"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
Melancholy Maids: Researchers have discovered a promising gene for depression but it seems to be influential only in women:
Research results, published this week in the American Journal of Medical Genetics, show significant evidence of a link between unipolar mood disorders and a specific region of chromosome 2q33-35 in women. A gene in this region is believed to contribute to the vulnerability of women in families with a history of recurrent, early onset major depressive disorder to developing mood disorders. The same genetic background in men did not increase their chances of developing mood disorders.
This isn’t your typical gender-biased research study, though. The study actually did look at the gene in both men and women in eighty-one families. The correlation between mood disorders and the presence of the gene was highest among women members of the families. The gene codes for a protein that’s involved in translating DNA into the proteins that make the body work. It could be that the protein’s function is influenced in some way by estrogen, resulting in the higher incidence of mood disorders in the women with it, but not the men.
Although it should never be used as an excuse for behaving badly, there’s no denying that estrogen levels can affect the moods of some women. A better understanding of the biochemistry of the protein involved may someday lead to better treatment for PMS and post-partum and post-menopausal depression. posted by Sydney on
11/02/2002 11:11:00 AM
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Tough Luck: One of Britain's top private health insurance plans will no longer pay for caesarean sections - regardless of the reason:
AXA PPP Healthcare says the rise in "lifestyle" Caesareans means it can no longer tell which claims are genuine and which are not. The ruling will affect thousands of women, and patients who have already booked into private hospitals facing a 7,000 pound bill.
The number of births by Caesarean section has doubled in the past 20 years and about one in five pregnant women chooses to have her baby that way. In some private hospitals the figure is nearly one in two.
In England, women can book caesarean sections in advance at some hospitals. It's a trend that seems to have gotten out of hand there. A fifty percent C-section rate would be considered scandalous here in the states, although our rates are increasing, too. It's ironic that this is being driven by patient choice, since the anti-caesarean section movement in the 1970's was driven by women's health advocacy groups who looked on them as procedures of convenience for (male) doctors. Turns out that given the choice, a lot of women prefer them for convenience, too. (Although I would argue that in the long run they're not as convenient as a vaginal birth. They have a longer recovery time - weeks instead of days.) posted by Sydney on
11/02/2002 07:51:00 AM
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Nicotine Cough Drops: Not really, but they might as well be. The FDA has approved a nicotine lozenge to help people quit smoking. The one concern I have is that, unlike the nicotine gum, nicotine lozenges will result in prolonged close contact of nicotine with the mucosal surfaces of the mouth and tongue. They could conceivably result in higher rates of oral cancer, in much the same way that chewing tobacco does. posted by Sydney on
11/02/2002 07:34:00 AM
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Shakedown: Members of of the Washington, D.C. area's largest health insurance company won't be able to use the Children's Hospital without paying a steeper price. The hospital balked at the company's efforts to squeeze them further:
"CareFirst started off the negotiation asking for a 12 percent decrease in rates," said Jody M. Burdell, a Children's vice president. "We asked for a 20 percent increase. CareFirst really needs to pay rates that are comparable to other managed care companies' rates."
The insurance company denies this account, but there's no reason to suspect the hospital of lying and every reason to expect the insurance company to try to save face in an effort to avoid losing subscribers. Carefirst made $92.4 million last year.
How Do You Cure a Broken Heart? With a good defense. Research suggests that the heart has the ability to save itself from injury:
The protein, called mitoKCa, helps channel potassium into the mitochondria, where it appears to play an important role.
Previous research has already suggested that the uptake of potassium into the mitochondria is somehow important in the ability of the cell to stay alive when placed under extreme stress - such as that caused by a heart attack.
A chemical which "opened up" these channels appeared to help protect rabbit hearts against the the damage caused by an attack.
It's too early to say how this will wash out in practical terms, but maybe someday it'll lead to a drug to prevent cellular injury during heart attacks. posted by Sydney on
11/01/2002 08:16:00 AM
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Down Under: The World Health Organization subjected Australia to the same sort of faulty statisitcal analysis used by the Institute of Medicine and found their hospitals dangerous:
According to the World Health Report 2002 almost 17 per cent of patients suffer "measurable" harm while undergoing unrelated treatment in health care facilities.
That figure is well ahead of the next-highest nations on the list, the United Kingdom and Denmark where the risk is assessed at 10 percent and the United States where the risk factor is less than 4 percent.
A Case in Point: One of the counter-protesters at the Ohio rally was a Cleveland lawyer who had represented a Cleveland-area family against a Marion obstetrician. I thought that was odd, since Marion is a small town, about a three hour drive from Cleveland, much of it along back country roads. Turns out, the lawyer's client is now sixteen and has since moved to the Cleveland-area, where there are many more malpractice attorneys, and many more who advertise aggressively for clients. The story of the family is here:
Bank's daughter, Mary, was awarded $900,000 for injuries sustained during childbirth. A Marion jury blamed her doctor, Carol Solie, formerly a physician at Smith Clinic, for using improper force during the 1986 delivery at Marion General Hospital and causing Erbs Palsy, partial paralysis from damage to nerves in the neck.
Mary's right arm is paralyzed, making everyday tasks like washing her hair and eating difficult, her mother said.
Of the jury award only $118,000 was for economic damages. Lancione said if Goodman's bill was already in place, the most the 16-year-old could have received was $418,000, minus legal fees.
Bank, who now lives in Medina, said that is not enough to pay for a lifetime of care for her daughter.
"(Economic damages) can take care of basic needs, but there's nothing extra for Mary," Bank said. "After fees she would have been left with between $100,000 and $125,000. And there are many special things Mary is going to need."
Not to sound callous, but the partial paralysis of a limb doesn't leave a person incapacitated. It's hard to believe that she has much trouble eating, either. I'm sure she's capable of feeding herself and preparing her own meals. I know my stroke patients learn to do this, and they have to get used to the loss of a limb's use. That sort of disability is easier to overcome when you've had it since infancy. You just learn to do things with one hand as you go along, you don't have to "relearn" anything. There's no reason to think that a child with the loss of the use of an arm is going to need other people to care for her for the rest of her life. If there were, the economic damages would have been much higher. Notice, too, that even the lawyer says that under the proposed Ohio tort reform bill, the family would have been awarded $418,000, but once he subtracted his fees they would only be left with $125,000 at most. He's taking almost three-quarters of the money! That's outrageous, and it just underscores the need for tort reform. posted by Sydney on
11/01/2002 07:57:00 AM
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News from the Homefront: 3,000 Ohio doctors rallied at the State House yesterday to support tort reform:
Goodman's bill would cap pain and suffering jury awards at $300,000 and limit how much plaintiff's attorneys can collect for representing victims.
A more comprehensive tort reform bill, containing similar measures, was enacted in 1997 but was struck down by the Ohio Supreme Court in 1999.
There were some counter-protesters there - trial lawyers and a few of their clients. They typically tried to take the focus away from limiting their financial rewards and framed it as an issue of patient rights:
"No matter what name it's given, this bill is nothing more than an immunity bill for doctors and a cash cow for the insurance industry," said John A. Lancione, who recently represented a Cleveland-area family in a malpractice suit against a Marion doctor.
It isn't an "immunity" bill. Patients who believe they were wronged would still have the right to sue, and still be able to collect unlimited economic damages. What they won't be able to do is collect unbounded sympathy money in the form of "pain and suffering". And what lawyers won't be able to do is milk that sympathy for their own financial benefit.
One in a Million: They say that syphillis is on the increase:
The syphilis rate increased from 2.1 cases per 100,000 people in 2000 to 2.2 cases per 100,000 last year, the CDC said. More than two-thirds of the new syphilis patients were men.
So, that means that last year 21 people out of a million had syphilis, and this year 22 people out of a million had syphilis.
One in a million. posted by Sydney on
11/01/2002 06:46:00 AM
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After research oversight boards reached mixed conclusions on these issues, the Food and Drug Administration announced Thursday that for the next month it will accept public comment on whether the University of California, Los Angeles, and Cincinnati Children's Hospital should inoculate 40 2- to 5-year-olds with smallpox vaccine. They would be the first children to get the shots since routine vaccination ended in 1972.
Information about the studies in question are available here. You can submit your comments to the FDA here. Comments already received can be viewed here. (There aren't any yet.) posted by Sydney on
11/01/2002 06:30:00 AM
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Doing Something Right: The good news is that deaths from heart failure are decreasing. The bad news is that hearts still fail:
The risk of dying after a diagnosis of congestive heart failure -- the most common reason for hospitalization among the elderly -- has dropped by around one-third since the 1950s, according to new data from the nation's longest-running heart study.
But the disease, which strikes about 550,000 Americans each year, still kills more than half of patients within five years of diagnosis, according to the report published in today's New England Journal of Medicine.
In other words, don't take away our research grants just because we're studying a disease whose treatment is getting better. posted by Sydney on
10/31/2002 07:16:00 AM
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Trans-Atlantic Tales: And in news from the single-payer healthcare system across the ocean, doctors rejected the latest contract proposal:
The contract, drawn up after years of negotiations between the BMA and Department of Health, was originally presented as a "win win" deal for consultants.
However, many doctors criticised the contract saying it gave NHS managers too much power and threatened their independence.
1. Malnourishment
2. Unsafe sex
3. High blood pressure
4. Smoking
5. Alcohol
6. Bad water and poor sanitation
7. Iron deficiency
8. Smoke inhalation from indoor fires
9. High cholesterol
10. Obesity
I wonder how they teased some of those out of the ultimate cause of death? Malnutrition and bad sanitation, I can see. If someone dies of intestinal parasites it's probably from poor sanitation, and if someone dies of Beri-Beri it's probably poor nutrition. But indoor fires, high cholesterol and obesity? Do people suffocate in large numbers from their indoor fires, or do they develop asthma and emphysema at higher rates? Coroners don't look over a dead body and say, "Hmmm. Two hundered and twenty pounds. Cause of death - too fat.". Presumably the cholesterol and obesity deaths were due to heart disease, a disease which has many causes, all of which usually tend to occur at the same time.
Tales from the North: In the single-payer healthcare system to the north, they have a doctor shortage for a couple of reasons. For one, the government determines how many medical students will be educated at a time, and right now the number that are allowed is lower than the need. The result is that a lot of Canadians who want to become doctors are forced to elsewhere, then they never go back. For another, established doctors have been fleeing south to avoid their system:
Rosser says that as many as 5,000 Canadian specialists and family doctors have been lost to the United States in the past 10 years.
Who’ll Be the Judge? The Institute of Medicine released another report yesterday, this one suggesting that federally-funded government healthcare programs, like Medicare and Medicaid, pay doctors based on the quality of their care:
In the next two years, the government should issue standards to evaluate treatment of 15 common health conditions, like diabetes, depression, osteoporosis, asthma, heart disease and stroke.
By 2007, doctors, hospitals and other other health care providers in the six federal programs would have to submit data to the government showing how they treat patients with any of the 15 conditions.
Starting in 2008, each federal program would publicly report data comparing the quality of care available from health care providers who treat its patients.
Although on the surface this sounds like an inherently good thing, in reality it’s a much more costly approach to providing medical care. For one thing, who defines what “good care” is? Just two years ago, “good care” would have been putting all post-menopausal women on hormone replacement therapy whether they wanted it or not. As things stand now “good care”, according to our government, is ordering mammograms on women in their forties although the latest studies suggest this is neither cost effective nor of a benefit to them. "Good care” is putting everyone with certain choleseterol levels on expensive cholesterol lowering medication, whether they want to take it or not, even though high cholesterol is only one of many risk factors in heart disease, one that can be controlled with diet and exercise, and one whose improvement reduces heart disease by only three to four percentage points. "Good care” is ordering $200 bone densitometries on every woman over sixty-five every two to five years. "Good care” is getting diabetics blood sugar readings below a certain average, their cholesterol below a certain number, and their blood pressure below a certain level - all of which can add up to a lot of expensive drugs and result in only a marginal improvement in outcome. The truth is, that such “quality standards” are usually reduced to easily observable data, such as lab values or claims data. The result is that the doctor becomes more concerned with the data than with the patient. That’s why you’ll find cardiologists insisting that their patients remain on blood thinners even though they’ve just bled into their brains, why you’ll find endocrinologists increasing insulin doses even though the patient is passing out with occasional episodes of hypoglycemia, and why you’ll find doctors putting people on two or three cholesterol lowering medications - all in an effort to force down a number on paper. These kinds of guidelines will only increase the overall amount of money spent on healthcare, and make doctors more likely to aim their treatment goals at achieving "averages" rather than individualizing care.
Then there’s this aspect of it:
The recommendations assume that doctors and other providers will take major strides to computerize medical records, perhaps with tax credits and other federal incentives for the purchase of information technology.
Under the panel's recommendations, Dr. Omenn said, health care providers would have to submit "audited patient-level data," and it makes no sense to cull such information from paper medical records and insurance claim forms.
Current computerized medical records systems are expensive and have yet to reach a level of design that makes them very useful. We’re still waiting for a good system that works better than paper. Although in theory, they should speed up the documentation process, I’ve had a lot of physicians and “efficiency consultants” tell me that in reality they slow down the patient flow. Forcing doctors to convert all of their current paper records to electronic ones will be a very expensive proposition, and one whose costs will end up being born solely by the physicians. If this requirement goes into effect, you can expect a lot more physicians to drop Medicare and Medicaid. posted by Sydney on
10/31/2002 06:41:00 AM
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Fountain of Youth Discredited, Again: Estrogen apparently doesn't help memory, either. At least not in rats:
Led by Gary Wenk of the University of Arizona at Tucson, the team surgically removed the ovaries of rats to induce menopause. The loss of the ovaries also affected the hypothalamus, a key region in the brain, in ways that are similar to the changes that occur among menopausal women.
As described in the October issue of the journal Behavioral Neuroscience, the researchers then put the rats through a water maze test to measure their memory. They found the ovary removal was not enough to impair the animals' performance, but as soon as the rats were given either regular estrogen replacement therapy or induced chronic brain inflammation, the animals' water maze test scores worsened. Furthermore, the rats that received both procedures performed far worse than those receiving either estrogen alone or subjected to brain inflammation -- which simulated the effects of Alzheimer's.
News From a Single-Payer System: Canadian doctors are facing the possibility of being forced into group practices by their government:
Primary-care reform is about changing the way family doctors work. Instead of working as independent practitioners, they would work in larger practices, along with other health professionals including nurse practitioners, physiotherapists and social workers.
Keep the CAT in the Bag: Recent research suggests that CT scans are overused in children with head injuries:
About 2 percent of all children's ER visits are for head injuries. Major trauma definitely requires a CT scan, but Atabaki noticed that doctors gave widely varied reasons for scanning kids with minor injuries -- some merely cited pressure from worried parents.
Together with four other hospitals -- Strong Memorial Hospital in Rochester, New York, Hasbro Children's Hospital in Providence, Rhode Island, New York's Mt. Sinai Hospital and Inova Fairfax Hospital in suburban Washington -- she studied 1,000 patients.
CT scans found an intercranial injury in less than 7 percent -- just 65 children.
There's another diagnosis in kids that gets over-scanned because of parental pressure - headaches. It's hard to convince a parent to wait and see if the headaches their child has had for two weeks will go away, as most do. And if by chance the child happens to be in the small percentage who have a tumor causing the headache, the doctor gets blamed for delayed diagnosis and faces not only parental anger, but a potential lawsuit.
posted by Sydney on
10/30/2002 07:07:00 AM
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The HapMap Project: Not happy maps, but international maps of genetic haplotypes, genetic sequences that determine physical characteristics and in some cases disease prediliction:
Scientists have long hunted associations between genes and illness, with notable success in diseases caused by a single defect.
But mankind's great killers are believed to be caused, or accelerated, by patterns of a dozen or so genes working together, and scientists have had a harder time nailing down those associations, in part because they lacked a catalogue of the common variants.
"The HapMap project will create a powerful tool for linking differences in the genome to differences in health, including increased risk for common illnesses," said Huanming Yang, director of a genetic institute in Beijing and leader of China's contribution to the project.
Happy as a Louse: It's getting harder to get rid of lice. They're developing resistance to the shampoos and lotions that we use. So, how do you keep lice in a lab so you can develop better ways of killing them? You can’t keep them in cages as you would mice, at least not traditional cages:
In a setup that looks nothing like a human head, the lice are placed inside tubes with a tuft of human hair. A thin plastic membrane stretches over the bottom of the tube, fooling the lice into believing it is a scalp. The tube is then lowered into a container of blood, which a louse can feed on through the membrane.
"They lay their eggs there, they raise their kids there and they eat there," Clark said. "They're happy." posted by Sydney on
10/30/2002 06:18:00 AM
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Coming Soon: The Institute of Medicine has embarked on a study of complementary and alternative medicine. It will be a couple of years before we know the results, but if their past performances are any indication it will produce a book length paper telling us that the medical establishment overlooks alternative and complementary medicine to the detriment of patients. There will be a selection of physicians on the committee who will use their appointment as nothing more than resume padding. The actual collection of data and writing of the report will be left to the non-physician staff. Meetings will be held in which the staff hears from practitioners of alternative medicine and others who have an interest in it. The result will be yet another biased report, and more federal money will be diverted from science-based research into exploring whether modalities like aroma therapy or yoga can prevent and cure diseases. posted by Sydney on
10/30/2002 06:15:00 AM
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Senior Bush administration officials said their suspicions were still tentative, but they said it was possible the gas used in the raid was an aerosol version of a powerful, fast-acting opiate called Fentanyl.
In interviews Monday, senior American authorities and private experts said the agent used by the Russians was probably similar to one of a small arsenal of nonlethal weapons that the United States is quietly studying for use by soldiers and police officers against terrorists.
Several scientists said the United States had conducted research on Fentanyl, a well-known drug with many medical applications, as a human incapacitant for nearly a decade.
One senior law enforcement official said the use of an incapacitating agent to free hostages was unprecedented. ``I'm aware of no hostage situation anywhere in the world where such an agent has been used,'' the official said.
But a senior administration official said that if the drug used in the incident was Fentanyl, that would probably not constitute a violation of a 1997 treaty banning the use of lethal chemical weapons.
Fentanyl comes in all sorts of forms - a patch, an aerosol, a liquid, and an oral form. It's even available as a lollipop for kids . It's as good a candidate as any for the Russian gas.
UPDATE: Best of the Web Today says that their physician friend doubts fentanyl is the gas because it's a solid and because it can be reversed by a drug called Narcan that binds to the same receptors and blocks the narcotics’ action. Fentanyl isn't just available as a solid. It's also an injectable liquid, and it's a drug that can be absorbed through the thin lining of the oral cavity. It wouldn't be such a stretch to develop an aerosolized version that would be absorbed through the lining of the respiratory passages as it was inhaled. As to the Narcan issue, Narcan can reverse opiates, but it's generally much shorter-acting than the opiates it reverses. If given a massive overdose, such as would be likely in a gassing situation, it would take repeated injections of it at large dosages to keep the drugs reversed. In addition, it doesn't reverse damage already done. When a narcotic suppresses respirations and puts people to sleep, the oxygen going to their vital organs is decreased and damage occurs. According to Goodman & Gilman's, the bible of pharmacology, fentanyl has a long half-life and has a tendency to build up in the tissues. It took a while to get the hostages to the hospitals, during which the gas would have done its damage to the heart, the lung, the kidneys, and the brain. Narcan wouldn’t be the same easy solution it would be for someone who just sucked a few too many fentanyl lollipops and was excessively sleepy.
Errata: A survey of Colorado physicians reveals that doctors think less highly of the Institute of Medicine’s contention that our healthcare system is rampant with errors than the public does. It isn’t that we think we’re perfect, but that we object to the blatant falsehood of statements like this:
Respondents were asked to assess their agreement with several statements from a 1999 report by the Institute of Medicine that found preventable medical errors to be the eighth leading cause of death in America.
Aargh! Will this lie never die? Here’s the figures for the top ten leading causes of death in 1999 and 2000. The eighth leading cause of death was Alzheimer’s. Medical errors aren't listed as a cause of death at all. There's a category of accidents which includes accidents of all sorts - from car accidents to falling down the stairs. It's hard to believe that medical errors make up a large percentage of that particular category.
In fact, it turns out that they don’t. Subsequent studies have shown that significant errors occur at a far lower rate than the Institute of Medicine would have us believe. Others have shown that the methodology of the studies on which the Institute of Medicine's position paper was founded were flawed. The Institute based their claim that doctors are the eighth leading cause of death on a study done by a team of Harvard researchers in the 1980’s that looked at adverse events in a sampling of New York state hospitals and a similar study from hospitals in Utah and Colorado. ( I can only link to the Harvard study.) The Institute took those studies one step further and extrapolated the data to apply to the entire country. There’s a fundamental problem there. It’s invalid to apply data from one year (1984 in the case of the Harvard study) to another year (1997 for the Institute’s data), and it’s invalid to apply data from one state to the entire nation. For some reason the reviewers of the Institute’s paper gave this shoddy statistical work a pass, but these guys have done an excellent job of pointing out its flaws.
Drug complications were the most common type of adverse event (19 percent), followed by wound infections (14 percent) and technical complications (13 percent). Nearly half the adverse events (48 percent) were associated with an operation. Adverse events during surgery were less likely to be caused by negligence (17 percent) than nonsurgical ones (37 percent). The proportion of adverse events due to negligence was highest for diagnostic mishaps (75 percent), noninvasive therapeutic mishaps ("errors of omission") (77 percent), and events occurring in the emergency room (70 percent). Errors in management were identified for 58 percent of the adverse events, among which nearly half were attributed to negligence.
How do you judge an “error of omission?” It sounds suspiciously like something that would be far easier to detect in hindsight than at the time of treatment. As for the others- “drug complications, wound infections, and technical complications”, those are known risks of treatment, not errors. An error is when you write the wrong number down for a dosage or pick up the wrong medication and give it to a patient. An error isn’t a post-op wound infection or a drug side effect.
The Institute of Medicine is an arm of the National Academy of Sciences. Its job it is to provide the federal government with unbiased analysis to help guide healthcare decisions. Unfortunately, the Institute has a tendency to set out with an agenda whenever it analyzes a problem, and this report was no different. Their study on racism in medicine was stacked with committee members whose life work was devoted to studying racism. The study on errors was done by people whose life work it is to monitor doctors and hospitals. It isn’t clear who was responsible for gathering the information and putting it into a report. The committee on healthcare quality whose members are listed at the beginning of the report has physicians as members, but it’s the nonmedical staff whose names appear on the title page. In the methodology section they mention the people whose input was critical to the report. They have a member from the National Patient Safety Foundation, a member from the Institute For Safe Medication Practices, and a member from the Joint Commission on the Accreditation of Health Care Organizations. They even had the creator of the system for aviation reporting. He, and one person from the VA system were the only two doctors involved in the discussions that led to the report. It’s highly doubtful that either of them are actively involved in diagnosing and treating patients. Such a collection of committee members has a natural bias toward finding errors in the system, and toward overestimating errors. Their lack of experience in practicing medicine as a group only compounds that bias. How can you expect policy wonks to understand the nuances of diagnosis and treatment, let alone to tell the difference between a complication and an error? You can’t. And that’s the fundamental problem with the Insitute of Medicine’s report on errors. It was put together by a committee of biased individuals who lacked the knowledge or the inclination to recognize flawed methodology, flawed definitions, and flawed statistics.
Do medical errors happen? Of course they do. No one’s perfect, and those errors that do occur should be minimized as much as possible. But the incidence of errors has been greatly conflated and exaggerated by the Institute of Medicine’s report. It is the one and only source for the lie that the medical profession is the eighth leading cause of death in this country. They have slandered the medical profession and undermined the trust that’s the cornerstone of the doctor-patient relationship. And they did it all with taxpayer money.
UPDATE: A reader emailed this information nugget:
The CDC tracks something called "complications of medical and surgical care". This was the cause of 3059 deaths in the year 2000. (quite a bit less than the 49,558 deaths from Alzheimer's) I would think that medical errors are a subset of this category.
Medicaid Shakedown: Pfizer will pay Medicaid $49 million (link requires registration) for "overcharging" the program for Lipitor, a cholesterol medicine:
The settlement will be split between the federal government and the states because Medicaid is a jointly funded program.
The charges stemmed from a whistle-blower lawsuit alleging that educational grants by Parke-Davis to the Ochsner Health Plan in 1999 constituted a rebate that lowered the price of the drug for the Louisiana insurer. Federal law requires drug companies to offer the Medicaid program the lowest price paid by any purchaser.
The suit was brought in 1999 by John David Foster, who worked for Parke-Davis at the time. Pfizer acquired Parke-Davis through its 2000 takeover of Warner-Lambert. The settlement represents more than double the $21 million the Medicaid program was overcharged, according to Foster's lawyer, Joel Androphy. Foster will receive about $6 million for his role in the settlement, Androphy said.
“Educational grants” seems like an awfully broad category, and the health plan presumably used other Pfizer drugs besides Lipitor, so it’s hard to understand how the federal government can justify this as overcharging. I’m much more sympathetic to the pharmaceutical company on this one. Federal healthcare plans like Medicaid and Medicare have a disconcerting tendency to create elaborate rules that no one can understand. There exists a whole industry of consultants who earn a living helping physicians understand the rules so they can avoid being accused of fraud. Yet, put two consultants together and they won’t be able to come to an agreement on the proper interpretation. I’m sure the rules for drug companies are no different. posted by Sydney on
10/29/2002 06:32:00 AM
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Monday, October 28, 2002
Quirky Medical Site Alert:The Reconstructors a team of investigators from the future who have to travel back in time to retrieve lost medical knowledge. posted by Sydney on
10/28/2002 06:50:00 AM
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New Birth: There's a growing body of evidence that depression may be linked to the brain's ability or inability to regenerate new neurons. Some see this as proof of that we have little control over our moods:
Whatever the relationship between depression and brain-cell birth, the whole line of research illustrates an important and under-appreciated fact about the nature of depression.
"This is not self-indulgence, this is not failure of will," Sapolsky said. "This is as biological a disease as diabetes."
To some extent this is true. In some cases of severe depression, the malady goes beyond a person's capacity to change their frame of mind, but there are many other cases in which it doesn't. What if it turns out that we have the ability to influence the growth of our neurons? That "changing our attitude" amounts to changing our neural pathways? It's very likely that this is what happens. It doesn't necessarily follow that depression is beyond the pale of our mind's influence in the same way that diabetes is.
posted by Sydney on
10/28/2002 06:48:00 AM
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Our Genes Are Not Our Destinies:Wired Magazine has one reporter’s account of navigating the world of genetic testing. It’s a very well-done piece. He had his entire genome screened for disease-causing mutations and found that he has two mutations that predispose him to high blood pressure. The consequences:
Pumping on the StairMaster, I nudge the setting up a notch, wishing, in a way, that I either knew for sure I was going to die on, say, February 17, 2021, or that I hadn't been tested at all. As it is, the knowledge that I have an ACE and ATHS deep inside me will be nagging me every time I get short of breath.
There’s a lot of potential for genetic testing to help us individualize medical therapy - to predict which medication would work best in each patient, for example. But it will never be the means to predict our health future. Too many outside influences have to be factored in, too many chance occurrences on the molecular level for our genetic make-up to be used as a map for our destinies. posted by Sydney on
10/28/2002 06:36:00 AM
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News From the Frontlines: My faithful radiology correspondent sent along this account of the consequences of sex bias in healthcare:
Is it just me or does it seem that we have gone way overboard on the issue that common diseases present differently in men than in women. My opinion is not meant to be sexist and I hope that subconsciously that isn't the motivation, but it seems that some researchers are publishing articles such as this one that is basically useless to the daily practitioner, and provide more fodder for the media health coverage, especially those geared towards women or looking to attract women viewers or listeners. It may be an easy and popular way to pad your CV, but appears to provide no useful information for a physician.
In some ways, it seems to me that it also encourages the somewhat incorrect idea, that women are completely ignored in our medical community.
I apologize for this somewhat sour view, but I guess my experience has a lot to do with my attitude. After working predominantly in a woman's health arena for many years, the amount of dollars and time thrown at only women's health in most hospitals today is amazing. Aside from the plethora of breast centers, gyn centers, there's a tremendous industry of women's support groups flourishing in and around hospitals today. I know I am partly to blame for the programs at my facility, but of late, I'm really starting to wonder whether we've gone way over the line.
This was driven home to me recently by a woman who was the mother of a 17 year old I had the misfortune to do a testicular ultrasound on recently when I informed her that her son had a large testicular mass that he had been ignoring for the last 8 - 9 months. When I explained to her that this was not an uncommon neoplasm and predominantly struck young men, not infrequently in their teens, she looked around the room and the adjacent hallway, covered in information posters and displays on breast cancer, obstetrics, and women's support group offerings, and said to me, " Why don't we hear about that?" I had no answer. How many middle and high schools or colleges teach boys and young men about testicular self exam and the importance of seeking a physician's expertise when they feel a testicular lump?
I'm not sure how much education girls get in female health from school, but there is certainly a disproportionate amount of media coverage devoted to women's health compared to men's health. The underlying assumption is that women don't understand their bodies and need education, and that men do know their bodies and are less likely to ignore problems. This isn't true. In my experience there is no sex difference in the capacity for denial.
And by the way, that stroke story I posted about yesterday is all over the media, predictably giving more credence to the sex differences in stroke symptoms than they deserve. posted by Sydney on
10/28/2002 06:09:00 AM
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Consequences of Single-Payer Healthcare: Jane Galt has a post that discusses further potential fall-out from a single-payer healthcare system and Deinonychus explains why healthcare isn't a public good. (Scroll down to October 14.) posted by Sydney on
10/28/2002 05:53:00 AM
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Sunday, October 27, 2002
Parity of Living: Nicholas Kristoff’s column yesterday about repressed women in Saudi Arabia quoted a couple of Saudi women who are fortunate enough to have lives outside the domain of their husbands. An assistant professor, a dietician, and a university professor took him to task for criticizing the treatment of women in their society. The abaya, they say, is their choice to wear. But, of course, it isn’t their choice. It might be something that these particular women don’t mind wearing, but it is by no means their “choice.” Other women, like the women physicians he interviewed, are aware that their treatment could stand some improvement:
Maha Muneef, a female pediatrician, emphasized that Saudi Arabia is progressing, albeit more slowly than many women would like. "My mother didn't go to any school at all, because then there were no girls' schools at all," she said. "My older sister, who is 20 years older than me, she went up to the sixth grade and then quit, because the feeling was that a girl only needs to learn to read and write. Then I went to college and medical school on scholarship to the States. My daughter, maybe she'll be president, or an astronaut."
Another doctor, Hanan Balkhy, seemed ambivalent. "I don't think women here have equal opportunities," she acknowledged. "There are meetings I can't go to. There are buildings I can't go into. But you have to look at the context of development. Discrimination will take time to overcome."
The second doctor reminded me of a woman with whom I shared an airport bus not long ago on the way home from a medical conference. She was dressed more like a New Jersey Italian than a woman of modest religious values. I was a little surprised when we struck up a conversation and she revealed she was a Saudi physician. She had the air about her of a woman breathing the last air of freedom. She had boxes of medical texts that she had bought from the vendors at the conference that she couldn’t purchase in her homeland, and she talked glowlingly of all the things she was able to do during the week long conference. She spoke glowingly about her country, too. She obviously loved it, and was looking forward to returning to her family, but she echoed the thoughts of the physician who spoke to Kristoff. A lot needed to change, but change would have to come slowly. She thought it would be a disaster to force sudden change on the country. She obviously enjoyed the privileges of a tolerant and progressive family. She had been allowed to go to school, to have a job, to travel alone to the United States, and to wear what she wanted.
She was a marked contrast to some of the women I have met in my practice who live under a less tolerant and progressive male regime. I don’t have a large population of fundamentalist Islamic patients, but I do have a handful, and I can’t help but feel enraged by the treatment of the women at the hands of their husbands. Unlike my airport bus companion, they aren’t allowed to wear what they want, even though they’re in the United States. Even on the hottest days, they wear heavy black garments from head to foot. Their husbands, meanwhile, take full advantage of living in the West and dress in comfortable blue jeans, T-shirts, and sneakers. Maybe the wives chose to dress that way, but I don’t get the sense that they do. They act more like cowed creatures than women making a free choice.
They walk behind their husbands, not beside them, and they rarely come into the exam room without their husband. It’s the husbands who do all the talking, and most infuriatingly of all, when they refer to their wives, even in their presence, they never call them by their name or refer to them as “my wife,” but only as an impersonal “she” with the tone of voice that is just a hair-breadth above what an indifferent dog owner would use. I want to say to those men, “In this office at least have the courtesy to refer to your wife by her name.” But, of course, I don’t. That wouuld be too confrontational and bordering on rudeness. Maybe I’m being overly sensitive. Maybe it’s just a cultural and language difference, but I don’t think so. These women literally have no voice. They won’t make eye contact, they won’t accept a proferred handshake, and they won’t answer questions. They seem acutely uncomfortable being adressed at all, as if they’re afraid they’ll say the wrong thing. And it isn’t just a language barrier. I have other patients who must rely on interpreters, and they aren’t shy about engaging me. They make eye contact. They speak freely to the interperter. They are anything but silent. The fundamentalist Muslim women, on the other hand, don’t say a thing. Not even to their husbands. When I see this sort of behavior in a woman from any other background I suspect abuse, but when I see it in a woman from a fundamentalist Islamic background I’m expected to view it as “normal”.
I should emphasize that these families are a very small minority of my Islamic patients. I have plenty of patients who are practicing Muslims who enjoy healthy, respectiveful marriages; who have a choice in what they wear; who are allowed to talk for themselves; and whose husbands acknowledge that they have names. The problem that I have with the strictest fundamentalists is that they aren’t treating women with the respect and dignity that they deserve - and that they get away with it in the name of religion. And most of all, I object to those within that movement whose goal it is to make the rest of us live that way. posted by Sydney on
10/27/2002 12:00:00 PM
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Parity of Reasoning: Another study came out last week purporting to show that women experience diseases differently than men. A few years ago, the buzz was that women had different symptoms for heart disease (note the differences are only expressed as odds ratios, a choice that distorts their significance). This time, it’s strokes:
Overall, researchers found that women were 62 percent more likely to say they were feeling sensations that aren't on the traditional list of stroke symptoms.
"Our findings have important consequences for stroke diagnosis and treatment," said Dr. Lewis Morgenstern, director of the stroke program at the University of Michigan's medical school and senior author of the study published yesterday in the Annals of Emergency Medicine.
"All stroke treatments are time-dependent, so if women are not diagnosed promptly, it will slow down the effort to treat them," he added.
Let’s look at the study and see what that “62 percent more likely” really means. The study found that 8% of men and 12% of women experienced pain as a stroke symptom and 12% of men and 17% of women had a change in the level of consciousness, symptoms that were deemed “nontraditional” stroke symptoms for the study. Traditional stroke symptoms were defined as loss of balance and paralysis of at least one part of the body. Twenty percent of men and fifteen percent of women reported balance problems. Twenty-four percent of men and fifteen percent of women reported paralysis. There was no one symptom that could be defined as occurring overwhelmingly in women or in men. The most common symptoms clocked in at a proportion of one-fifth to one-fourth of all those reported. (Motor weakness at 24% for men and “nonclassifiable” as 22% in women. But that doesn’t mean women are more likely to have “nonclassifiable” symptoms. Men also had those at a rate of 22%.) Stroke presents with a myriad of symptoms that varies from individual to individual. Some people will report nothing more than a “mental haziness” and others will present in a coma. Some will have a funny feeling in an arm or leg, and others will have a complete loss of their use. The important thing is for physicians to remember the many faces of stroke and consider it in their differential diagnosis regardless of the sex of the patient.
posted by Sydney on
10/27/2002 08:42:00 AM
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