"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
Public Health Skepticism: There's a growing number of parents out there who eschew childhood vaccinations, and evidently there's quite a few of them on an island off the coast of Washington:
Eighteen percent of Vashon Island's 1,600 primary school students have legally opted out of vaccination against childhood diseases, including polio, measles, mumps, rubella, diphtheria, whooping cough, tetanus, hepatitis B and chicken pox. The island is a counterculture haven where therapies like homeopathy and acupuncture are popular, and where some cite health problems among neighbors' children that they attribute to vaccinations.
The nationwide average for dropping out of vaccines is around two percent. Most of the parents interviewed in the article are well-off, all of them seem to be well-educated, yet they've rejected one of the most successful public health programs we have.
Before immunizations were routine, pediatric wards were full of children in iron lungs who couldn't breathe on their own thanks to polio. When I was in training, older physicians used to tell horror stories of children gasping for their last breaths as pertussis (whooping cough) closed up their airways, and there was nothing they could do to stop it. Measles used to be a significant cause of blindness and deafness. Congenital rubella caused all sorts of birth defects. The success of the immunization programs against these highly communicable diseases have wiped them from our collective memory. Now, the vaccines seem worse to many than the diseases. (Same as smallpox, no?)
Some of the parents explained why they made their choices:
Vaccine resisters cite an array of reasons. "Sometimes it's distrust in government, feeling it's in bed with the vaccine industry and `everyone's making money off our kids,' " Mr. Salmon said. Sometimes the objections are religious, as among Christian Scientists and some Amish congregations. Sometimes a community is scared when a child is truly harmed by side effects; the live polio vaccine, for example, is thought to cause about eight deaths a year.
Some parents are upset at the sheer number of injections a child must get — usually about 20 by age 2. Others are convinced — despite evidence to the contrary — that vaccines are highly likely to cause severe health problems, like seizures and autism.
..."I consider well-baby care to be a capitalist plot," Maryam Steffen, a mother of four said only half-kidding.
Then there are those who have more confidence in their own bodies than in medicine:
...Ms. Forest's grandson Deven had whooping cough two years ago and, she conceded, probably passed the disease to 10 other children, including an infant.
"Yeah, that bothered me," Ms. Forest said. "But I called everybody and we studied up on what you can do to build up the immune system."
The baby "did just fine," she said. "On Vashon Island, you have middle-class people who eat healthy and keep warm. If everyone was poor-poor, not breast-fed, not eating right — that might be a reason to vaccinate." But she and her daughter remain steadfastly opposed.
They were lucky. There was one mother on the island, however, who changed her mind after facing whooping cough in her infant son:
"My son would turn all shades of purple," she said. "He stopped breathing several times and we took him to the hospital. My daughter was terrified of going to sleep because then it got worse. She would vomit all over the place. My husband cracked ribs from coughing."
Now, Ms. White said, she would advise other mothers to vaccinate against whooping cough, polio and tetanus, but only with the newest vaccines. She still has not vaccinated Julian, now 3, against measles, mumps, rubella or chicken pox.
I have no statistics to back this up, but it’s been my impression that there’s been a growing wariness about vaccines since we’ve expanded childhood vaccinations to require immunizations against diseases that are either not all that easily communicable, like hepatitis B, or that aren’t all that dangerous, such as chickenpox. There was resistance to universal adoption of these vaccines within the practicing physician community as well, but it was over-ridden by the academics who make up the advisory panel on immunization practices and the professional societies.
I remember sitting in conferences when these recommendations were being put forth - conferences designed for pediatricians, and conferences designed for family physicians. There was always very vocal dissent from the audience during the discussion sessions. Hepatitis B would be put to better use if directed at at-risk populations - healthcare workers, sexually active teenagers, IV drug users. It made no sense to add three more shots to an infant’s regimen when they may never grow up to be at risk. Chickenpox was an inconvenient, but not life-threatening illness. The immunization itself could cause a mild case, and there were reports of kids getting shingles from it. Besides, no one could say with any certainty how long the immunity from the vaccine would last. What would happen when kids grew up, their immunity to the virus waned, and they got chickenpox? It’s much more dangerous in an adult than it is in a kid. What if those adults were young and pregnant, the worse-case scenario?
The counter argument from the lecturer would always be that the hepatitis B vaccine was the first chance to immunize against cancer (liver cancer, a complication of hepatitis B infection), no one could predict what a kid would grow up to be like, and that a small percentage of hepatitis B patients have no idea where they could have gotten it. For chickenpox, it was that the vaccine has been used in Japan for twenty years, and so far they hadn’t seen an increase in adult cases, that a small minority of children developed bad skin infections from scratching their rash, and besides, what about the small chance that a child could develop a weakened immune system either from cancer or from cancer treatment, and then get exposed to chickenpox? Immunizing everyone would protect these kids from a life-threatening illness.
So, the rest of us went back to our practices and started the difficult job of selling these immunizations to our patients. It wasn’t an easy task. Parents had the same doubts and reservations that my colleagues and I had. I’m still not that enthusiastic about either hepatitis B or chickenpox vaccines.
Hepatitis B immunization is now required for public school attendance in my state, (and forty-two others) but it was a requirement that came about after heavy lobbying by Smith-Kline, the company who manufactures it. The mandatory requirement was also supported by physician groups, but it left people wondering if there wasn’t some sort of financial collusion between the doctors and the vaccine industry. (For the record, I don’t believe that to be the case. I think those physicians who advocate them sincerely want to eradicate as many diseases as possible.) I have to confess, though, I often wondered the same thing as I sat in those conferences where just outside the assemblyroom stood lavish displays by vaccine producers.
UPDATE: A reader emailed these observations about Vashon Island:
It seems to me the Vashon Islanders, and others, who eschew vaccinations exhibit a class and cultural elitism that rides on the back of the vast majority who practice responsible public health--I wonder if they would be so confident of their children's immune system if they were transferred to S.E. Asia, Africa, or if the majority of residents on the Island did not vaccinate their children--by the way--what happens to children who are not vaccinated, grow up, travel the world, and are exposed to these diseases as adults?
What happens is they're more likely to catch those diseases. Even if those families were transported to parts of the world without high immunization rates with their health and wealth intact, their immune systems would be pitifully prepared to fight those disease naturally. The whole idea behind immunizations is to give the body's natural defenses a boost to help them ward off disease. If our systems were perfect, there wouldn't be any disease in the first place. posted by Sydney on
11/30/2002 12:19:00 PM
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Waiting Room Reading: Ran across this article on teenage smoking habits while I was waiting for my kids to get their haircuts:
Teenagers smoke for some of the same reasons they always have: It looks cool, and they identify it with rebellion. And knowing the risks, as kids now do, may only enhance the appeal. But there's more to it than that. In addition to the old temptations to smoke, kids today have a constellation of reasons that are unique to their generation.
"I see kids experiencing pressure to look like the successful people they see on TV, which for teenage girls, means the actresses on Friends, for example," says Michael Levine, a professor of psychology at Ohio's Kenyon College, who specializes in body image and eating disorders. The current fashions for young girls -- baby tees, belly-baring halter tops, spaghetti-strap tanks -- flaunt more of their bodies, which means more self-scrutiny and, inevitably, self-criticism sooner. Given these pressures, smoking may seem like a quick fix, a diet trick that girls are afraid to go without.
The web version is an abbreviated version of the print article, which has abundant examples of one other key factor in teenage smoking without ever pointing to it as a factor - parental smoking. The print version tells the story of one father and daughter who shared a cigarette after an argument, to diffuse the tension. It worked, but the daughter hasn’t quit smoking. And in example after example of teenage smokers, the article mentions parenthetically that at least one of the parents smokes. Yet, it doesn’t address the influence of parental smoking on teenage smoking. The influence is significant:
In one study, when parents who did not smoke advised their children (school ages of grades seven to 12) not to smoke, 69 percent of the children never began smoking. However, when parents did not verbalize disapproval, the percentage of children who never began smoking dropped to 53 percent. When parents who smoked advised their children not to smoke, 55 percent of the children never began smoking. But when the parents did not tell their children that they disapproved of smoking, the percentage of children who never began smoking dropped to 24 percent.
Smoking parents are twice as likely to have children who also smoke. Children learn by example. They are far more influenced by what goes on at home than they are by ads they see on television or on billboards. Want to keep your kids tobacco free? Then don't smoke. posted by Sydney on
11/30/2002 07:57:00 AM
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Friday, November 29, 2002
Songs of our Fathers: I've posted a review of songs the Pilgrims sang at Blog Critics. I know it's a little late for Thanksgiving, but better late than never. posted by Sydney on
11/29/2002 05:24:00 PM
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Alternative Medicine Update:Newsweek's cover story this week is devoted to alternative medicine. It was overshadowed by the Saudi money trail scoop that appeared in the same issue, but it isn't too badly done. It concentrates on alternative therapies that actually have some use, such as acupuncture and biofeedback. My biggest quibble is that it pains traditional medicine as cold and uncaring, while assuming that “alternative medicine” is the opposite:
What draws people to CAM and integrative medicine is not a desire for efficiency but a longing to be cared for.
Then, they use as an example an oncologist who incorporates meditation classes into his practice:
Harris thought the doctor was planning to make pasta when he arrived at the meditation class bearing an assortment of metal and crystal bowls. The bowls were in fact musical instruments from Egypt and Tibet. As Gaynor tapped them with a wooden mallet, Harris says she felt the music “washing through every cell in my body”—a fair description considering that water (which makes up 70 percent of our mass) is a perfect medium for sound waves. The words of the other doctors—”incurable,” “medically untreatable,” “nine months if you’re lucky”—were still echoing oppressively in Harris’s head. But meditation helped her quiet them and summon her dad’s old refrain: “We’re survivors; we don’t give up.” Within four months, she had changed her mind about chemo. With Gaynor’s encouragement and the support of her peers, she was able to approach it not as perdition but as “a wonderful gift.” She experienced what she now recalls as “a state of grace and healing.” Four years later, she’s as happy as she has ever been in her life.
Why is such care still the exception instead of the rule?
Maybe because fewer people are interested in watching their doctor beat a bunch of crystal and metal bowls than the article would have you believe. I’m glad things worked out well for Gaynor. She obviously wasn’t put off by the Tibetan music, but a lot of people would be. The true art of medicine is tailoring your approach to the beliefs and personalities of each individual patient. You don’t have to enlist Tibetan meditation practices to do that, and in fact using them across the board would alienate a good many.
Pediatric Alternatives: The same issue also dealt with the use of alternative medicine in children, which is something you don’t read much about in the popular media. This one was particularly well-done, with the right note of caution about side effects and safety and the untested nature of many treatments. It, too, focused on harmless and often effective techniques like biofeedback, diet, and acupuncture. It’s not on the website, but the print issue had a prominent photograph of a teenage boy getting cupped for low back pain. Cupping involves heating up a glass bowl and applying it to the skin to create a vaccum that pulls on the skin. It can leave the back marked with burns and hickeys. There’s also no reason to think that it would be effective for back pain, except in its ability to distract you from it. My other concern is that a teenager with chronic back pain should have a thorough work-up for treatable causes before going to alternative methods. Chronic back pain in kids is unusual and warrants more aggressive investigation than it does in the middle-aged.
Then, there was the reference to chamomile tea, which made me smile and think of Peter Rabbit:
I am sorry to say that Peter was not very well during the evening. His mother put him to bed, and made some chamomile tea; and she gave a dose of it to Peter! "One tablespoon to be taken at bedtime." posted by Sydney on
11/29/2002 09:12:00 AM
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"We have shown that music recruits neural systems of reward and emotion similar to those known to respond specifically to biologically relevant stimuli, such as food and sex, and those artificially activated by drugs of abuse," Zatorre concluded in his published paper. "This is quite remarkable, because music is neither strictly necessary for biological survival or reproduction, nor is it a pharmacological substance."
Radical Medico: The Pakistani doctor who says Bin Laden is in good health, and who paints himself as a humanitarian who treats all comers, has a shadier past than he lets on:
Pakistani intelligence agencies say that Aziz has been involved in radical Islamic politics since his student days in Lahore. He was also a regular visitor to Raiwind, a center near Lahore which gathers millions of Muslims from across the world for religious training. He was arrested two days before the annual Raiwind gathering.
He's also known for his work among Islamic radicals in Kosovo, Kashmir, and Afghanistan. He certainly gets around, doesn't he? Hope he isn't trained in face transplants. posted by Sydney on
11/29/2002 08:22:00 AM
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Putting on a Good Face:Face transplants may be closer than we think:
According to medical journal Lancet, a face transplant can be carried out by extracting the face of a donor, by removing the skin, subcutaneous fat, arteries and veins within a few hours of death.
At the same operating theatre, another team of surgeons would prepare the recipient, by cutting away any scarred tissue from the face.
The implications are mind-boggling. You could easily imagine well-financed morally bankrupt people killing and stealing a face to change their identities, but it’s hard to imagine anyone else feeling comfortable with the face of a dead person. posted by Sydney on
11/29/2002 08:21:00 AM
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Bad Science, Bad Law: McDonald's isn't the only victim of the trend for the overweight to blame anyone but themselves for their dietary indiscretions. Even before the McDonald's cases, a snack food maker was sued sued for making a fattening snack:
If it's true that misery loves company, the Golden Arches should be cheered about the $50-million suit that free-lance journalist Meredith Berkman, 37, launched earlier this year against Robert's American Gourmet Food, makers of the snack food Pirate's Booty, for ruining her diet. Researchers at the Good Housekeeping Institute found that the addictive (pardon the editorializing) corn puffs contained three times the fat listed on the label, and this inaccurate information, claimed Ms. Berkman, caused weight gain and emotional distress. Other snackers in a separate class-action suit agreed to a settlement requiring American Gourmet Food to distribute $3.5 million in product coupons.
I thought this must be a joke. But it isn’t. And I thought it must really be over the mislabeling of the food, but the woman's argument isn’t that the higher fat content made her or her family have higher cholesterol levels. She really is blaming the fat content for her weight gain:
The suit, couched in ironic language, claims damages for all those who have put on weight or had to spend longer at the gym.
But “fat content” has nothing to do with caloric content. If the calories had changed on the label, then she would have a case. Please tell me, though, that the bit about other class-action litigants settling for coupons from the company is a joke. posted by Sydney on
11/29/2002 08:14:00 AM
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From the Land of Fruits and Nuts: A study published this week in JAMA suggests that nuts prevent diabetes:
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Women who reported eating the equivalent of a handful of nuts or one tablespoon of peanut butter at least five times a week were more than 20 percent less likely to develop adult-onset, or type 2, diabetes than those who rarely or never ate those products.
Of the 28,989 women who never or almost never ate nuts, 1,314 developed diabetes. That’s 4%. Of the 4,314 women who ate nuts five or more times a week, 115 developed diabetes. That’s 3%. Hey! That’s practically the same proportion. Looks like nuts aren’t all they’re cracked up to be. posted by Sydney on
11/28/2002 01:49:00 AM
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Over The Counter: Claritin, the popular allergy drug, is finally going over the counter. This would seem to be good from a patient standpoint. Now you can buy a non-sedating allergy medication without a visit to the doctor. But, it has its down side as well. Insurance companies won't pay for it, and they'll encourage people to use it in place of other, covered, prescription allergy medications:
Robert Seidman, chief pharmacy officer at WellPoint Health Networks Inc., of Thousand Oaks, Calif., said that patients with his company would indeed be induced to buy Claritin. He said the company would cover more expensive prescription alternatives only when patients had side effects with Claritin, or if the medicine failed to help them.
It's a curious thing, but medication that seems to work quite well, suddenly stops being effective when it becomes over the counter. I saw this happen to Monistat, the anti-fungal cream for yeast infections. Before it went over the counter, it was the treatment of choice and patients rarely complained that it didn't work. Once it became over the counter, patients began to claim it didn't work for them. The same with Zantac. Before it was over the counter, it was very effective for ulcers and gastritis. Now, even the higher dose prescription version of it doesn't seem to be effective.
In the case of Monistat, I used to think that patients just wanted the medication that would be covered by insurance - i.e. the prescription variety. But now that I've seen the same thing happen to Zantac, I have to wonder if there isn't some sort of reverse placebo effect going on here; that there's an suspicion that over-the-counter medication is less potent than prescription medicine which influences its subjective effectiveness.
We'll see what happens with over-the-counter Claritin. Ten to one there will be a sharp increase in people who find it no longer works so well for them.
UPDATE: A reader sent along this Canadian (where they have more over-the-counter options than the US) about easily availability and efficacy:
Claritin has been available over the counter here in Canada for quite a long time (more than a decade, IIRC). A quick Web search showed that Canadian OTC Claritin is identical to American perscription Claritin (loratadine 10 mg); indeed, there's an e-company (www.only-in-canada.com) that is buying Canadian Claritin and reselling it to Americans (for a small markup, of course). Is it that much easier to take medications like Claritin OTC in Canada than it is in the U.S. (regulations/market demand/whatever)? [ed. note - Yes, it is.]
FWIW, I have hay fever (partially controlled by an annual course of Pollinex R), and I've found that Claritin doesn't really work to control my residual symptoms. I'd claim this is because it's OTC instead of persciption :-) , except that another non-drowsy antihistamine called Reactine (cetirizine hydrochloride 10 mg, sold by Pfizer) does work for me--and Reactine is also OTC in Canada.
Bioterror Preparedness Update: The CDC is putting together a video conference on smallpox preparedness, but it doesn't seem to be getting much publicity outside the public health field. Although the course description says it's also meant for primary care physicians, I've yet to hear any announcements about it, and it's slated to take place in only a week. This is a good step, though, in the right direction. The web page says that CD-ROM versions and video tapes will be available, too, so perhaps we'll see some of that distrubuted and used to educate those of us on the front lines. posted by Sydney on
11/28/2002 12:55:00 AM
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Food for Thought: Some things to chew on as you prepare for tomorrow's feast. The New York Times has an interview with a chemist who writes about food. I've never read any of Dr. Wolke's work, but there is a book that sits on my cookbook shelf about the science of cooking, On Food and Cooking by Harold McGee, which is an excellent resource for the biology, the chemistry, the physics, and the history of food and cooking. And speaking of the history and science of food, here’s the story behind that perennial Thanksgiving favorite, green bean casserole. posted by Sydney on
11/27/2002 08:24:00 AM
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D'em Old Bones: The FDA has approved a new drug for osteoporosis. It stimulates new bone formation, but it comes with a hefty warning:
FDA officials said the drug, given by injection daily, will carry a special warning because in laboratory tests teriparatide caused cancerous bone tumors in rats. Such tumors have not been seen in 2,000 people who tested the drug in clinical trials, officials said.
The clinical trials involved about 2,000 men and women who took the drug for 19 months. The rat findings still give me pause. posted by Sydney on
11/27/2002 07:53:00 AM
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The Real World:ViewFromTheHeart has a link to a description of what happens when you go to the dentist office without insurance, as well as a host of other great posts - from why you should never antagonize a nurse to the drawbacks of automated chest compression devices. posted by Sydney on
11/27/2002 07:30:00 AM
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Genetic Revolution: Derek Lowe dissects Craig Venter's latest genetic efforts, and the cloned baby is supposedly due in January.
UPDATE: CNN points out a discrepancy in the cloned baby claims:
In April, Antinori claimed that he knew of three pregnancies -- then in the ninth, seventh and sixth weeks of development -- involving cloned babies. He said on Tuesday that the oldest of these was about to be born.
However, according to his statement in April, the longest pregnancy would have passed nine months in mid-November. Antinori would not explain the discrepancy on Tuesday. posted by Sydney on
11/27/2002 07:29:00 AM
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Carping: Iain Murray takes down Adam Clymer's account of claims that political motives are behind some recent changes at the NIH website. The most vocal Congressional critic of the changes had this to say about the removal of some condom information and abortion/breast cancer links:
"We're concerned that their decisions are being driven by ideology and not science, particularly those who want to stop sex education. It appears that those who want to urge abstinence-only as a policy, whether it's effective or not, don't want to suggest that other programs work, too."
I’m concerned that Mr. Waxman and the politcial activists egging him on are driven by ideology and not science, particularly those who want to stop abstinence education. It appears that those who want to urge sex-education-only as a policy, whether it's effective or not, don't want to suggest that other programs work, too. posted by Sydney on
11/27/2002 07:24:00 AM
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Tuesday, November 26, 2002
Bioterror Preparedness Update: Instapundit says his state seems to be prepared, and it looks like the Administration is finalizing their plans for smallpox vaccination. posted by Sydney on
11/26/2002 11:25:00 PM
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Trust: Ross at The Bloviator sent these comments on patients and trust:
I disagree with you. I think these poll results have everything to do with the Tuskeegee Incident - which was all about medical professionals conscientiously setting forth to conduct experiments on blacks without their knowledge and consent - and nothing to do with "To Err is Human," which largely had to do with inadvertent and/or systems mistakes that occur during efforts to provide treatment to patients.
Could you expound a bit on why you dismiss Tuskeegee as a central facet of black distrust of medicine, but are so quick to shoulder the Institute of Medicine with the blame? If you were to poll blacks across the nation, do you honestly think that more of them would have familiarity with "To Err is Human" & a report on racism in medicine or the Tuskeegee Incident?
See, for example, this op/ed from last month on the black artificial heart recipient. His beliefs may have been flawed or unfounded, but they were not shaped by studies on wrong-side surgery and medication errors.
I fear that, given your interest in discrediting the publications by the Institute of Medicine, this may be a case of having a particular hammer, and seeing these survey results as a particular kind of nail.
I admit that black America isn’t my social milieu, so I can’t say with any certainty how strongly the Tuskeegee incident colors the community’s views on physicians. The bit about the father of American gynecology and experiments on women slaves mentioned in the editorial he links to is unfortunately true. But, the "To Err is Human" reports and the report on racism have both been in the news a lot more lately than the Tuskeegee incidents, and people tend to remember most what they've recently heard a lot about. I also doubt that the Tuskeegee experiments have much to do with the white sentiments, which were also strongly mistrustful of doctors. (And for the record, I’m not out to “discredit” the publications of the Institute of Medicine. Only those that are based on poor statistics and faulty reasoning. In fact, I spoke favorably of their report on the health care system last week.)
Nick Schulz sent along some ideas on the trust issue, though, that are extremely pertinent and right on the money:
Our healthcare system is so totally confusing and transparency is so difficult that it makes it almost impossible for people to feel that the system is trustworthy - and that suspicion extends (unfairly or not) to doctors. Is my doctor prescribing this because I need it? How much does he get out of this? Is this procedure really necessary? Does my insurance company think it's necessary? Does the federal government? Will this procedure be approved by my insurance provider? How do I weigh all these things against what I believe I need to be healthy and well?
A huge trust builder is transparency (same goes for, say, financial markets). As the layers of bureaucracy pile up, it makes transparency difficult. This - more than anything else like, say, cost - was what doomed Hillarycare. I can't overstate how much people crave simplicity - I bet they'd even be willing to pay more for it.
In truth, this probably has more to do with the issue of trust than either the Tuskeegee experiments or the IOM reports on errors and racism. posted by Sydney on
11/26/2002 11:05:00 PM
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Basic Mistrust: This is a sad commentary on the state of US healthcare. According to a recent poll, most patients don't trust thier doctors:
They found that 63 percent of the African Americans and 38 percent of whites surveyed believed doctors often prescribe medication as a way of experimenting on people without their knowledge.
One-quarter of blacks and 8 percent of whites thought their doctors had given them treatment at some time as part of an experiment without their permission.
I've had patients insinuate something like that when we have to go through a few different blood pressure medications to find the right one for them. I don't hear that as much now that I reinforce at every visit that this is a trial and error approach, but it's the only approach we have.
Still, the lack of trust found in the survey is disturbing. Trust is the cornerstone of any doctor-patient relationship. A patient who doesn't trust his doctor is never likely to do well. No trust means poorer compliance with medication and less willingness to be forthcoming when giving a history. Perhaps the Tuskegee experiments had something to do with it, but those were so long ago, I doubt it. Could the flawed, sensationalized reports like those on errors in medicine and racism in medicine put out by the Institute of Medicine have something to do with this? Most definitely. Ideas have consequences. Even those based on falsehoods. posted by Sydney on
11/26/2002 08:20:00 AM
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Celebrity Medical Watch: Actor Stephen Furst, who played Flounder in Animal House, has written a book, Confessions of a Couch Potato, about obesity that has some useful insights on its cause and treatment:
"I sat, I ate, I grew," he writes in the book. "I felt different from everyone else - like an alien. The looks I received when I was 320 pounds were ones usually reserved for three-eyed monsters, half-man half-woman reptiles, creatures with hideous rolls of skin that sweated profusely and giggled when they walked. That last one really was me."
...He describes himself as a food addict. "My bourbon is bonbons, my martini is manicotti (with extra cheese). Forget cocaine; bring on the Cocoa Puffs. Actually, when I was a child I used to eat sugar Frosted Flakes with chocolate milk, but I digest, I mean digress."
He was diagnosed with diabetes, and when he began developing limb-threatening complications, decided to make some major life changes:
The actor met with a dietitian, and much of what he learned was "common sense," he says. "You can eat a lot more vegetables than you can cotton candy. Bring on the veggies. Stay away from the fluffy carbs."
He figured out ways to cut fat and control carbohydrates. He revamped his cooking style. He made lots of soups, and when he was on the road and hungry, he drank coffee.
Furst lost about two pounds a week for a year. "One of the key things I did to stay on my diet is I never allowed myself to get hungry. As soon as I got hungry, I'd eat healthy foods."
At first he couldn't exercise at all, but he took the batteries out of his remote control and started walking over to change the channels on the TV. And he'd go upstairs to get things he needed instead of sending his children.
Later, he began doing yard work and started with 10 minutes on the StairMaster. Now, he goes to the gym three times a week and does the StairMaster for 20 to 30 minutes and lifts weights on machines for 20 minutes or so. On the other days, he takes extra long walks with his dog.
Potions Bought: More on the nefarious marketing techniques of pharmaceutical companies. This time, for neurontin, an anti-seizure drug that is gaining in popularity for a lot of other unapproved uses:
Even though the Food and Drug Administration has approved it only as an add-on drug for epilepsy and for shingles pain, more than 80 percent of prescriptions for it are written for bipolar illness, anxiety, posttraumatic stress disorder, all kinds of pain, insomnia, restless leg syndrome, hot flashes, migraines, and tension headaches.
Using a drug for unapproved conditions isn’t necessarily a bad thing, as the article points out:
This freedom to prescribe drugs for unapproved uses is a cornerstone of medicine, physicians said, a form of experimentation that has led to many important discoveries. And in the end, that could be true in the case of Neurontin, where evidence is building that the drug helps ease some patients' excruciating neuropathic pain, physicians said. Henry Esterman of West Roxbury, who took it for nerve pain in his lower back related to diabetes, said he was ''very grateful for it. The pain was unbearable, and nothing else touched it.''
I’ve used the drug with success for diabetic nerve damage, too, and would hate to lose the opportunity to use other drugs in similar ways. But, the use for diabetic pain is based on the theory that the nerve problem is similar to the process involved in shingles, so it’s really an expansion of an already approved use, and based on sound theory, if not on evidence. The danger comes when the companies abuse the system and hype their drugs for uses that don’t have any basis beyond wild speculation:
Beginning in August 1994, the company recruited hundreds of physicians, particularly those who prescribed competing drugs to patients, to participate in teleconferences about Neurontin. The company also targeted continuing medical education courses for doctors and hired Medical Education Systems in Philadelphia in 1997 to draft a series of 12 scientific articles on anticonvulsant therapy, including expanded uses, monotherapy, bipolar disorder, and migraine.
Why should drug companies have access to the prescribing habits of physicians? They shouldn't. And the sad fact is that a lot of doctors don't realize they've been targeted in this way. If they did, they wouldn't be as receptive to those sales pitches.
Medical Education Systems contacted faculty members considered authorities in their field and chosen by Parke-Davis, and paid them $1,000 each to author the articles. The Globe could not determine whether all 12 articles were published, but some were, including articles on gabapentin's role in the treatment of pain, mania, and mood and anxiety disorders. At least three of the articles gave no hint to readers that Parke-Davis had paid for them, and even had a hand in reviewing drafts - the sort of disclosure many scholarly journals routinely require.
On June 20, 1997, Medical Education Systems senior editor Mary Anderson wrote to Allen Crook, Parke-Davis product segment manager, about one of these articles, a discussion of the role of gabapentin and another drug in the treatment of mood and anxiety disorders. ''Please make any comments directly on the manuscript and return it to me,'' she directed.
The company is obviously holding way too much sway in these supposedly objective reviews. With this sort of system, only the positives get accentuated, to the benefit of the company and the detriment of everyone else:
''Its share of the market, its sales, really exceed its efficacy,'' said Dr. Jerrold Rosenbaum, Mass. General's chief of psychiatry. ''The question is, was the company denying investigators access to negative data when they asked for it?''
Health Unbought: The health insurance crisis buzz is on the ascendant in the media. It’s everywhere you look now that the election is over. The New York Times had a detailed account of the ways in which it’s affecting the middle class. (You always know that a big political push for something is gearing up when the press describes a crisis as reaching the “middle class”.) The article is about as good an argument as any for divorcing health insurance from employment. One of the families they profile makes $75,000 a year, but because the husband's employer doesn't offer health insurance, they can't get affordable coverage. A self-employed couple had to give up healthcare benefits for their employees and themselves when they became unaffordable, and another woman died of a heart attack because she was afraid of the cost of calling 911 without insurance. She had lost her job and not signed up for COBRA coverage.
As South Knox Bubba has argued before, linking our healthcare insurance to employment is one of the key problems with our system. It’s very difficult to find an insurance company that will offer an individual policy. They’d rather negotiate with businesses, and the bigger the better. In fact, their risk pools are the businesses, rather than general population. One of my patients, a union rep, recently told me how difficult it is for his company to find affordable healthcare insurance. He represents about fifty workers at a small manufacturing plant. They have several people who are in their late fifties, and a couple of people who had some serious health problems this past year - cancer, heart attacks, etc. Because of those sicker employees, they had trouble finding affordable health insurance for the entire company. They ended up settling for one with fewer benefits than they would have liked. It’s no wonder that companies are loathe to hire older workers. They make their health insurance risk pools worse.
I’ve said this before, but I’ll say it again. A better system would be one similar to car insurance, home owner insurance, and life insurance. Policies should be individual, the risk pools should be the general population, and insurance should kick in only after a certain amount of costs have been exceeded. Then, companies wouldn’t be taking on so much financial risk by hiring older workers, people wouldn’t have to worry about losing their insurance when they lose their jobs, and employers would be more willing to hire the disabled or welcome back the injured. Even more importantly, it would give the self-employed a fighting chance to obtain insurance.
Health Bought: There was something else in that New York Times piece that was very disturbing. It’s the description of how one of the families felt when they had to go to the doctor without insurance coverage:
Then their daughter came down with strep throat. "That was rather humiliating, being in the doctor's office without insurance," Ms. MacPherson said. "You become very obvious to everyone."
This is from the family that has a $75,000 a year income. Surely, they could afford the $50 to $70 office visit for strep throat and the ten dollars for penicillin. But it isn’t the cost she’s talking about, it’s the shame. Why should anyone feel ashamed for not having insurance? Yet, I know what she means. The first question out of any receptionist’s mouth at a physician’s office is, “What type of insurance do you have?” It’s asked so often that people have come to believe that insurance coverage is a requirement for a visit to the doctor. A negative answer is heard so rarely, that the receptionist is likely to raise her eyebrows if the answer is “none.” I’ve often been vaguely aware of this sense of shame in patient’s I’ve seen without insurance coverage. I experienced it myself when I opted to go to an urgent care without my HMO’s permission and told them I was paying cash. We’ve come to think of complete and full health insurance coverage as the norm. Anything less is a sign of failure.
Let me disabuse everyone of that notion right now. Doctors prefer cash-paying patients to insurance companies. For proof, consider this Mississippi doctor who dropped all insurance plans and began charging everyone a flat $40 fee:
Determined not to hang up his stethoscope, Dr. Todd Coulter is trying an experiment of his own. At his small family practice in Ocean Springs, he has also sworn off insurance and charges $40 dollars cash per visit.
"When we stopped taking insurance our overhead dropped immediately by $2,800 a month. Just dropped."
This is my fantasy. Cut out all the middle men and deal only with the patient. It doesn’t get more efficient than that. And consider this, the patient and the doctor have a relationship. If there are extenuating circumstances, the doctor can cut the patient some slack in the payments. This could work everywhere. Health insurance for the big expenses. Individual responsibility for the small ones. It would be more humane than our current system.
(Thanks to Jim Miller for pointing me to the Mississippi doctor. DB also has more on this, and on the insurance crisis in general.) posted by Sydney on
11/26/2002 07:30:00 AM
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The Debate Continues: The Washington Post had an op/ed that suggested experimenting with gradual health insurance reform by leaving it up to the states, with the help of federal grants. It was followed up with a very interesting online discussion, too.
And More Debate: A reader in the healthcare business sent along an account of his more favorable experiences with Medicare:
I don't think you need to worry about an immediate career in sales, however, while I am not sure of the nature of your practice I certainly do not find Medicare any more cumbersome, if as cumbersome, as the number of private insurers/HMOs with which we deal. I am the executive director of a free standing non- profit Mental Health agency that provides a very comprehensive range of emergency psychiatric services--we employ 120 persons (eight physicians), operate an inpatient unit, provide 24/7 out patient services, see 6500 persons per year and admit 140 persons per month to our inpatient unit. I have a strong hunch our billing staff would prefer the simplicity of Medicaid and Medicare over the problems presented by private insurers--varying rate schedules, pre-approval/authorization requirements, (particularly a night mare in emergency services), inaccessible 1-800 numbers, retrospective denials, differing limits on service, concurrent approvals, changing panels, on going rate negotiations, etc. One of our local hospitals has recently limited (for all practical purposes) psych admissions to Medicaid (child and adolescent therefore does not receive Medicare) as the current rate structure of the two largest HMOs in town only reimburses about 30-40% on the dollar for services provided(coincidentally the two HMOs are owned by the two largest Hospital Systems which does not include this hospital). While federal/state insurance plans certainly have problems ( as I can attest since we recently had a comprehensive Medicaid audit--with findings) the sheer volume of services and the standardization of eligible services and rates makes it quite easy to do volume billing and financial planning--the debate goes on.
The key difference between us is the difference between primary care and psychiatry. Health insurance companies are notoriously bad about paying for mental health services. They dicker and dicker and do everything they can to avoid paying for it. In primary care, it’s a cardinal law of coding that you never assign a psychiatric diagnosis code to an office visit, at least not if you want to get paid. You use codes for the symptoms - insomnia, fatigue, chest pain, palpitations, anything but anxiety or depression if you can avoid it. Psychiatrists and psychologists don’t have that luxury. Medicare and Medicaid, on the other hand, are better at paying for mental health.
It’s true that a single-payer system would mean a less complicated system. There would only be one entity to deal with rather than a multitude, but that’s about the only advantage. That one entity would use its clout to set prices. Even worse, it will almost certainly try to micromanage patient care, too, as Medicare and Medicaid and insurance companies, too, already do.
Something Completely Different: Just because I've always liked the legend of Johnny Appleseed. (Turns out the truth’s even better.) Added bonus: click here to buy a descendant of one of his trees. posted by Sydney on
11/25/2002 08:30:00 AM
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Single Payer Fallacy: Jonathon Cohn repeats the misconception that Medicare is popular with doctors in his argument for a single payer healthcare system. (This same myth was put forward in a New York Times op/ed a while back):
Medicare has a large bureaucracy, but most physicians today will tell you it's a more reliable payer--and a less onerous overseer--than private managed care companies. Indeed, far from true "socialism," Medicare allows doctors and hospitals to remain privately employed.
Medicare is very much more onerous than most insurance companies. In fact, insurance companies take their cues from Medicare. All that's wrong with insurance reimbursements and oversight was borrowed by the insurance industry from Medicare. The coding system for physician reimbursement is complex and confusing. They bicker about diagnosis codes for everything from lab tests to office visits and surgical procedures.
They accuse physicians and hospitals of fraud and impose stiff financial penalties when what's really at issue is a disagreement with the interpretation of their byzantine office visit codes or hospital stay codes. They reimburse at a very low rate, which is why you read about doctors giving up Medicare to avoid going bankrupt.
The day that a Medicare system becomes the only system is the day I’ll seriously consider giving up medicine. I'd rather work in retail than work under a system like that. posted by Sydney on
11/25/2002 08:18:00 AM
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Wonderful Eponyms: A bacteria named Wigglesworthia has had its genome mapped. Its name comes from an entomologist named Wigglesworth. Could there be any better name for an entomologist? posted by Sydney on
11/25/2002 08:15:00 AM
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Blame the Parents: The New York Times ran an op-ed about the fast-food lawsuits this weekend, called Don't Blame the Eater. The writer used his own experience as a latch-key kid to defend their fast food choices:
I tend to sympathize with these portly fast-food patrons, though. Maybe that's because I used to be one of them.
I grew up as a typical mid-1980's latchkey kid. My parents were split up, my dad off trying to rebuild his life, my mom working long hours to make the monthly bills. Lunch and dinner, for me, was a daily choice between McDonald's, Taco Bell, Kentucky Fried Chicken or Pizza Hut. Then as now, these were the only available options for an American kid to get an affordable meal. By age 15, I had packed 212 pounds of torpid teenage tallow on my once lanky 5-foot-10 frame.
Well, I grew up as a typical late-1970’s latchkey kid, but my mother would have punished me severely if I left the house on my own and went to fast food restaurants by myself. Why couldn't his mother leave food in the house for him? And for the record, I was a portly teen, too, but it wasn’t because I was eating a lot of fast food. In fact, I’m still a portly person, but I don't have any sympathy for those who blame others for their own poor choices, or the bad choices of their parents. posted by Sydney on
11/25/2002 08:05:00 AM
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Doctor Evolution:The New Republic has an interesting article on the reformation of residency training. The author is an internal medicine resident at Massachusetts General, but his article concentrates mostly on the cowboys of medicine, the surgeons. They aren’t too happy with the idea of reform:
That fact--that unflappable, recalcitrant individualism and the willful internalization of responsibility that comes with it--was reiterated to me again and again by residents. Most residents in Derek's position couldn't imagine transferring the task to another doctor in the middle of the night. In mid-June, when Ferguson convened a meeting with the resident surgeons at MGH to talk about the reduced work hours, he half-expected them to be overjoyed about the cuts. Instead, he said triumphantly, "Many of them were just indignant." Residents complained bitterly about work hours, but, when push came to shove, they could not bring themselves to pass off work to others. In other words, at least part of the reason for the work-hour crisis actually lay in the culture of medicine itself--a culture that had evolved for nearly 100 years.
New York has had limitations on residency hours for over ten years now. I did my residency training there, the first year that they implemented them, and I honestly can’t say it was detrimental to my education. When we were on call, we went home the next morning after we had finished rounding on our patients. We worked in teamsr, and signed our patients over to the person who was on call for that day. After a while, we were all pretty familiar with one another’s patients. The number of patients we could be responsible for was limited to fifteen, and the number of admissions in one night were limited to six. It was a humane system, and it didn't deprive me of the privilege of learning to think well while fatigued.
Most of us rarely spent more than 28 hours at the hospital. Senior residents told me that before that, they used to be in the hospital for well over thirty-six hours trying to get their work done. Everyone was pretty pleased with it - except the surgical residents. They were always complaining that it deprived them of needed cases and experience. Looks like things are no different in Massachusetts. posted by Sydney on
11/25/2002 07:42:00 AM
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Sunday, November 24, 2002
Smallpox Vaccine Update: The Washington Post headline says that Bush is leaning to limiting smallpox vaccine to healthcare workers and the military, but the article makes it sound as if the door is still open:
Bush will most likely put off deciding the most sensitive question of whether the vaccine will be made available to all Americans, the officials said. Bush aides have concluded there is no reason to make such a commitment yet, preferring to use the time while more vaccines are licensed to gauge how to predict and control side effects as the inoculation is given to troops, health care workers and emergency responders.
...In a gesture to those who favor broader distribution, administration officials are discussing a mechanism to make the vaccine available in limited quantity to those who actively seek it. "There is some discussion of making it available to people who feel they absolutely have to have it," a senior Bush aide said. "The question is, can the government just hold on to a stockpile?" The likeliest mechanism in such cases would be expanded participation in experimental programs.
It would seem that the Administration is moving towards a plan to proceed with caution, and it makes sense to allow people to have the vaccine if they really want it, rather than to deny them that opportunity. Especially when you consider this:
The Israeli government this week reported that it had administered the vaccine to 12,000 people with only four known cases of relatively mild side effects. Further, an intelligence review concluded that Iraq and North Korea have the pathogen and that al Qaeda has been pursuing it.
