"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
Face to Face:GruntDoc had a recent rash encounter in his emergency room that made him acutely aware of the need for bioterror preparedness. posted by Sydney on
10/05/2002 06:14:00 PM
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While federal officials said last week they have developed an emergency plan to vaccinate the entire population against a smallpox attack, Dr. D.A. Henderson, a special adviser to the Department of Health and Human Services, said at least two key decisions have not been made.
One is the conditions under which the plan would be put into effect. The current smallpox vaccine causes more reactions than any vaccine available in the United States, Henderson said, explaining why mass vaccinations have not begun. "It's got to be a societal decision," he said.
The other is whether the government will assume liability, which could run into billions of dollars, for the deaths or injuries a massive immunization campaign might produce. About 25 years ago, the government assumed liability for mass immunizations against swine flu, but some oppose imposing the burden on the government again.
"There's a lot of discussion going on about this in the administration and Congress," said Henderson, a professor of epidemiology at Johns Hopkins University. posted by Sydney on
10/05/2002 09:28:00 AM
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Crazy Larium Update: The FDA has made the makers of Larium, the malaria drug that's being investigated as a potential catalyst for the Fort Bragg domestic violence murders, provide more stringent warnings on its label:
The FDA said on Friday that the Lariam label had been changed to stress that the drug is contraindicated for preventive use in patients with active depression, recent history of depression, generalized anxiety disorder, psychosis, schizophrenia or other major psychiatric disorders. The new label also puts added stress on a contraindication for preventive use in patients with a history of convulsions, the agency noted.
The drug, however, hasn't been implicated in the Fort Bragg violence, it's only being investigated. posted by Sydney on
10/05/2002 09:22:00 AM
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Genetic Revolution: Get a CD with the map of your own genome, for only $500,000! Word of advice: save your money until the technology exists to actually do something with that information. By that time, the price of the CD's may be lower by a factor of 1,000. posted by Sydney on
10/05/2002 09:19:00 AM
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Her Business Pays Off: A smoker received $28 billion in her lawsuit against Phillip Morris, even though she clearly chose to smoke:
"Testimony during the trial showed that Ms. Bullock was aware of the health risks of smoking and was warned repeatedly of those risks by her doctors over four decades, and her daughter also urged her to quit. Her response: 'I am an adult, this is my business..'" posted by Sydney on
10/05/2002 09:11:00 AM
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Doctors and Insurance Companies: Ross, at The Bloviator is upset about the proliferation of class-action lawsuits brought by doctors against insurance companies. He’s worried that these suits will ruin the insurance companies and leave patients without health insurance coverage. He also seems to be under the impression that the physicians have joined them in the hopes of benefitting from jackpot justice. Although the insurance companies may find themselves in financial straights if they were to be hit with large damages, most doctors aren’t in it for the money. They’re genuinely fed up with the games insurance companies play to dodge their financial obligations. The only recourse they have is the law. The following is a partial list of the various ways insurance companies delay paying physicians and hospitals:
-A patient is seen and treated in the office. The doctor submits the bill to the insurance company, which, according to the contract it has with the doctor, is supposed to pay the bill within a certain number of days, say 30. On the thirtieth day the doctor doesn’t get a payment. Instead he gets a form from the insurance company claiming they need more information about the visit. Was it for a pre-existing a condition? To make it even more difficult, the letter doesn’t specify which diagnosis for that visit it has concerns about, and sometimes it doesn’t even state the day of service. So, if a patient saw the doctor for two things - say an ear infection and to have his blood pressure medicine renewed, or if he’s been to the office twice for two separate problems, the doctor’s staff has to call to clarify things, a process which can take minutes to days. Then, the form has to be mailed back to the insurance company. They won’t accept the information by phone. This happens even if the condition is clearly not a pre-existing one. In fact, I see it most frequently for office visits that have been for an acute problem such as an ankle sprain or an ear infection. The only reason the insurance company has for doing this is to delay payment by another couple of months.
-A patient is admitted to the hospital for chest pain. Tests show that he has severe coronary artery disease and needs coronary by-pass surgery. He needs surgery urgently, but not emergently. The next day is Sunday, a day when the operating room is only staffed adequately for emergencies. (With the cut in payments, the hospitals can’t afford full staff on Sundays) Or perhpas it’s the middle of the week, but all the surgical suites are booked for the next day, or there are more emergency cases than expected and the patient’s surgery gets delayed a day. The patient is stable enough to wait in the ICU on intravenous blood thinners, but not stable enough to go home for a day. The delay isn’t because his doctors are lazy or because the hospital wants to crank out an extra day of insurance money, but because it wouldn’t be safe to stretch the resources of the operating rooms and staff to cram him into the schedule. The insurance company refuses to pay for the day he spent in the hospital on intravenous blood thinners because it wasn’t “medically necessary.” They do the same thing with other surgeries, too, that are needed urgently, but not emergently. They refuse to acknowledge the limitations of resources and manpower, and the nature of some diseases and their appropriate treatment.
- A doctor belongs to an HMO. Every so often, he’s supposed to get a check for his capitation payments - the amount of money the insurance company has agreed to pay him for each patient who signed up with him. The check doesn’t come. He calls the HMO and gets shuffled from department to department without ever getting satisfaction. The check finally comes two months late, but lower than the doctor expected. He suspects he has more patients with that plan than the insurance company is giving him credit for. He asks the insurance company to give him regular updated reports that tell him how many patients he has with that plan. The insurance company, somehow, never gets around to it.
Ross is skeptical that 600,000 physicians could have the same grievances against the companies. I’m skeptical, too. I don’t think there are 600,000 doctors signed up for the class action suits. (In 1999 there were only a little less than 800,000 physicians in the country.) There’s no reason to think that the insurance companies are singling out certain doctors to delay payment. These sorts of tactics are their standard way of doing business. What they do to one of us, they do to all of us across the board, so a class-action lawsuit is certainly a legitimate approach.
As to the consequences as far as insurance company’s bottom line - so what? Their ruin could be the saving of our healthcare system. They aren’t in the business for humanitarian reasons, or because they have some divine mission to lower healthcare costs. They only serve as middle men who inflate the cost of basic healthcare, especially when it comes to primary care. A substantial amount of the overhead of a physician’s office goes to paying staff to submit bills to and try to collect from the insurance companies. Doctors who have quit accepting insurance payments and charge their patients directly at the time of service report that doing so let’s them cut their fees by 30% to 50%. Liberal insurance coverage that completely shields the patient from the cost of their care also fosters indiscriminate use of medical testing and drugs. When patients have to shoulder some of that financial burden, they’re more willing to take the prudent approach to testing and to accept generic drugs over brand names.
The majority of doctors never welcomed managed care. We just had no choice as more and more employers moved to the system in the 1980’s and 1990’s. Health insurance needs to return to what it once was - insurance for catastrophic medical bills, not insurance for run-of-the-mill doctor’s visits and minor illnesses. posted by Sydney on
10/05/2002 09:05:00 AM
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Friday, October 04, 2002
Genetic Revolution Blowback: The "bubble boy" who was cured by genetic therapy, has now developed a condition similar to leukemia, in which his white blood cells run amok. It isn't certain yet, but there's a possibility that the therapy itself caused the problem:
Scientists have long theorized that retroviruses, which were used in the suspended experiments, could trigger cancer. The risk was that the virus, which integrates itself into the patient's DNA, would lodge in or near a cancer-causing gene.
There's a lot we don't know about genes and how they work. Yet, it would be too harsh to criticize the research. The immune deficiency that the boy had was severe and life-threatening itself, so the experimental therapy provided him at least some hope. posted by Sydney on
10/04/2002 01:24:00 PM
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West Nile Update: The CDC confirms that West Nile virus can be transmitted through breast milk. Having it isn't a contraindication to breastfeeding, however:
The child is healthy and his mother is recovering, the Centers for Disease Control and Prevention said. The CDC said it was virtually certain the virus came from breast milk, though there is no way to be completely sure.
I repeat, the baby is healthy, and never showed any signs of illness. When this whole West Nile thing is over, it may well prove to be the most benign disease to have ever attracted so much money and attention.
Bad Parenting: The BMJ has a discussion this week on the ethics of designing babies. Not designing them to be bright or beautiful or talented, but designing them to have the same physical disabilites that their parents have. The discussion was stilmulated by this couple, two deaf lesbians who chose a man with a strong family history of deafness as the father of the baby, in the hope that the baby would be deaf like them. They justify the choice by wrapping it in Deaf pride:
"...there are many, many deaf people who specifically want deaf kids." This is true particularly now, particularly in Washington, home to Gallaudet, the world's only liberal arts university for the deaf, and the lively deaf intelligentsia it has nurtured. Since the 1980s, many members of the deaf community have been galvanized by the idea that deafness is not a medical disability, but a cultural identity. They call themselves Deaf, with a capital D, a community whose defining and unifying quality is American Sign Language (ASL), a fluent, sophisticated language that enables deaf people to communicate fully, essentially liberating them -- when they are among signers -- from one of the most disabling aspects of being deaf.
Sharon and Candy share the fundamental view of this Deaf camp; they see deafness as an identity, not a medical affliction that needs to be fixed. Their effort -- to have a baby who belongs to what they see as their minority group -- is a natural outcome of the pride and self-acceptance the Deaf movement has brought to so many.
What this really is, though, is an attempt to keep the children from growing up to exist beyond the pale of their parents’ experience. This sort of thing is common in parents everywhere - in the immigrants who get upset when their children are “Americanized”, in parents who discourage their children from going on to college, in the smalltown parents who don’t want their children to move away to the big city, or in parents who protest marriage outside their own religious or ethnic group. It all just boils down to the same parental angst of “how 'ya gonna keep 'em down on the farm?”. posted by Sydney on
10/04/2002 08:39:00 AM
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Depressive Chic: I have only one thing to say about Newsweek's cover story on teenage depression. Why, if every case study photographed for the story has been healed by psychiatry, are they all posing with chic sulleness? Wouldn't it be a better argument for the powers of psychiatry over teenage angst to have them posing as happy and adjusted?
OK, I Lied: I have one other thing to say. The caption that goes with the first photograph makes me wonder about the validity of some of these diagnoses:
Eric Suarez, 17, who suffers from bipolar disorder, takes nine medications daily to treat his depression-some for the symptoms and others to combat the side effects of those drugs.
That's called polypharmacy, and it's not a good thing. Usually when you have to keep throwing more and more drugs at a problem and then throw even more drugs at the problems created by the drugs, you’ve got the wrong diagnosis or the wrong drugs or both. posted by Sydney on
10/04/2002 08:36:00 AM
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Is Violence a Health Problem? The World Health Organization's catalog of global violence is getting a lot of press, which is the intention of the WHO:
Unlike many WHO reports, this one is not simply being released. It is being "launched" in a day-long program in Brussels that will be followed by an effort over the next six months to persuade governments that violence is a preventable health problem.
I always become acutely uncomfortable when social ills are defined as “public health problems.” It implies that medical professionals should be able to make people behave themselves. Certainly, injuries from violence and health problems caused by addiction are problems that medicine can address, but curbing violence is better left to the law than to the health field.
Hmm.. I'm not sure what to make of this. Medpundit is mentioned briefly at the Utne Reader's Web Watch site. It's under the heading "Questionable Doctors." Yours truly is a "related link." Does that mean I'm a "questionable doctor," or do they like the site? posted by Sydney on
10/04/2002 08:32:00 AM
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Thursday, October 03, 2002
Public Health Bogosity:The Bloviator responds to Instapundit on the mixed up priorities of public health. Ross is much more sympathetic to the public health system, seeing their diversion into urban sprawl and social issues like crime and violence as a necessary evil to keep themselves funded:
Perhaps now, with such a heavy emphasis on bioterror defense, the public health community (at least in the U.S.) can use the cash infusion to shore up its systems and move away from projects that are not traditionally "public health" related, such as (I'd argue) urban sprawl studies; however, I would not be surprised to see the public health community continue in these efforts. They've been burned enough times before, standing helplessly by as their funding dries up when legislators' fickle fancy turns back to sexier issues that capture the attention of seniors and soccer moms. And funding once provided is not readily relinquished.
I don't think they'll give up on the non-medical issues, either, but not because they're worried about funding. I think they've become so used to concerning themselves with such nonsense that they've come to view things like urban sprawl and domestic violence as true public health issues as important as, and for some of them more important than bioterrorism or infectious diseases. posted by Sydney on
10/03/2002 12:51:00 PM
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Yet More Statin Hype: The cholesterol lowering drugs that are the darlings of physicians everywhere are in the news again. Now, they’re being promoted for use in children. Based on a small sample of children in the Netherlands (173), the researchers have concluded that the drugs areas “safe as they are for adults” and have no effect on growth. How can you know that in such a small sample size? You can’t. Furthermore, there’s some evidence that statins cause more muscle inflammation than we give them credit for. Finally, the role of cholesterol in children and their peculiar growth needs, let alone its influence on their future health, is far from clear:
Because no long-term studies of the relationship of blood cholesterol levels measured in childhood to coronary heart disease in later life have been conducted, the relationship of childhood cholesterol levels to the atherosclerotic process must be inferred from less direct evidence.
It’s much too premature to call for using these drugs in children, but I suspect the American Heart Association, beneficiary of statin-producer donations, will soon be promoting it. posted by Sydney on
10/03/2002 08:44:00 AM
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Mapping Malaria: The genetic codes of mosquitoes and the malaria parasite have been mapped. The potential benefits:
"If we can identify the receptors that mosquitoes use to smell humans, we should be able to design novel repellants and attractants that can substantially reduce the incidence of malaria, West Nile encephalitis, dengue and yellow fevers and other mosquito-born diseases," said project member Laurence J. Zwiebel of Vanderbilt University.
Another study assessed which mosquito genes are turned on or off after the mosquito sucks blood from a person. Mosquitoes consume as much as four times their weight in blood-equivalent to a 100-pound woman drinking a 50-gallon drum of water. Among the genes that turn on after that feast are some that help the insect detoxify the potentially deadly iron found in human blood.
Scientists want to develop new chemicals that block that process, rendering blood meals fatal to the insects. Other genes apparently help egg cells mature inside the female after a meal of blood, suggesting that a drug able to block those genes might work as an insect contraceptive. posted by Sydney on
10/03/2002 08:26:00 AM
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Reporting Biases of Their Own: The headlines about this study all scream prejudice in describing its findings that more minority children with fractures are investigated for possible child abuse than white children. The study, however, deserves further scrutiny. First, it was a survey of patient records at an urban hospital, the Children’s Hospital of Philadelphia. There are far more poor minorities than there are poor whites in urban Philadelphia. Poor people often have no regular doctor - they get their care at the hospital clinics or forego it all together. So.. when they get admitted to the hospital they get admitted to a teaching service rather than to the care of a doctor who is familiar with them and their families. The teaching service doctors know nothing about them personally. When doctors have no prior knowledge of a patient, they err on the side of caution and have a lower threshold of suspicion for things like sexually transmitted diseases, drug abuse, and child abuse. This is true regardless of race.
The study didn’t limit itself to examining children admitted only to the teaching service. It looked at all admissions, regardless of insurance coverage, and regardless of their prior relationships with their admitting physicians. Here’s the criteria they used for admission:
”Primary criteria for admission to the hospital included concern about possible child abuse or a parent’s ability to care for the child, need for surgical intervention or cast-care teaching for children with femur fractures, delay in time to casting due to significant swelling, young age of the child, and other significant diagnoses or injuries warranting admission.”
Now, what sort of families do you think would fall into the category of “concern about possible child abuse or a parent’s ability to care for the child”? It certainly isn’t the urban parents living in gentrified regions of the city who are more likely to be white and more likely to have established relationships with a pediatrician or family doctor. It’s far more likely to be the urban poor who use the emergency room for primary care, and who are overwhelmingly from minority groups. This self-selects for the minority children to be treated with more suspsicion for potential abuse. More of them were probably admitted for that very reason. The results section of the study confirms that the minority children were poorer than the white children. Seventy-percent of the white children had insurance coverage, compared to only eighteen percent of the minority children.
It gets even worse. The authors had the cases reviewed blindly by child abuse experts who decided on the basis of the history and the x-rays whether or not each case was likely an accident or likely abuse. The reviewers had no idea what race the children were. By this process, they determined that 12% of the white children’s fractures were due to abuse. The treating physicians, on the other hand, suspected abuse in 22% of white children - nearly twice as many as the blinded reviewers. The results for minority children were similar. The reviewers determined that 27% of their fractures were likely caused by abuse, while the treating physicians thought so in almost twice as many cases - 52%. Notice that even the reviewers who had no clue as to the children’s race, suspected abuse in more minority children than white children, and note that the treating physicians overestimated abuse by the study’s criteria at the same rate in both white and minority children.
The real moral of the story is not that doctors are prejudiced against minority parents. It’s that we over-report abuse. This we do because there are laws that require us to report any suspected case of abuse, no matter how shaky the evidence. We can get in big trouble if we don’t. Much better for us, and the child, if we err on the side of caution and mistakenly report a case than if we err on the side of leniency and miss one.
The other moral of the story is that there is more child abuse among the poor. That’s no surprise either. There are higher rates of drug and alcohol use and criminal behavior among the poor, too. There are a significant number of people out there who are poor because they can’t keep their personal demons at bay long enough to hold a productive job.
And the final moral of the story is that the researchers obviously allowed their own biases to influence the interpretation of their results. They've assumed that any difference in care is caused by race without considering any of the other contributing factors. If they weren't biased, they would have recognized the role poverty played in their findings instead of ignoring it. posted by Sydney on
10/03/2002 08:08:00 AM
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Bioterror Antidotes: Got thisUSA Today op/ed that calls for more research into anti-viral drugs to treat smallpox, from The Bloviator. It wouldn’t be a bad idea to explore the possibilities of anti-virals, but we can’t rely on them for preparedness plans. There’s simply no way to evaluate their effectiveness in people sans a smallpox outbreak, and the treatment record for antivirals so far hasn’t been stellar. They never cure a disease, they only shorten it or help lessen the symptoms.
Bioterror Anecdotes: Last week I was in a frenzy firing off email to my local and state health departments and the HHS about the failure to educate practicing physicians on appropriate bioterror responsiveness. These were the responses I got:
Local Health Department: No response or acknowledgement.
State Health Department: The director punted to the state's epidemiologist who sent a condescending reply, assuring me that my local health department had been giving conferences at hospitals (they haven't), and directing me to websites that I had already mentioned in my email.
Department of Health and Human Services: Actually sent a brief and personal response saying they realized this was a problem and that they're working on it with the CDC.
Of all of those, I least expected a response from the HHS and most expected a response from my local health department. Tells you something about my local health department, doesn't it? I harbor a hope that they're the exception rather than the rule, but I suspect that they're the rule when it comes to preparedness planning.
Cleaning Up Blood: A US trial is being done to test blood that's been chemically treated to inactivate any virus particles that might be in it. If successful, and safe, that could take care of the current West Nile virus and transfusion problems. posted by Sydney on
10/02/2002 07:23:00 AM
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Unrealistic Expectations: British women report that giving birth is "more painful than they ever imagined". As my grandmother's doctor once told her when she complained of a particularly painful delivery (at home, with no anesthesia in those days), "Well, you didn't expect it to be as much fun coming out as it was going in, did you?" posted by Sydney on
10/02/2002 07:18:00 AM
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More Cancer Screening Controversy: A study in China calls into question the value of self breast examination:
The study followed more than 266,000 female factory workers in Shanghai for more than a decade. Half were taught to do monthly self-exams. The other half received no information on screening. The researchers studied the population in China because mammography and ultrasound are not widely available there.
...After 10 to 11 years, researchers found almost no difference between the two groups in the rate of death from breast cancer. Among those in the instruction group, 135 women died of breast cancer. Among women in the other group, 131 died.
It's always been conventional wisdom that self breast exam alone isn't adequate for detecting breast cancer. The question, however, is if doing it in conjunction with mammography has any merit. Judging from the recent controversies over the value of mammography, it may not. posted by Sydney on
10/02/2002 07:09:00 AM
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Bioterrorism Preparedness Update:Here's a take on the problems confronting an adequate bioterrorism preparedness program by someone involved with Harvard's school of public health. The attitudes of public health officials are chief among them:
Public health people tend to view bioterrorism as another item on a long list of health risks that includes tobacco use, obesity and substance abuse -- health problems with known mortality rates and intervention strategies. They observe funds being allocated to an unknown risk and intervention while the downturn in the economy leaves programs with a predictable occurrence, effectiveness and history -- such as flu vaccination programs -- underfunded.
Meanwhile.. In the same issue of AMA Medical News there's this rundown on the state of preparedness. It's largely a self-congratulatory piece on how great a job professional societies have done with their websites and conferences on educating us about bioterrorism. Notice that no where in the article is there a single example of efforts on a local level to educate all physicians. The web has been a wonderful source of good information, but the audience for it is limited. Not every doctor turns to the internet for medical education. posted by Sydney on
10/02/2002 06:50:00 AM
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Drumming Up Business:RangelMD.com had an excellent post yesterday on asbestosis and trial lawyers. Here’s the money quote:
"Using a slide projector to highlight a line from a Wall Street Journal story, Baron read a sentence aloud: "It says, 'The plaintiffs' bar is all but running the Senate.' "I really strongly disagree with that," Baron said, smiling. "Particularly the words 'all but'." -Fred Baron, a partner in Dallas' largest plaintiffs' firm and a force in the influential Association of Trial Lawyers of America
And by the way, the technique that RangelMD mentions of parking a trailor with an x-ray machine at the local union halls to drum up asbestosis cases is a very wide-spread one. A good proportion of my patients are retired GM and Ford workers, and everyone of them has had x-rays taken by lawyers at their union halls. A number of them have given me copies of their reports, concerned because they’ve been told they have evidence of disease. Everytime I repeat the x-rays, they come back with normal readings from our hospital’s radiologists. posted by Sydney on
10/02/2002 06:42:00 AM
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Tuesday, October 01, 2002
Why Men Eat Chocolate: Research suggests that men eat more chocolate when they're happy. They showed them clips from films that were designed to stir various emotions, and offered them chocolate while they were watching them:
Macht and his colleagues studied 48 healthy men of normal weight, showing them film clips intended to induce joy (from When Harry Met Sally), sadness (The Champ), anger (Cry Freedom) or fear (Silence of the Lambs). Then they gave them a piece of chocolate, and asked them how much they enjoyed it, and whether they wanted more.
It's a pretty big leap of faith to assume that When Harry Met Sally made men feel happy. Maybe it just made them feel bored.
UPDATE: A reader agrees:
Sorry, but this study seems a little flawed to me. First, the "joy" movie was a chick-flick. If they really wanted to see what happens to a man, feed him chocolate while watching "Blazing Saddles". They also missed out by not having an action movie in the mix. This shows a poorly designed experiment to me. Put a bowl of M&Ms in front of them while watching "Terminator 2" and see what happens. Or maybe the Super Bowl. "When Harry Met Sally", come on! I agree with you - they were bored. They were trying to induce pleasure the only way they could - by eating chocolate and writing "Please kill me!" on the wrappers before throwing them out the window. posted by Sydney on
10/01/2002 08:21:00 AM
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Crackdown: The feds have told drug companies to put the kibosh on their financial gifts to those who can influence drug choices. Those who can influence drug choices range from practicing physicians who get money to sit through a lecture on the drug of the day to researchers who get research grants and stipends from the companies, to pharmaceutical benefits plan managers who get paid to switch people to the companies' drugs:
The new standards say "switching arrangements," under which drug companies offer financial incentives to shift patients from one drug to another, "are suspect under the anti-kickback statute."
Similar arrangements, under which companies pay drugstores or pharmacy benefit managers to contact patients or doctors to encourage them to change from one drug to another, are also suspect, the government said. It warned companies that they would run afoul of the law if they rewarded pharmacies and pharmacy benefit managers for "moving market share" from one product to another.
The inspector general said that payments to consultants, advisers and researchers "pose a substantial risk of fraud and abuse" if the payments exceed "fair market value for the services rendered."
The new guidelines say that drug makers can violate the kickback statute when they offer entertainment, recreation, travel, meals or similar benefits; when they sponsor "educational conferences"; and when they offer research grants, gifts, gratuities and "other business courtesies" to doctors, hospitals and other health care providers who influence the prescribing of drugs.
Smallpox Scare: The Hart Senate Office Building was shut down yesterday after someone found a piece of paper with the word smallpox written on it. It could have just been someone's memo to themselves to bring up the topic at a meeting or to do some research on it. Or it could mean something more ominous.
Authorities tested the area and found no trace of smallpox virus. I'm not sure how sensitive their tests are for such things. I guess we won't know for sure until two weeks (the incubation time for smallpox) have passed.
And More Smallpox Vaccine News: We now have enough to vaccinate everyone. So let's get cracking, and do it, before a scare like the one they had in the Hart Building becomes a real one.
posted by Sydney on
10/01/2002 08:09:00 AM
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Our Canadian Brothers: Doctors in Newfoundland are on strike today to protest their low pay. They make anywhere from 20% to 50% of their counterparts in the rest of Canada. (Who also complain of inadequate reimbursement.) posted by Sydney on
10/01/2002 08:07:00 AM
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Agony or Ecstasy? I confess to being more than a little puzzled by all the fuss over the recent ecstasy research. Both camps seem to be firmly set in their preconceived notions about the dangers or potential benefits of the drug. One thing is clear - you should never mess with brain neurotransmitters unless you absolutely have to. The consequences can be too grave. Ecstasy appears to have a particularly potent effect on those neurotransmitters. Using it for recreational purposes is just flirting with disaster. posted by Sydney on
10/01/2002 08:07:00 AM
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Killed by Kindness: An excellent essay by Abigail Zuger on the hazards of having a doctor with too much empathy. This is something that deserves more attention by the medical profession. All of us have known doctors like this - people who let their sympathy trump their judgement. All of us have probably done the same on an individual basis at some point, but there are doctors out there who consistently practice with more sympathy than sense. I, too, once had a colleague like this. His motto was "the customer is always right." He gave everyone anything they asked for - antibiotics for colds, high doses of narcotics for benign pain, tranquilizers for mild stress. He even once fed a man with active pancreatitis in the hospital because he complained about being deprived of food. (The treatment for pancreatitis is to rest the gut by allowing no food to enter it.)
The depth of the problem only became apparent when he left the practice. It was one of the most aggravating periods in my life. I assumed the care of the majority of his patients, and most of them made no bones about telling me how inferior I was to their beloved physician. A few of them even called their HMO to complain about me because I wouldn’t give them antibiotics for their runny noses. They claimed I was refusing to treat them. I ended up telling the majority of them to go elsewhere.
There’s a fine line that doctors toe every day to try to remain objective in the face of suffering without seeming cold and impersonal. We have to keep our distance to some degree or run the risk of doing more harm than good. There are two things in this life that you don’t want - a priest and a doctor who always agrees with you. posted by Sydney on
10/01/2002 08:02:00 AM
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Increasingly Uncovered: The number of people without health insurance has increased - by a whopping 0.4%. That's not really a whole lot, even though it represents millions of people, it's still only 14.6% of the population. If we ever got to the point where most people were uninsured, I bet we would see a dramatic drop in healthcare costs. Most doctors would prefer to bill their patients directly and avoid all the insurance company hassles. Getting payment through insurance companies actually requires more overhead - you have to have someone to haggle with them over every denied bill, which is, sad to say, just about every bill. If we could just charge our patients for their office visits, the price of an office visit would be a lot less than it is now. But, when the vast majority of people are insured, you just about have to accept the insurance plans in your community to make ends meet, unless you're the only doctor in town. posted by Sydney on
9/30/2002 07:42:00 AM
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Mississippi, Again:George Will explains how Mississippi's reputation for jackpot justice reaches beyond medicine and medical malpractice:
Mississippi juries have awarded plaintiffs $1.8 billion since 1995. The Mississippi law that allows plaintiffs to combine their cases with others nationwide, along with a notoriously pro-plaintiff local judge, has made Jefferson County (population 9,695) the wonder of the legal world: Between 1995 and 2000, some 21,000 plaintiffs sued there. No wonder Mississippi's insurance commissioner says 71 insurance companies have stopped doing business in the state.
To shore up the infrastructure, the CDC this summer gave the states $918 million in emergency funds, to be used only on the health response to bioterrorism. The Health Resources and Services Administration added $125 million to prepare hospitals.
"The system is only as strong as its weakest link," Gerberding said. "My highest priority is to ensure not only that we can detect a threat, but that we can get countermeasures deployed, down to the level of individual citizens. I worry that in some jurisdictions, that capacity does not exist."
At least the CDC realizes there’s a problem at the local level. Now, do they have the means and the will to shore up those weakest links? I’m not even sure they have the authority to order local health departments to shape up. This might be a potential role for the Department of Homeland Security, to mandate that local or state health departments implement plans for a bioterrorist attack and give them a deadline to have them ready. Right now, it seems like an awful lot of them are dithering over it and not doing much in the way of active planning. posted by Sydney on
9/30/2002 07:33:00 AM
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An Ambulance for Israel: A group of Northeast Ohioans is sending an ambulance to the Israeli version of the Red Cross. posted by Sydney on
9/30/2002 07:25:00 AM
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Anesthesia Addicts: RangelMD had a post yesterday about addiction rates in anesthesiologists. It’s a lot higher than in any other specialty, and always has been. You’ve got to wonder how many of them select anesthesiology as a specialty with the intention of gaining easy access to drugs, especially when you read about guys like this. posted by Sydney on
9/30/2002 07:24:00 AM
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Goodbye Soap and Water: Research shows that soapless hand cleaners are superior to soap:
Researchers at the Veterans Administration Medical Center in Washington. D.C., measured the effects of switching to the alcohol rinses two years ago. Dispensers were put in all patient rooms and outpatient clinics.
New cases of drug-resistant staph infections decreased 21 percent, while resistant enterococcus dropped 43 percent. Both of these are serious, hospital-acquired infections.
Among the first to study the gel's advantages was Dr. Didier Pittet of the University of Geneva Hospitals in Switzerland. Four years of use there cut hospital-spread infections in half.
Thank goodness. I switched to the alcohol based solutions a couple of years ago after frequent hand washings left my hands chapped and bleeding at the end of the day. I always worried, though, that I wasn’t killing as many germs with the waterless version. Now, I can rest easy and keep my skin intact. posted by Sydney on
9/30/2002 07:20:00 AM
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Sunday, September 29, 2002
Thought for the Day: "The idea that the government would withhold the only effective means of protecting the population from a terrible disease until an epidemic is confirmed is new to public health. Prevention, in this new concept, obviously has no meaning for the `sentinel' Americans who will become ill and die of smallpox as trigger for the government's response. That is not good public health, and is certainly not good protection from bioterrorism." - J. Donald Millar, former director of the smallpox-eradication program of the Centers for Disease Control and Prevention. posted by Sydney on
9/29/2002 08:23:00 AM
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Suffer the Children: The Bush administration has expanded its Children's Health Insurance Program to include unborn children, so that pregnant women can use the funds to get prenatal care. This is a worthwhile goal, since the program provides help for those who aren't poor enough for Medicaid, but don't have health insurance. Yet, abortion advocates are tripping all over themselves to label this as a move against women’s rights :
Gloria Feldt, president of the Planned Parenthood Federation of America, said: "This regulation is ridiculous. It elevates the status of the fetus above that of the woman. It does not provide prenatal care to the woman in whose body the fetus resides. It makes the fetus eligible for prenatal care, but treats the woman as a mere vessel, an incubator.
By what twisted logic is providing healthcare to a pregnant woman the same as treating her as a vessel? Prenatal care benefits the mother by far more than it benefits the baby. Women without prenatal care are much more likely to have seizures from undiagnosed pre-eclampsia, much more likely to give birth to huge, pelvic damaging babies because of undiagnosed gestational diabetes, and much more likely to have fatal complications from undiagnosed misplaced placentas. To claim that offering them prenatal care is akin to putting their babies’ health above theirs is just downright ridiculous. posted by Sydney on
9/29/2002 08:21:00 AM
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Pharma Promos: Last week, a drug rep promoting a new decongestant dropped this (the nose at bottom left of page) off at my office. Now you know where the money goes. posted by Sydney on
9/29/2002 08:13:00 AM
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Herpes Halt? Hardly: Researchers say that the antiviral drug, Valtrex, can prevent the spread of herpes between sexual partners. Don't get too excited, though. Here's the numbers:
The volunteers were randomly given either daily Valtrex or dummy pills, offered advice on using condoms and then followed for eight months. Two% of those taking Valtrex passed on the virus to their partners, compared with 4% on dummy pills.
The treatment nearly eliminated herpes symptoms in the partners, even if they caught the virus. Just half of 1% of those whose infected partners took Valtrex got herpes sores, compared with 2% in the comparison group.
Very tiny percentages in both cases, and hardly of any true clinical significance. Yet another example of how researchers give in to the temptation to put the best possible spin on their results, and how the media swallows their claims without any attempt at scrutiny. posted by Sydney on
9/29/2002 08:11:00 AM
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Innovation In Trouble: The Oregon Health Plan, an ambitious Medicaid plan that actually rationed care, is in financial trouble. Providers are opting out of it because of poor reimbursement, and the state doesn't have the money to cover even their rationed care:
"We were trapped between the Legislature, who wouldn't give us enough money, and the federal government, who wouldn't allow us to restrict services," Glass said.
This is sad. When the health plan was introduced, it was hailed as a potential model for Medicaid programs everywhere. Why is it that we as a society can't come to terms with the idea that not all medical care is necessary or equally worthy of reimbursement? posted by Sydney on
9/29/2002 08:05:00 AM
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West Nile Update: The virus has been isolated in breast milk. It’s not clear, however, whether or not it can cause an infection via breastmilk. At this moment, the only virus known to be transmitted through breastmilk is HIV. posted by Sydney on
9/29/2002 08:03:00 AM
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Mississippi Burning: A Mississippi state senator, who is also an optometrist, resigned in disgust over his state's inability to reach an agreement on malpractice insurance reform. posted by Sydney on
9/29/2002 07:55:00 AM
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A Cry For Help: A recent survey of family physicians found most of them feel unprepared to manage a bioterrorist attack:
Nearly all (95%) of the survey respondents agreed that "a bioterrorist attack is a real threat in the United States," Hickner and his colleagues report in the September issue of the Journal of Family Practice. And most doctors (96%) believed anthrax was the most likely biologic agent to be used.
Still, less than 30% of the doctors believed the US could effectively respond to such an attack and only about a quarter of the physicians said they would know what to do, study findings indicate.
"Most family physicians do not feel confident in dealing with a possible bioterrorism attack in their communities," Hickner said. "Most desire more education so that they will be able to confidently handle such situations."
Indeed, more than 90% of the physicians surveyed said they were interested in receiving training about how to respond to a bioterrorist attack, the researchers report.
This is a message the local health departments need to hear. I wrote to my state health department, a department which has benefited from HHS funds for bioterrorism, voicing my concerns about the lack of any effort to educate practicing physicians on how to respond to a potential bioterrorist threat. They pointed me to websites that I already regularly visit (essentially ignoring the point I made about many physicians not being connected to the internet), and assured me that my local health department has been providing grand rounds at local hospitals and medical conferences at the nearby medical school. If that’s true, they’ve been a well-kept secret, because I haven’t heard about them, and none of my colleagues can remember hearing anything about them, either. I wrote my local health department to voice the same concerns, but as of yet, no answer. I don’t really expect to get one. They’re too busy trying to educate me about preventing falls in the elderly. posted by Sydney on
9/29/2002 07:49:00 AM
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