten or twenty years ago, women were just told to take it because it was the belief of the medical community that estrogen was good for them. Too often, the patients weren’t given any say in the matter at all. This is especially egregious considering that, with the exception of treating hot flashes and vaginal dryness, the purpose in taking the medication was to prevent a condition that might develop (heart disease, osteoporosis) rather than a disease that already exists.
The same thing happens with cholesterol-lowering medication. This is medication that, in most cases, must be taken for the rest of one’s life to maintain cholesterol at acceptable levels. The sole purpose of taking it is to reduce the risk of developing disease. Taking it all of your life doesn’t mean that you won’t some day end up with a heart attack, it only means that you have less of a chance to end up with one. Most of the time, that distinction isn’t communicated to patients. Instead, they are told that they have a certain cholesterol level and that medicine is indicated to bring the cholesterol down to the acceptable standard. Like estrogen replacement therapy, we do this because it is the accepted belief of the medical community that lowering cholesterol is good. In this case, though, it goes even further than that. We know this is good care because we have been given guidelines that tell us so. Insurance companies and hospitals know this is good care because they read the guidelines, too. They use them to monitor the quality of care that physicians deliver. The result is that there is pressure on the physician to get those cholesterol levels down to acceptable levels. Cholesterol becomes a disease rather than a risk factor. Patient preferences are taken completely out of the equation.
Statistics have played a role here, too. Take a look at some of the studies that influenced the guidelines (here, here, here, here, and here.) They all have a fondness for expressing their results in terms of relative risks and risk reductions. It sounds so much more impressive to say that heart attacks were reduced by 31%. But, in terms of pure numbers, the differences in the number of heart attacks is only a few percentage points. How many people would take cholesterol medication if they knew that it really only gave a benefit of 3 or 5 fewer heart attacks per 100 people taking the medication? What are we going to tell our patients when, after twenty or thirty years experience with them, we discover their long-term side effects and consequences?
We should exercise more care when counseling patients on taking preventive medicine. It’s become too common to prescribe preventive medication as if we were treating disease itself. They aren't the same at all. Patients should be given the straight facts and a chance to make their own decisions when it comes these issues. posted by Sydney on
7/13/2002 05:29:00 PM
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The Reading Room:The Medical Letter has an on-line public reading room with free access to several of its articles, including ones on cholesterol medication, treatment of anthrax, bioterrorism, and traveler's advice. posted by Sydney on
7/13/2002 11:53:00 AM
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AIDS in Africa: Another reader had these cogent observations about the AIDS epidemic, and suffering in general, in Africa:
Unfortunately, sending food is likely as unproductive as the money and drugs. These countries are starving because their government (aka current thugs in power) have chosen to destroy the farms and steal the food.
In three of them (Zimbabwe, Malawi, and Mozambique) the government makes no effort to hide the fact that food aid goes only to government supporters. The remainder is sold on the world market to get cash for the government. The others hide it better, and in a few cases are so close to total chaos that massive theft is as much the result of lack of government as it is government.
Zimbabwe used to export 50% of its agro production and used to be one of the best fed of the sub-saharan countries. The difference is pure politics. The farmers are political enemies of the government. They are being murdered. Their farms are being destroyed. And now the government refuses to distribute food to the surviving opposition.
So what do you do? Sending food does nothing to help the starving. It helps those who are killing them. Overthrowing the government is politically unpalatable. It is a great tragedy.
Yes, it is a great tragedy. And it makes the grandstanding by people like Clinton and Mandela on AIDS funding all the more shameful. Clinton has it exactly backwards. He's blaming all the governmental chaos on AIDS. It's the government chaos and resulting famine that is responsible for the AIDS crisis. It's disheartening to hear someone of Clinton's stature and world-standing echo the blather of the AIDS political activists rather than using his position to highlight the hard truths about the issue. posted by Sydney on
7/13/2002 07:28:00 AM
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Federal officials said they felt confident in
reporting that the number of new H.I.V. infections
has been stable in recent years, with an estimated
40,000 Americans becoming infected each year.
Government officials estimate that 900,000 Americans
are living with H.I.V. or AIDS. The number has
increased by 50,000 since 1998, largely because
advances in treatment have controlled the infection
in many people, allowing some to go back to work and
live longer.
If 40,000 are infected each year, shouldn't over 120,000
new infections have been logged since 1998? So why only
50,000? No one at the CDC really answers that question
ever. The 40,000 a year is plucked almost out of thin
air, and used for funding purposes. (And factoring in
deaths doesn't help either. The total number of deaths
for those three years is a decelerating 50,000. That
still leaves 20,000 alleged infections unaccounted for.)
I take these numbers to say that
850k estimated AIDS cases in 1998
+120k estimated new cases, 1998-2001 (3 years * 40k cases/year)
- 50k deaths, 1998-2001
------
900k estimated AIDS cases in 2001
There's a discrepancy, since 850 + 120 - 50 actually equals 920,
but the estimates for AIDS cases and new cases per year are so
soft that I still don't see a problem. The original story says,
"One reason for the continued spread of H.I.V., however, is that
about half of the 900,000 infected Americans have not been given
a diagnosis or treated or both."
So 20k more-or-less seems well within the margin of error. posted by Sydney on
7/13/2002 07:17:00 AM
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Trying to Control Medical Costs: The Senate Health, Education, Labor and Pensions Committee approved a bill on generic drug availability. The bill is to be introduced to the rest of the Senate:
The generic drug bill would amend a 1984 law designed to speed generic drugs to the market. Lawmakers and consumer advocates have long contended that drug companies have abused patent laws to prevent consumers from getting lower-cost generics.
The bill attempts to stop abuses of an automatic 30-month delay that the maker of a brand-name drug gets when it files suit to stop a generic from entering the market. Many companies have filed repeated suits to win continuous delays, prompting complaints from lawmakers.
Under the committee's bill, a brand-name drug maker would be limited to one 30-month stay per generic application.
It's a small step to make sure that generic versions of drugs are available as soon as they can be without infringing on legitimate patents.
And Doing Their Best to Defeat Those Efforts: On the same day, the same Senate committee voted to require insurance companies to pay for colonoscopies. I’m all for colonoscopies. They’re the best way to find colon polyps and prevent colon cancer, and at current prices ($600-$800), they are considered
cost effective, but requiring insurance companies to cover them (or any procedure for that matter) only drives up insurance premiums. posted by Sydney on
7/12/2002 05:33:00 AM
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Motherwitless:The Bloviator had a post about this overly affectionate mother (scroll down to Wednesday's post, the archive isn't working), and now the articulate anchors at CNN have covered it, too.
Paula Zahn and Elizabeth Cohen dance around the sexuality of an eight year old sucking on his mother’s breast. They act as if the shock and disgust it illicits in people come from some puritanical bias. Of course people are disgusted, because it is sexual. Why do women breastfeed their children? To feed them. Why do people have sex? For comfort and pleasure. Are these women feeding their children when they put them to their breast? No. Why are these women putting older children to their breasts? For comfort and pleasure. What is this? Sex.
And by the way, wouldn’t an eight year old child sucking on a baby bottle be just as odd? (although not as creepy) posted by Sydney on
7/12/2002 05:32:00 AM
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Pestilence and Famine:Instapundit had a link yesterday to this post by Martin Roth on the incidence of HIV/AIDS in Christian and Muslim countries in Africa. The incidence, however, is more likely to be related to famine than to religion. The highest rates are in those countries whose populations are starving:
Earlier this month the United Nations asked for $507 million to buy food for people in the hardest-hit region, which includes Malawi, Zambia, Lesotho, Zimbabwe, Swaziland and Mozambique and is home to 60 million people. Of those people, about 12 million will suffer food shortages in the coming year.
According to Martin Roth’s post those nations have the following HIV/AIDS rates:
None of the Muslim countries make the list. Famine is always followed by pestilence. The body can’t fend off infection when it’s emaciated, even when given drugs to help. That’s why the solution to AIDS and other diseases in places like Africa is not likely to be found in just throwing money and drugs at them. posted by Sydney on
7/12/2002 05:30:00 AM
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Turning the Law on Itself: In an attempt to draw attention to a silly law, a group is suing an organic bread maker, because their product causes cancer. This lawsuit is a joke, along the same lines as the "Letters from a Nut" books, but some activists in California really are going after makers of french fries:
The nation's top French fry sellers, McDonald's and Burger King, have already been targeted in the acrylamide scare by a small California environmental group which has been accused in the past of "bounty hunting" for flooding California authorities with Proposition 65 notices.
Burger King said last week the legal action was "frivolous and totally ludicrous."
Jackpot Justice: Mississippi continues to lose obstetricians because they can't find affordable malpractice insurance in the state. The reason:
Since the first of the year, five lawsuits against physicians and hospitals have resulted in verdicts totaling some $28 million, according to the group. In recent years, eye-popping, $100 million-plus verdicts and settlements gave Mississippi a reputation as a haven for trial lawyers.
Don't think that the problem is confined to Mississippi or the other states fingered by the AMA as having malpractice insurance problems. It's nationwide:
Though Mississippi's problem is one of the worst, the average malpractice award nationwide is now $3.5 million, the AMA says, and insurance companies have raised liability premiums to doctors 79 percent in less than 10 years. The group is lobbying for national reform.
The Elephant in the Rooom: Try as I might, I can no longer ignore the news about the demise of hormone replacement therapy. It’s everywhere. My ears are still ringing from all the telephone calls I got yesterday about it. All the hoopla comes from this study sponsored by the NIH. It was designed to confirm the supposed benefits of estrogen replacement therapy, but had to be stopped because women taking estrogen were developing more breast cancer and other complications than those who weren’t. As a result, the NIH made this announcement :
The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) has stopped early a major clinical trial of the risks and benefits of combined estrogen and progestin in healthy menopausal women due to an increased risk of invasive breast cancer. The large multi-center trial, a component of the Women's Health Initiative (WHI), also found increases in coronary heart disease, stroke, and pulmonary embolism in study participants on estrogen plus progestin compared to women taking placebo pills. There were noteworthy benefits of estrogen plus progestin, including fewer cases of hip fractures and colon cancer, but on balance the harm was greater than the benefit. The study, which was scheduled to run until 2005, was stopped after an average follow-up of 5.2 years.
The part of the study that was stopped was only that involving women taking both progesterone and estrogen. It isn’t clear yet if women taking estrogen alone have the same risks. My guess is that they would. Although it is possible that progesterone is somehow modulating the effect of the estrogen, it is estrogen receptors that are present on breast cancer tumors and that can make them more aggresssive. Estrogen still has a role to play in relieving hot flashes. It’s really the only thing we have to treat them. It’s also the only thing we have to treat the vaginal dryness that results from menopause; a dryness that can be so bad it makes sex impossible.
Estrogen therapy has always been one of those treatments that patients have too often been bullied into taking. With very little evidence women were told to take it, no questions asked. It never really should have been given the status it was given, as this article from the NY Times makes clear. Turns out that the whole widespread notion that estrogen replacement therapy was essential, had its roots in a slick drug company campaign:
The tale of estrogen therapy began in 1966, when an enthusiastic doctor, Robert Wilson, wrote a best-selling book. He called it "Feminine Forever" and flew around the country promoting it, telling women and doctors alike that estrogen, the feminine hormone, could keep women young, healthy and attractive. It was just so natural — women would be replacing a hormone they had lost at menopause just as diabetics replace the insulin their pancreas fails to make.
"At age 50, there are no ova, no follicles, no theca, no estrogen — truly a galloping catastrophe," Dr. Wilson wrote in 1972 in The Journal of the American Geriatric Society, referring to the eggs and surrounding tissue. But, he continued, estrogen can save these women. "Breasts and genital organs will not shrivel. Such women will be much more pleasant to live with and will not become dull and unattractive."
Dr. Wilson died in 1981, but his son, Ronald Wilson, said yesterday that Wyeth-Ayerst had paid all the expenses of writing "Feminine Forever" and financed his father's organization, the Wilson Research Foundation, which had offices on Park Avenue in Manhattan.
Mr. Wilson, who lives in Cary, N.C., said the company had also paid his parents to lecture to women's groups on the book. Wyeth said it could not confirm the account because it was so long ago.
By 1975, Wyeth's product, Premarin, had become the fifth leading prescription drug in the United States, said Nadine F. Marks, an associate professor at the University of Wisconsin at Madison, who co-wrote a research paper on hormone therapy. "Even textbooks for gynecologists and obstetricians in the 1960's would explain how a woman's life could be destroyed if she didn't have estrogen in her body," Dr. Marks said.
Even now, Wyeth is busy protecting its profitable hormone therapy. Last night, at 7:30pm, while I was doing the dishes, a knock at the door brought a a letter from the company, hand-delivered by UPS overnight air, alerting me to the study and reminding me that it only pertained to women using estrogen and progesterone together, and that estrogen was still useful for osteoporosis prevention, and menopausal symptoms. And we wonder why drugs cost so much.
posted by Sydney on
7/11/2002 06:29:00 AM
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Arthroscopic Artifice: Arthroscopic placebo surgery for arthritic knee pain is just as good as the real thing. I’ve actually heard orthopedic surgeons say they didn’t think arthroscopic surgery did much for arthritis pain. In fact, the orthopods I refer to don’t routinely do it for arthritis. That’s not to say it isn’t done. There are other orthopedists in our community who do arthroscopes for arthritis, or “scoping for dollars” as a resident I once knew used to call it. posted by Sydney on
7/11/2002 06:24:00 AM
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More Merck-Medco:Derek Lowe has some thoughts on the Merck-Medco accounting, and a link to a Forbes piece on it. (scroll down to Monday's entry) He's puzzled as to why they would count the copays, too. posted by Sydney on
7/11/2002 06:22:00 AM
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Merck-Medco’s Accounting: A reader had this to say about Merck-Medco’s dubious revenue counting:
“I don't think counting the co-pay as revenue matters all that much. Their competitor also does it that way according to some analysis I read. Also if they inadvertently tell the pharmacist to collect $5.00 instead of $10, they are liable to the pharmacy for the additional $5. The accounting had no effect on net income since they offset it with and equal expense except for the few cases where they made the mistake indicated above. Then the expense would be higher. Since the bottom line is the important thing and not revenues per say, and this had no effect on the bottom line, (except as noted above), then why should anyone consider it misleading? I will admit that for a while everyone was focusing on revenues as if that were all that mattered, but that silliness had no basis in reality anyway. The important thing is net income. To compare it to Enron is just ridiculous, not to say unfair.”
Well, I never compared it to Enron, but I still suspect they counted the co-pay to make their revenues seem higher. posted by Sydney on
7/11/2002 06:19:00 AM
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Wednesday, July 10, 2002
A Case for Tort Reform: Two carpet installers who admit they read the label of an adhesive they used, admit they understood the adhesive was flammable and should not be used inside, used it inside anyway, caused an explosion, were burned badly, sued, and won $8 million dollars.
The most damning aspect of the case is that at first the jury ruled in favor of the adhesive company:
The jury verdict forms, however, were signed by only five jurors. In a civil case, six of eight jurors must agree for a binding verdict. So, Common Pleas Judge James E. Murphy instructed the jury to resume deliberations until the necessary six agreed on the case.
Hours later, the jury said it was hopelessly deadlocked, but resumed deliberations on the judge's order. At some point, attorneys for both sides asked for and were denied a mistrial.
By late Monday afternoon, the panel rang a bell signaling a verdict. But their decision, reversing the earlier finding, caught most in the courtroom off guard.
The jury voted 6-2 to award Roach $5 million and Falkner $3 million. The men had sought $20 million and $15 million, respectively.
Obviously, those jurors just got too tired to continue to argue the meaning of "flammable". posted by Sydney on
7/10/2002 08:26:00 AM
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Dr. Davey Crockett: The Bush nominee for surgeon general, Richard Carmona, is coming under attack. He certainly is colorful, to say the least. Like Davey Crockett, he's had many bold adventures, and like Davey Crockett, he likes to embroider them in the telling. People say he's abrasive and egotistical (well, he is a surgeon), that he's difficult (he is a surgeon), and that he lacks people skills (he is a surgeon), but his patients like him (he is a surgeon?). Not surprisingly, he's made a lot of enemies. One of them, Dr. Charles W. Putnam, has been busy writing disparaging letters about his nemesis:
Charles W. Putnam, a University of Arizona surgery professor who has worked with Carmona, told Kennedy in the letter that he did not want as his surgeon general someone "who was removed from his two previous administrative appointments ... because he could not work in an effective or even a civil manner with health professionals and other constituencies of those positions."
Dr Putnam didn’t stop there. He also brought up a shoot-out that Dr. Carmona had and won, with a man who was threatening another driver after an auto accident. Dr. Carmona, at the time, was acting in his capacity as a sheriff’s deputy. The other man died from his wounds. It was discovered later that he was insane and had just murdered his parents. Dr. Putnam thinks that Carmona should have had more compassion for the victim:
"It is patently clear that Sheriff Carmona ... not Dr. Carmona, was at center stage," Putnam said of the shootout in his letter to Kennedy. "Could not a physician have recognized the behavior of a mentally ill individual and responded in kind?"
Well, no. You can’t tell the difference between mental illness and plain old out of control rage when someone is on a rip. Dr. Putnam is being much too hard on Dr. Carmona. Others have criticized him because he didn’t rush to help the man after he shot him, as initial media reports had indicated, but instead went back to his car and reloaded his revolver first. Still others interpret his killing of a homicidal lunatic as a violation of his Hippocratic oath.
As Donald Rumsfeld would say, “Oh my goodness.” First of all, you can’t tell if someone’s dead unless you are right up on them. You have to hear their breath, feel their pulse, and see their chest move. To do this, you have to touch them. Who among us is brave enough (or dumb enough) to go up to a homicidal lunatic on the ground and touch them without re-arming himself? Presumably, Dr. Putnam would be. I’d sure as hell make sure I was protected before I went within striking distance.
As for the bit about the incident violating the Hippocratic oath, that’s just ludicrous. The Hippocratic oath is intended to set guidelines for a doctor’s behavior with his patients, not his day to day personal interactions, or his relationship with society at large. That “do no harm” phrase refers to treating patients. It doesn’t mean a doctor can’t defend himself or those around him with deadly force if necessary. It does mean he can’t give his patients a lethal dose of a drug or perform abortions, both of which are mentioned immediately after the “do no harm” phrase in the oath. Oops! I guess we don’t take that part of the oath seriously anymore, do we?
And About Those Board Exams: The other complaint that the LA Times article makes against Dr. Carmona is that he had to take his general surgery boards three times before passing them. They imply that this makes him unsuitable for the job. Well, not so fast. Here are the minimal requirements for the job:
-A medical degree from an accredited medical school
-At least one year of postgraduate medical training
-Licensure to practice medicine in 1 of the 50 states
Dr. Carmona exceeds them. You don’t need to be board certified to be surgeon general. David Satcher doesn’t appear to have been. He isn’t listed in the diplomate directory of the American Board of Family Practice, and he doesn’t mention his board certification status in his resume. Joycelyn Elders isn’t listed in the directory for the American Board of Pediatrics, although her resume claims that she was “certified” in pediatric endocrinology. Antonia Novella, (appointed by Bush pere), however, is board certified in pediatrics.
You certainly don’t have to be a good doctor to be surgeon general, presuming board certification makes you one, which it doesn’t. Surgeon generals never touch patients. Dr. Carmona does seem to be wanting in administrative and management skills, but is that even necessary anymore for a surgeon general? According to the office’s own website, the surgeon general has been demoted from being in charge of public health affairs to being a spokesperson for public health policies. It’s hard to imagine how anyone could mess that up. (Well, OK, Joycelyn Elders did.)
UPDATE: The buzz is that Carmona will be confirmed. But, the most interesting tidbit was this:
Further complicating Carmona's role is that Bush has asked Congress to shift all bioterrorism issues from HHS to a new Homeland Security Department. Asked how that would affect Carmona's vow to work on the issue, Pierce said, "I'm not going to speculate on that."
I guess the CDC will pretty much be out of the loop on bioterrorism prevention. posted by Sydney on
7/10/2002 01:34:00 AM
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Healthcare Crisis Redux: I was going to write something about the renewal of the healthcare crisis, but DB's Medical Rants beat me to it. He’s right that the crisis never went away, it was just hidden for a while by the smoke and mirrors of managed care. I don’t share his optimism about the ability of retainer medicine to cut costs. People who pay big bucks to have a doctor at their beck and call aren’t likely to forgo an expensive test they’ve heard about and set their hearts on just because the doctor tells them it isn’t cost effective or worthwhile. They’ll only listen to that sort of reason if they have to pay for it out of their own pocket. And from what I understand of retainer medicine, the patient’s insurance still pays for things like testing and hospitalization. Our basic attitude toward healthcare has to change if we are to bring down costs. As the governor from Vermont (who, by the way, is a physician, put it:
"The truth is Americans want everything and they don't want to pay for anything," said Gov. Howard Dean (D-Vt.), who is running for president on a health care platform. "We need to admit to ourselves that health care is expensive because we all want the best for our families."
Having health insurance has only contributed to this attitude:
Patients with health insurance are primarily insulated from the true costs, said Patricia Salber, medical director for Kaiser Permanente's General Motors team. That makes everything from full-body scans to the newest antihistamine irresistible -- and it pushes up costs overall.
This is exactly right. That’s why generous Medicare coverage for prescription medication is a bad idea. If the government foots the bill for drugs, the patient has no motivation to choose the least costly. They are far more likely to demand drugs their friends or family have used with success, or ones they’ve read about or heard about in commercials. People make more responsible decisions when they have to shoulder at least some of the financial responsibilities for those decisions. I’ve noticed this in my practice when patients suddenly go from insurance coverage that provides for drugs to Medicare when they reach 65. Suddenly, they aren’t so attached to Celebrex or Vioxx; plain old ibuprofen or acetaminophen will do for those arthritis pains. Suddenly, they no longer insist that their drugs be brand name; generic will do. And you know what? By and large, they do just as well as they did before with the more expensive drugs.
More and more, it seems that the solution lies not in government or employers providing more money for healthcare, but in them providing less. Let insurance cover catastrophic illnesses. Let the patient take responsibility for everything else. That’s the only way to get a more discriminating, and cost-conscious healthcare system.
A Case in Point: As if to illustrate why the price of medicine is so high, Newsweek has as its cover story, insomnia, which is a symptom, not a disease. This is a personal odyssey, for the author has insomnia. In search of a solution, she goes to a sleep lab, where for $1200 to $1600 (don’t worry, it’s covered by insurance!) she sleeps under surveillance, her every breath and every heart beat and every movement monitored and recorded. They also ask her questions about her sleep habits, caffeine consumption, etc. and do a physical exam. What does all this get her? The advice to cut back on caffeine, try a prescription nasal spray for possible allergies, and behavioral therapies to help her deal with the nightly worries that keep her awake. Gosh! That’s what I often tell my patients, and I don’t charge them $1200 for the advice. But, then again, I’m just one of those ignorant primary care physicians the article refers to, who know nothing about sleep disorders because sleep physiology isn’t taught in medical schools. I guess that’s why my advice is only worth $50.
Another Case in Point:Woman’s Day magazine, meanwhile, is urging its readers to ask for routine urine analysis to screen for kidney disease, even though it’s widely recognized that this is not cost effective. The simple office urine test can detect protein or blood in the urine that could indicate kidney disease. The problem is, those elements can be there when there is no kidney disease, too, and they often are. Depending on the study, blood is in the urine of anywhere from 10 to 20 percent of healthy adults. Protein is found in the urine of around 17 percent of healthy adults. In both cases, the presence of serious disease was only found in 2% or less of the positive testers. This may not seem like such a big deal because the office urine test is so inexpensive, but the tests that must be done to further evaluate it can become quite expensive. In the case of protein, the urine has to be collected for 24 hours and the amount of protein excreted in that time measured to determine if there is a disease. For hematuria, the testing is more expensive. That involves Xray imaging such as IVP’s and CT scans, and often a surgical procedure to look inside the bladder for tumors (which can easily cost upwards of a thousand dollars.) It can become quite expensive to chase down a false positive result, not to mention traumatic to the patient. If everyone followed the advice of Woman’s Day and their featured kidney specialists, our healthcare costs would be spiraling even further out of control than they already are.
So why do the kidney specialists in the article recommend this approach? Because they are thinking only in terms of their speciality. As kidney specialists, they only see diseased kidneys. They think there is more of it out there than there really is. They’re blind to all the healthy people out there, and they fail to take into account the number of people without disease who would turn up on those screening tests. That, at least, is the kindest spin I can put on their position. I could also be cynical and say that screening everyone would be a boon to their business because a lot of those false postives would be referred to them for further evaluation. posted by Sydney on
7/10/2002 01:20:00 AM
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A Personal Perspective: A reader emailed these comments about the Atkins diet:
I've been on a variation for one over the last year, and I'm losing weight. I'm not sure why, other than the fact that, yes, I'm probably eating less than I burn (and hiking more, but I've always hiked as much as I can.)
But there's one thing I've noticed. The big reason it seems to work for me "I'm not hungry." When I eat large amounts of carbohydrates (a trivial thing to do in our society,) I'm never satisfied. When I don't, I am. One cheeseburger, without a bun, and I'm fine until dinner. Two cheeseburgers, with, and fries, and I'm hungry again at 2PM. Once I figured this out, I stopped eating the rice with Chinese, stopped eating potato chips, and I've lost weight.
I'm wondering if anyone's looked at this. If some people's hunger mechanisms are reacting incorrectly to large carbohydrate intakes, which all "classic" diets have, I'm not surprised they fail -- either they fail to follow the diet from hunger, or they eat so much "diet" food that it
doesn't work.
The New York Times Sunday Magazine article that inspired this, did mention that eating carbohydrates seems to stimulate hunger:
David Ludwig, the Harvard endocrinologist, says that it's the direct effect of insulin on blood sugar that does the trick. He notes that when diabetics get too much insulin, their blood sugar drops and they get ravenously hungry. They gain weight because they eat more, and the insulin promotes fat deposition. The same happens with lab animals. This, he says, is effectively what happens when we eat carbohydrates -- in particular sugar and starches like potatoes and rice, or anything made from flour, like a slice of white bread. These are known in the jargon as high-glycemic-index carbohydrates, which means they are absorbed quickly into the blood. As a result, they cause a spike of blood sugar and a surge of insulin within minutes. The resulting rush of insulin stores the blood sugar away and a few hours later, your blood sugar is lower than it was before you ate. As Ludwig explains, your body effectively thinks it has run out of fuel, but the insulin is still high enough to prevent you from burning your own fat. The result is hunger and a craving for more carbohydrates. It's another vicious circle, and another situation ripe for obesity.
I don’t know how important this mechanism is in controlling hunger, but there might be something to it. I wouldn’t be surprised if some of us are more sensitive to it than others. (DB’s Medrants has more technical observations on this.) posted by Sydney on
7/10/2002 01:13:00 AM
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More Smallpox Evidence: This week's BusinessWeek has a commentary on smallpox vaccine that gives further evidence that Iraq likely has the virus as a weapon. North Korea may have it, too. (I would link to it, but you need a subscription to access it, so I'll just quote it):
"The risk of a terrorist attack can't be quantified. But homeland security experts note ominously that both Iraq and North Korea vaccinate at least some of their military, suggesting that they may have stockpiles of smallpox. And Russians once produced tons of highly weaponized forms of the virus, some of which may now be in terrorists' hands." posted by Sydney on
7/09/2002 08:26:00 AM
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Dubious Drug Shortages: NPR is doing a series this week on shortages of common drugs. This link is from yesterday's story. Today they covered the deliberate shortages created by wholesale distributors of drugs to artificially raise their prices, but that story won't be available on their website until after 12PM today.
UPDATE: Here's part two of the segment. I always suspected those sudden shortages in common drugs were caused by manufacturer's or wholesalers holding back for profits. But whenever I entertained those thoughts, I would scold myself for thinking like a conspiracy nut. Turns out I wasn't so crazy after all. posted by Sydney on
7/09/2002 07:54:00 AM
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Organically Grown: Evidently, organically grown really is better:
In an earlier study, Danish organic farmers had twice the sperm density when compared with greenhouse workers who were exposed to herbicides and pesticides. posted by Sydney on
7/09/2002 07:44:00 AM
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All Aids, All the Time: You would have to live in a cloister to be oblivious to all the HIV news out there this week. Every newspaper and every news service has stories on the subject. From new drugs, to the ignorance of nations and individuals, to hopes for a vaccine, to AIDS as class struggle. You can’t go to a news site anywhere without finding an article on HIV. Even JAMA is completely devoted to the virus this week.
All of this attention isn’t because there has suddenly been some breakthrough in the treatment or prevention of the disease. It’s just that the HIV scientific community knows how to put on a whopper of a show. They’re having their world-wide AIDS conference this week in Barcelona, and they’ve attracted more media attention than even a Hollywood starlet would want.
None of the news coming out of the meeting is worthy of all that attention. None of it is a breakthrough in treatment, and a lot of it is nothing more than hype to get more funding, as Andrew Sullivan pointed out yesterday:
“Federal officials said they felt confident in reporting that the number of new H.I.V. infections has been stable in recent years, with an estimated 40,000 Americans becoming infected each year. Government officials estimate that 900,000 Americans are living with H.I.V. or AIDS. The number has increased by 50,000 since 1998, largely because advances in treatment have controlled the infection in many people, allowing some to go back to work and live longer.”
If 40,000 are infected each year, shouldn't over 120,000 new infections have been logged since 1998? So why only 50,000? No one at the CDC really answers that question ever. The 40,000 a year is plucked almost out of thin air, and used for funding purposes. (And factoring in deaths doesn't help either. The total number of deaths for those three years is a decelerating 50,000. That still leaves 20,000 alleged infections unaccounted for.)
HIV is a prime example of what goes wrong when a disease becomes politicized. Hype trumps science. We get stories like last week’s about AIDS destabilizing the world, and like the one Andrew Sullivan noted about alarming increases in the rate of infection. Meanwhile, the world becomes jaded by the alarmist cries, and soon no one listens anymore. It would be far better for their cause if the HIV researchers confined themselves to science and stopped trying to lobby the world. posted by Sydney on
7/09/2002 07:39:00 AM
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Merck-Medco’s Creative Accounting: Merck-Medco has been accused of accounting fraud:
Merck & Co. recorded more than $12 billion in revenue over the past three years from its pharmacy benefits unit even though the subsidiary never collected the money. The news sent its stock down more than 2 percent.
The revenue in question is the co-payment paid by consumers with a prescription drug card to their retail pharmacy to cover their portion of the cost of a drug under an insurance plan. The pharmacy keeps the co-payment.
Whoa. By what stretch of the imagination did they count the pharmacy’s money as their own? Merck-Medco claims it makes no difference since they also included the co-payments in their costs, so the bottom line wasn’t affected. So why count the co-payments at all? Because it makes their sales look more impressive, $12 billion dollars more impressive. posted by Sydney on
7/09/2002 07:19:00 AM
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Missing in Action: What happened to RangelMD? Did his server get washed away in the Texas floods? posted by Sydney on
7/08/2002 01:29:00 PM
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Seinfeld Moment: It's amazing how often something comes up that reminds me of a Seinfeld episode. Do you remember that episode where Elaine eats a lot of low-fat ice cream and gets upset because she gains weight? In typical Elaine fashion, she blames the ice cream parlor for falsely claiming the ice cream is low fat, instead of admitting that she's just been eating too much of it. Well, that attitude is the focus of this New York Times Sunday Magazine article on the low-fat myth.
I'm not convinced, as the author seems to be, that high-fat diets like the Atkins diet are the miracle answer to all our weight woes. Nor am I convinced that low-fat diets are entirely responsible for them. There does seem to be, however, a prevailing attitude that eating low fat diets will help you lose weight. This attitude needs to be jettisoned. The thing that is most important in gaining, losing, or maintaining weight is the number of calories you eat. Period. It doesn’t matter if you eat 4000 calories of fat a day or 4000 calories of carbohydrates. Calories are calories and if you take in more of them than you burn off in the course of a day, you gain weight.
When I began reading the article, I scoffed at the idea that we as a society have gotten fatter because the federal government had recommended we eat less fat and more carbohyrates, but then I realised that those recommendations were taken up by the food industry as a means of promoting their products, and this certainly could have an effect on what we eat. The grocery store shelves in this country are laden with foods that scream out “no-fat” or “low-fat” on their labels. And they are invariably foods high in calories, like muffins and cookies and cakes. The author even quotes a person involved in the senate hearings on diet that started the whole low-fat craze:
Stone told me he had an inkling about how the food industry would respond to the new dietary goals back when the hearings were first held. An economist pulled him aside, he said, and gave him a lesson on market disincentives to healthy eating: ''He said if you create a new market with a brand-new manufactured food, give it a brand-new fancy name, put a big advertising budget behind it, you can have a market all to yourself and force your competitors to catch up. You can't do that with fruits and vegetables. It's harder to differentiate an apple from an apple.''
This probably has more to do with our increase in daily calorie intake over the past thirty years than any inate sense of hunger caused by the low-fat diet, as the author postulates. Another factor in our societal weight gain, is that we are getting older. As you get older, it gets harder to lose weight. That’s partly because of illnesses that limit the ability to exercise and partly because our metabolisms do slow down, especially in women after menopause. No doubt we will continue to see the national averages for weight increase as the baby boomers continue to age.
The increase in childhood obesity is also largely due to eating and exercise habits rather than a tendency toward low fat diets. I'm always amazed at the number of parents who feel it's necessary to take bags of Cheerios or cookies or crackers to a simple outing at the zoo. I see the same thing at church. The service is only an hour long, but all the kids around us have food with them to keep them quiet. (I notice this because my kids have always jealously pointed it out to me.) The elementary schools foster continual eating habits, too. Each of my children have a snack period in the middle of the afternoon at school, as if they can't be expected to go three hours without food. Couple that with the tendency to stay inside playing video games and watching television instead of playing outside, and you've got the perfect setup for childhood obesity.
So, although the Times article was a pretty good read, don't go out and load up on fatty foods. If you eat too many of them, you'll still gain weight.
The Atkins diet does help people lose weight, but it’s still more likely to be because they eat less on it. They aren’t anymore likely to keep the weight off than anyone on any other fad diet. The best approach to permanent weight loss is to learn to eat only the number of calories you need for your body everyday for the rest of your life. posted by Sydney on
7/08/2002 01:21:00 PM
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Bioterror Update:The Bloviator has some posts on the latest news on bioterror defense, including this update from the Washington Post on plans to expand the preventive use of smallpox vaccine. posted by Sydney on
7/08/2002 12:41:00 PM
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Thoughts of a Young Surgeon: A reader, who is a general surgeon, had these thoughts to share about the costs of practicing medicine:
I sometimes find myself ashamed and guilty of how I feel some times about such matters. One the one hand physicians are told that medicine is a "calling" and that we should devote ourselves above all to our patients. Medicine is somehow "special" in this devotion when compared to other professions. On the other hand physicians are described as "greedy" when issues of declining reimbursement or high liability costs are discussed. As my partner states, "No other business works solely on credit". When I perform a cholecystectomy I cannot demand payment up front ( as a plumber or even a lawyer can do), I am at the mercy of the patient's insurance company or Medicare/Medicaid (if they have coverage) to receive payment. If I am not paid, I cannot very well put the gallbladder back in. This is described as providing a "service to the community". However the community cannot and will not help me in paying my rent, salaries for my staff or my liability insurance. Society has forced physicians to look at their practices through the lens of a business model but then criticize us severely when we do.
The coverage of the closure of the trauma center in Las Vegas provides a case in point. When local circumstances cause the cost of business to rise to where expenses rise income, you have three options: 1. Work harder (see more patients) 2. Raise your fees or 3.Close and relocate. As you well know fees are set by the payors and do not rise at the appropriate pace. ( or as in the case of Medicare, they are falling). So physicians can either run a volume business or relocate. Seeing more patents means less time for each patient and again more dissatisfaction for the patients you do see. If you are an OB/GYN you pay a higher premium for seeing more patients. Thus the rise of "retainer" medicine as DB's med rants puts it. But if you leave you "just wanted to terrorize the community" by denying a service. I also find Assemblyman Perkins's statements, comparing the closure to a strike, to be amusing.
The public continues to demand that physicians act as selfless protectors of the public. But their actions have made being a doctor like having any other job. Residents, medical students, and those interested in medicine can see this. I feel that is why medical school applications are down, slots in general surgery remain open after the match, and resident work hours are under scrutiny. Survey after survey reveal that physicians retire as soon as they can and they are not encouraging their children to go into medicine. Soon the lines will meet and the fixes will have to be more painful and expensive.
That conflict between serving and surviving financially is an old and common one. Even in the old days, when medicine wasn't as costly, and doctors made housecalls, it was there. William Carlos Williams' wife used to get annoyed about his uncollected payments. But now, with the higher cost of medical care, third party payers, and rising overhead, it is becoming a greater force and a greater stress in day to day practice. There's no easy solution, you can't turn back the clock and take away all the technological advances that are now a routine part of patient care. One thing we could consider, though, is providing health insurance only for major problems, like emergency surgery or hospital care, and go back to paying out of pocket for routine care. posted by Sydney on
7/08/2002 08:23:00 AM
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Collateral Damage: The medical care of suicide bombing survivors. (link requires NY Times registration). Some examples:
-She needs to strengthen her right leg, badly damaged by three screws packed as shrapnel inside a suicide bomb that exploded at the trendy Moment Cafe here on March 9. A fourth screw lodged near her heart. Now this pretty young woman bears a scar more commonly seen in old men, a neat red line cut by surgeons from her collarbone down her sternum.
-"Ah-ah-ah! Ooo-ah!" moaned Motti Mizrahi as a therapist stretched his left arm, pinned inside a macabre cage in part of the treatment intended to save his hand. "Of course I am angry."
Like Ms. Ravid, Mr. Mizrahi, 31, was at the Moment Cafe that day in March when 11 people were killed. That he still has his left hand at all reflects how savvy Israelis have become about catastrophe. When the explosion left his hand dangling by a string of flesh, he had the presence of mind to run outside to the street.
He knew that rescue workers would not go inside until the cafe was flushed for other bombs.
-In a rehabilitation room in the Lowenstein Center, Maya DaMari, 17, limped through her exercises with a self-conscious smile: a hop through half a dozen colored hoops, a cautious bounce on a trampoline.
Five months ago she went with a friend to a pizzeria in Karnei Shomron, a Jewish settlement in the West Bank. A charming young man with bleached blonde hair said, "Goodbye, and I won't see you later," and blew himself up. Two Israelis were killed, including the friend she was eating with.
She keeps a newspaper clipping with a picture of an X-ray showing the 1.5-inch nail that is still lodged in the left side of her brain. It has partly paralyzed the right side of her body.
-Ilona hoped to become a model, and she is certainly tall enough. In fact, if she had been shorter she might have escaped unscathed: a friend standing in front of her absorbed most of the blast and died. But shrapnel hit Ilona in her head, taking part of it away.
In the last year she has learned to walk and talk again, though she can speak only about 30 words. She clearly understands far more than she can respond to. She likes her art therapy class, and on a recent day she painted a papier-mâché giraffe she had fashioned earlier, painstakingly, with one hand. She also made a decorative mirror, much to the surprise of the medical workers.
-Dr. Ricardo Segal, a neurologist at Hadassah, said the definition of success varies. A few recover fully. Others do not. He counted as a victory one young man, badly wounded with shrapnel in the brain, who lives far below his potential but well enough to work part-time at McDonald's.
-He walked down the hall to see a patient who was doing "very well," Ronit Tubul, 30, wounded on June 18 when a suicide bomber killed 19 other people on a bus in south Jerusalem. With her skull broken and shrapnel in her brain, it took two weeks before she could speak again.
It was hard to understand her low and jumbled whisper. But two words did come through: "For peace."
We too often only measure these horrid attacks on civilians in terms of numbers of dead. We forget about these, the survivors, who are living reminders of the depravity of those savage bombers.
Echoes of a Simpler Time: When drug companies kept their promises. To Eli Lilly's credit, they've continued to keep their promise to this woman and others involved in the same experiment. posted by Sydney on
7/08/2002 07:13:00 AM
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Sunday, July 07, 2002
Reader Thoughts on Smallpox Vaccine: A reader emailed these thoughts on the government's smallpox vaccine strategy:
From a purely military perspective the best approach is somewhere on the spectrum between mass pre-emptive vaccination and mass reactive vaccination. The details of vaccination risks and attack scenarios determine what you select. I suspect that once there is an assured supply of vaccine available, the present "500,000 medical staff pre-emptively vaccinated and mass reactive vaccination" will be modified. Given the high adverse reaction rate for smallpox vaccinations, my strategic choice would be:
- Pre-emptive vaccination for military staff and hospital medical staff
-Suggested pre-emptive vaccination for all other medical, police,fire, with warnings
-Available pre-emptive vaccination for the general public, but with very strong advisories about the potential adverse reactions.
-Pre-positioned vaccines for massive immediate reactive vaccination in the event of attack.
This balances the negatives of pre-emptive vaccination -- casualties,hysteria, backlash over casualties -- against the negatives of reactive vaccination -- much higher casualties in the event of attack, hysteria, backlash over lack of vaccination. Making pre-emptive vaccination available with warnings reduces the hysteria and backlash level for the reactive choice because those most concerned can get vaccinated. There is a much higher tolerance for personally chosen risks, so the adverse reactions will not induce much backlash.
From a military perspective it preserves the war making ability and the ability to provide the reactive vaccination. This discourages the potential attacker because they know that they will not inflict heavy casualties and they will face an enraged enemy military force. It also minimizes the self inflicted casualties.
I suspect that this sort of thing is exactly what the government is considering, and it is a vast improvement over the older CDC recommendations.
And on the Malpractice Insurance Crisis: The same reader had these thoughts on malpractice insurance premiums:
Just to be complete, the problem is more than just the legal claims.There are signficant costs from routine insurer mismanagement. (They manage their companies just as incompetently as they manage your paperwork.) There are huge secular costs from secular mismanagement. (They lost a bundle on really stupid price wars, really stupid underwriting, and really stupid investments.) There are also significant costs due to medical incompetence. There is evidence that appropriate use of specialization and certification has huge impact on outcomes. (The outcomes difference between high volume specialized centers and local treatment can be dramatic.) But there has been only glacial progress at revising treatment approaches to reflect this and other introspective analyses of medical treatment.
There are completely unrealistic attitudes by patients both in terms of accepting their own responsibilities and having realistic outcomes expectations. Some of this is understandable (if wrong). I've read the warnings on clinical trials (6 pages of "this probably won't work. this might kill you. Here are all the horrible things that can happen.") and then listened to people who signed the agreement and still think that this will cure them.
And there are the legal leeches who take advantage of all this.
I agree that some, but not all, of the dramatic rise in malpractice premiums is from insurance company mismanagement and bad investments. However, a lot of it is due to rising awards. Malpractice rates are highest in states that do not cap the monetary awards. This isn't because those states have more badly managed malpractice insurance companies, or more incompetent doctors. It's because the insurance companies have to pay higher damages on average in those states. I am a strong believer in the justice of our legal system. I would much rather an angry patient hire a lawyer than a gun to address any percieved harm. I also recognize, and feel strongly, that is my responsiblity to acknowledge and take responsibility for any mistake I might make. But, the damages that are awarded for pain and suffering can be outlandish. The current legislation for tort reform before Congress addresses this issue:
In April, a bipartisan coalition of representatives introduced a tort reform bill that includes everything from capping noneconomic damages at $250,000 to allowing future economic damages to be paid over time. And patients -- except when the injured party is a child younger than 6 -- would have three years to file a lawsuit. That statute of limitations is shorter than what exists in most states now.
No one is denied their day in court. No one is denied compensation for medical bills. The only thing they and their lawyers are denied is the chance to hit the big jackpot in jury prizes.
posted by Sydney on
7/07/2002 11:48:00 AM
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Alternative Medicine Watch: The Europeans are beginning to realize that herbal preparations have risks just like regular medication. They are calling for regulation of the herbal medicine market, as they should. We should, too. posted by Sydney on
7/07/2002 07:18:00 AM
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Bioterror Preparedness: At least one California county has wide-reaching plans for smallpox defense:
Many local health departments, as in Santa Clara County's case, have not waited for federal assistance but are already moving forward with their own bioterrorism preparedness plans.
By and large, they've been simply waiting to learn from federal authorities how many doses of the vaccine they can count on.
``We have started discussions with hospitals about how do we go about getting a vaccine to the appropriate `first responders,' '' said Joy Alexio, spokeswoman for the Santa Clara County Department of Health.
``Then, as we get further information from the federal government, we'll work with the state to develop details about how to institute mass vaccinations,'' she said.
This, too is a good sign. It means that the local health departments haven't necessarily been following the CDC party line, and have been thinking on their own. Of course, this is just one local health department. It's hard to say what all the others have been doing.
posted by Sydney on
7/07/2002 06:58:00 AM
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Celebrity Medical Watch: Ted Williams' cryopreservation. Is it for love or money? His daughter thinks the latter:
John Henry Williams ''told me we could sell Daddy's DNA,'' said Bobby-Jo Williams Ferrell, who is John Henry's half sister. At the time, Ferrell said she rejected the scheme.
