Commentary on medical news by a practicing physician.

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    "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.

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    Friday, May 23, 2003

    Developments: Michael Fumento explains how vaccines get made, and why predictions for a SARS vaccine in the near future are wildly optimistic.

    posted by Sydney on 5/23/2003 08:34:00 AM 0 comments

    Alien Attacks: A scientist in England thinks that the SARS virus may have come from outerspace:

    Chandra Wickramasinghe, director of the Cardiff Centre for Astrobiology in Britain, has put forward in the past the theory that disastrous influenza outbreaks and even bovine spongiform encephalopathy (also known as mad-cow disease) may have originated in space.

    In a letter to the British medical journal The Lancet, he says there is enough evidence to suggest that SARS fell to earth. Chinese authorities have reported that the seven people in the province of Guangdong who were the first to be infected with the virus had no contact with each other. Dr. Wickramasinghe says that the Chinese government has also been unable to document how a large number of SARS patients got the disease.

    "This leaves open the question of where the virus came from," Dr. Wickramasinghe said in an interview yesterday, adding that most microbiologists and virologists will dispute his claim that SARS fell from the sky.

    Although the "Cardiff Center for Astrobiology" calls forth unfortuante mental associations with the Cardiff Giant, Dr. Wickramsinghe’s letter (requires free registration) isn’t entirely wacky:

    We detected large quantities of viable microorganisms in samples of stratospheric air at an altitude of 41 km.1,2 We collected the samples in specially designed sterile cryosamplers carried aboard a balloon launched from the Indian Space Research Organisation/ Tata Institute Balloon Facility in Hyderabad, India, on Jan 21, 2001. Although the recovered biomaterial contained many microorganisms, as assessed with standard microbiological tests, we were able to culture only two types; both similar to known terrestrial species.2 Our findings lend support to the view that microbial material falling from space is, in a Darwinian sense, highly evolved, with an evolutionary history closely related to life that exists on Earth.

    We estimate that a tonne of bacterial material falls to Earth from space daily, which translates into some 1019 bacteria, or 20 000 bacteria per square metre of the Earth's surface. Most of this material simply adds to the unculturable or uncultured microbial flora present on Earth.....

    ...With respect to the SARS outbreak, a prima facie case for a possible space incidence can already be made. First, the virus is unexpectedly novel, and appeared without warning in mainland China. A small amount of the culprit virus introduced into the stratosphere could make a first tentative fall out East of the great mountain range of the Himalayas, where the stratosphere is thinnest, followed by sporadic deposits in neighbouring areas. If the virus is only minimally infective, as it seems to be, the subsequent course of its global progress will depend on stratospheric transport and mixing, leading to a fall out continuing seasonally over a few years.

    Addendum: My husband says this is wacky; that the microorganisms in the stratosphere get sucked up there from storms and water evaporation here on earth. He's got a point. After all, doesn't it sometimes rain fish?
    posted by Sydney on 5/23/2003 08:08:00 AM 0 comments

    Settlement: Aetna has settled the class action lawsuit brought against it by physicians for delaying payments and using market muscle to force unfavorable contracts:

    The settlement calls for Aetna to pay $100 million to doctors, an average of about $142 each, as well as $20 million to establish a foundation aimed at reducing medical errors, childhood obesity, and racial disparities in treatment. Aetna also would pay up to $50 million in plaintiffs' legal fees.

    Physicians also would gain an estimated $300 million over several years from the changes Aetna has agreed to make in systems to speed up payments to doctors and eliminate cuts to reimbursements that may have been made under the previous systems.

    Looks like Aetna can afford it:

    The company reported a $330 million net profit in this year's first quarter.

    I'm always a little stunned by those enormous health insurance profits. When you consider that the service they provide is taking the consumer's money and using it to pay a group of people's medical bills, the fact that they've got so much left over at the end of the day means that most people are giving to insurance companies far in excess of their healthcare needs. That might be understandable if people were paying to insure against a catastrophe. Catastrophes are infrequent but devastating when they happen. And companies who insure against catastrophe are taking huge risks, and so perhaps justify a sizeable profit. But insurance companies like Aetna cover even mundane healthcare needs. Wouldn't the average person be better off just paying for their own day to day medical care and reserving insurance for medical catastrophe?
    posted by Sydney on 5/23/2003 07:51:00 AM 0 comments

    Practice vs. Science: The National Association of Scholars blog has a post discussing the difference between practioners and scientists. The subject is the difference between practicing psychologists and research psychologists, but the same can be said for physicians:

    Tavris assumes (correctly, for the most part) that "scientists and practitioners in psychology are distinct groups." No, says Sternberg, they are not: "Many psychologists properly view themselves as scientist-practitioners or as practitioner-scientists." But scientists and practitioners - whether medical or psychological - necessarily differ in their aims. The aim of the scientist is to understand; of the practitioner to cure. My doctor doesn't advise against "alternative" therapies, even though she doesn't believe in them, because they can't do any harm and they might help. She is happy to try anything that might work. But varying more than one thing at a time in a scientific experiment usually makes the results uninterpretable. Scientists therefore avoid the practice. The same individual may, as Sternberg suggests, be both scientist and practitioner - but not at the same time or with the same set of motives.

    It took me a long time to realize this difference, but it's quite true. When I first met my husband he deeply offended me by sneering at the idea that doctors were scientists. But I was a premed student then. By the end of medical school I knew he was right. The practice of medicine is based on science, to be sure, but there's a world of difference between the medical researcher and the medical practitioner.

    But the best part of the post is the point the author makes about the undue influence of scientific and professional organizations on public policy:

    The take-home message is just this. Policy makers cannot short circuit the process of deliberation on science-based issues by listening to scientific organizations. Organizations, even scientific ones, exist for all sorts of reasons; scientific truth is only one of them. So when controversial issues with a scientific component are on the table - affirmative action, global warming, the death penalty, human cloning, whatever - our leaders would do well to downplay 'official' views. Let them listen to individual arguments and make up their own minds.

    posted by Sydney on 5/23/2003 07:35:00 AM 0 comments

    Thursday, May 22, 2003

    Death Knell: Assisted suicide, popular no more.

    posted by Sydney on 5/22/2003 08:43:00 AM 0 comments

    Media Responsibility: A British survey suggests that the media plays a disproportionate role in shaping public understanding of scientific developments - and that they don’t fulfill that role responsibly. Take, for example, the measles, mumps, rubella vaccine (MMR) which is much more controversial in Britain than it is here:

    Over half the British public wrongly believed that medical science was split down the middle about the safety of the MMR vaccine according to a new survey published today by the Economic and Social Research Council.

    Although almost all scientific experts rejected the claim of a link between MMR and autism, 53% of those surveyed at the height of the media coverage assumed that because both sides of the debate received equal media coverage, there must be equal evidence for each. Only 23% of the population were aware that the bulk of evidence favoured supporters of the vaccine....

    ... The study examined 561 media reports on MMR over a seven-month period. 56% of these stories were concentrated in one month between 28th January and 28th February 2002 - described by many scientists as a media 'feeding frenzy'. The focus of the story was the possible link between the MMR jab and autism, a fact mentioned in over two thirds of the articles. While the bulk of evidence showing that the vaccine is safe was used to balance the autism claims in half the television reports, only32% of the broadsheet press reported this. The report says:

    "Attempts to balance claim about the risks of the MMR jab tended merely to indicate that there were two competing bodies of evidence."

    The media does have an undue influence on our understanding of science. For most people, the popular media is the only source of information about scientific advances. None of us has the time to read all of the science journals out there. The sad thing is, the media shapes doctors’ perceptions of scientific advances, too. The zeitgeist is established in the papers and on the radio (NPR) and network news before doctors get a chance to digest the published work.

    Take for example, hormone replacement therapy. When the study published last year showing very small increases in incidence of breast cancer and heart disease in women on hormone therapy, many doctors in my community began unilaterally taking patients off their hormones in the belief that they were too dangerous to take. They did this even if their patients were taking it for legitimate reasons, such as hot flashes and osteoporosis prevention. The nuances of the study were ignored because everyone adopted the conventional wisdom as put out by the media.

    Science reporting benefits from the perception that because it's about science it must be accurate and true, unlike, say political reporting. But a reporters biases and misunderstandings can taint a science news story, too. And in many ways the subtleties of science are much more difficult to grasp and communicate than the subtleties of politics or other world events. But, that's why we have medical blogs now, right?
    posted by Sydney on 5/22/2003 08:18:00 AM 0 comments

    Mad Cow Madness: Iain Murray has a piece at NRO on the folly of Britain’s mad cow policies in the 1990’s, which ruined the nation’s beef industry and which were based on flawed estimates:

    As recently as November 2001, a leading researcher into the human toll of the disease estimated that somewhere near 100,000 people would die in Britain as a result of eating infected meat. The same researcher has just quietly released his latest estimates of the future death toll: the best estimate is 40 more deaths.

    What’s surprising is that the researchers mention in their new report that the number of cases of human mad-cow disease in Britain so far has only been 121. That's a far cry from 100,000.
    posted by Sydney on 5/22/2003 08:09:00 AM 0 comments

    Calories Out: Getting kids to lose weight may be as simple as turning off the television:

    The Stanford pediatrician has proved that limiting TV viewing to no more than two hours per day decreases weight gain for entire elementary school classes.

    Television watching is linked to adult obesity, too. So is sitting in front of a computer blogging.

    And then, there's this survey of teenage eating and exercising habits over the past twenty years:

    Researcher Lisa Sutherland of the University of North Carolina at Chapel Hill analyzed federal data on the diet, weight and physical activity of teens, ages 12 to 19. From 1980 to 2000, calories eaten rose 1 percent and obesity rose 10 percent, while physical activity dropped 13 percent.

    ... The study said that teenagers ate an average of 2,290 calories a day over the 20 years. It also said that while 42 percent of teens reported doing at least 30 minutes of physical activity on a typical day at the start of the study, only 29 percent did at the end.

    The study was funded by a grant from soft drink manufacturers, but that's no reason to sniff at the results. Especially if you're going to sniff at them this way:

    “We are pretty sure they are eating too much, no matter what the data say,” said Dr. Nancy Krebs of the University of Colorado Health Sciences Center in Denver, who chairs the pediatricians’ group’s committee on nutrition. “There is quite a consensus that it is due to a combination of factors.”

    Who needs data when you have consensus? Besides, the data doesn’t fit the current agenda:

    Accepting the conclusion that food is not a big part of the problem could take pressure off food companies to cut the calories they feed the nation, Hattner said.
           “There is enough clamor throughout the country that we are getting corporations to change,” Hattner said. “We need to continue that clamor.”

    But without exercise obesity will continue to rise regardless of what’s being eaten. (Unless the intake is at starvation levels.) As my partner likes to point out, a cow can get fat eating nothing but grass.
    posted by Sydney on 5/22/2003 08:06:00 AM 0 comments

    Wednesday, May 21, 2003

    Feed Me: The Wall Street Journal says we eat more because we’re being fed more (subscription required):

    A growing body of research shows that most people are blissfully unaware of how much food is being put in front of them, and they tend to eat whatever is on their plate or in a serving package. In studies using macaroni and cheese and submarine sandwiches, Pennsylvania State University researchers found adults ate at least 30% more calories when larger portions were put in front of them -- even though they generally were satisfied by the smaller portions.

    Package size makes a difference too. The same researchers found that women given a one-pound box of spaghetti to make a dinner for two removed an average of 234 strands. But if they were given a two-pound box and told to make the same dinner for two, they removed an average of 302 strands -- or 29% more. When frying chicken, women poured 3.5 ounces from a 16-ounce bottle of cooking oil, but used 23% more -- 4.3 ounces -- when they started with a 32-ounce bottle. Other studies of potato chips and chocolate candies show drastic increases in snacking when the subject is given a larger bag of food.

    Sounds as if we all have a collective memory of someone warning us not to waste that food because there are starving children in Africa. It's almost Jungian

    posted by Sydney on 5/21/2003 10:34:00 AM 0 comments

    Iraqi Medicine: Chuck Simmins says that things are going better in Iraq than you we're being led to believe. And observes that healthcare isn't as bad as one would expect in a war-devastated country:

    In Kirkuk, 13 of 16 primary health care centers and 46 of 56 health care facilities are now operational.

    Do you suppose it bothers the media that the Defense Department has a better reputation for truth telling than they do? Do you suppose they even realize it?
    posted by Sydney on 5/21/2003 10:23:00 AM 0 comments

    Amazing Bionics: One of my patients who has severe macular degeneration is going to get a miniature telescope implanted in his eye. He's very excited, even though the procedure is completely investigational and the risks are largely as yet unknown. Right now, he uses one of these. Not very aesthetically pleasing for a man who used to be a disco swinger.
    posted by Sydney on 5/21/2003 10:14:00 AM 0 comments

    Tick Advice: Had to remove a tick from my youngest son last night. It’s the first tick I’ve ever removed. I have to admit, my book learning left me in the face of a screaming six year old yelling hysterically, “Why me? Why me? Why me?” I turned to his older brothers who had just come back from a tick-infested boyscout camping trip ( and who probably imported the creature into their bedroom.) They suggested putting vaseline on it to “smother it”. Wrong. Thanks to Google, we did it the right way.

    Pulling them off isn’t as easy as it seems. They use fish-hook barbs to hang on tight. Turns out there are all sorts of instruments out there for pulling off a tick. There’s a tick lasso (neat), "German-engineered" tick tweezers, and the amazing tick-twister. But plain old tweezers work just as well.

    What I’m worried about is all of those bacteria that live in tick guts and get regurgitated into their victim’s blood stream, causing all manner of tick-borne diseases. Our tick was nice and flat, not bloated with blood, so my son’s exposure and disease risk is probably low.

    It wasn’t a deer tick, so we don’t have to worry about Lyme Disease. It wasn’t a black-legged tick, so we don’t have to worry about any of the Ehrlichioses. And it wasn’t a lone-star tick, so we don’t have to worry about STARI (Southern Tick-Associated Rash Illness). And unfortunately it wasn’t a blue tick.

    It was, however, a dog tick, which can carry Rickettsia rickettsii the organism that causes Rocky Mountain Spotted Fever, (aka “black measles”). It’s a much more serious disease than Lyme, especially in children, but fortunately, the incidence is low:

    Rickettsiae are transmitted to a vertebrate host through saliva while a tick is feeding. It usually takes several hours of attachment and feeding before the rickettsiae are transmitted to the host. The risk of exposure to a tick carrying R. rickettsii is low. In general, about 1%-3% of the tick population carries R. rickettsii, even in areas where the majority of human cases are reported.

    The incidence of all the other diseases is low, too, so there's no need to start antibiotics immediately after a tick bite. Just watch for signs and symptoms of an infection - a rash, fever, muscle aches, or any of the other symptoms listed in the links for the specific disease, and seek treatment if they develop.

    Ticks. Yuk.
    posted by Sydney on 5/21/2003 07:52:00 AM 2 comments

    Tuesday, May 20, 2003

    More SARS News: On the bright side, only sixteen people caught their SARS on an airplane:

    The World Health Organization says only 16 of the more than 7,800 people infected worldwide with SARS got the disease while aboard an airplane and that all those cases came before airlines began screening passengers for symptoms.....

    ....WHO medical experts in Geneva said all of the 16 cases of people contracting SARS while aboard a plane took place on four flights and before airlines adopted tough screening measures.

    "There were 35 flights on which SARS-infected people who were symptomatic with disease traveled," said Dr. David Heymann, WHO's chief of communicable diseases. "We know, however, that on only four of those planes was there actually passage of the disease."

    Of those, 14 were passengers sitting within four seats of the SARS patient and two were flight attendants, Ryan said....

    ....All 16 cases occurred before March 23, four days before the U.N. health agency recommended that airlines screen passengers for signs of SARS and advised that suspected cases not be allowed to travel.

    In other good news, the graph at the New England Journal of Medicine appears to show a decline in the rate of new SARS cases. (Scroll down past the article links. The slope of the line indicating new cases is less steep than it has been in previous weeks.) SARS could be seasonal, like other viruses, and this may just be the beginning of this year's end of the disease. If that's the case, we should be better prepared to deal with it next year when it recurs. Suspected patients can be isolated early and hospital staff can take appropriate respiratory precautions when dealing with suspected cases.

    posted by Sydney on 5/20/2003 08:26:00 AM 0 comments

    SARS Crackdown: The Chinese are getting tough on public spitting in an effort to curtail the SARS outbreak:

    Guangzhou - formerly known as Canton and the capital of Guangdong province where the Sars outbreak first appeared in November - has joined the campaign with a vengeance. About 1,000 public health workers have been sent out in teams to pounce on locals violating anti-spitting bye-laws.

    They have been given tough powers to fine miscreants 50 yuan - 10 times the usual rate and the equivalent of almost 4 pounds, which is a large sum in low-wage China. Other major cities are also said to be increasing fines. Citizens who drop cigarette butts, chewing gum or rubbish, or urinate in a public place, also face stiff fines.

    Well, at least they aren't executing them.
    posted by Sydney on 5/20/2003 08:21:00 AM 0 comments

    Price Busting: The pharmaceutical industry received a setback from the Supreme Court yesterday, which ruled that Maine can use its Medicaid program as a bargaining chip to force price discounts for all Maine residents:

    Under the Maine plan, drug makers would be asked to extend to other state residents the discounts they are required to give to Medicaid. If they refuse, the state would require doctors to get a prior authorization before prescribing their drugs for Medicaid recipients.

    Twenty other states are considering similar plans. It sounds like a good program, until you consider how low Medicaid discounts are. If the rate of reimbursement for drugs is anything like what it is for vaccines, then the drug companies are right to be alarmed. Last year, our practice gave $576 worth of the vaccine Prevnar to our Medicaid population. Our reimbursement was $26. We gave $300 worth of Comvax, a combination vaccine for Hib and Hepatits B. We were reimbursed $15.75. We gave $150 worth of DTaP. We were reimbursed $20.75. (Medicaid makes up only a small proportion of our practice. Our losses would have been a lot worse if we practiced in a more impoverished area.) Makes you feel sorry for the drug companies, doesn't it?
    posted by Sydney on 5/20/2003 07:42:00 AM 0 comments

    Mouths of Babes: My eleven-year-old son was reading the health section of the newspaper this morning, with headlines like "Summer means outdoor activity, jump in outdoor accidents. Doctor prescribes caution." and "Normal blood pressure no longer normal." After reading the articles he asked me, "Why do doctors make everything seem dangerous?" I didn't have a good answer.
    posted by Sydney on 5/20/2003 07:26:00 AM 0 comments

    Monday, May 19, 2003

    Genetic Modification: What will the Europeans think of this?

    posted by Sydney on 5/19/2003 08:01:00 AM 0 comments

    Therapuetics: Got a flyer in the mail the other day about therapeutic martial arts programs for kids with attention deficit disorder. I have no idea if it helps, but it makes sense that it would help. Martial arts puts a premium on training yourself to focus, after all.
    posted by Sydney on 5/19/2003 07:55:00 AM 0 comments

    Reform Rallies: Doctors around the nation were rallying for tort reform last week. They rallied in New Jersey and Illinois, and Florida where the tort reform issue did not pass because state legislators think doctors make too much money:

    Dr. Robert Cline, president of the Florida Medical Association and a Fort Lauderdale heart surgeon, said legislators were not swayed by doctors' testimonials that they can't afford the increased insurance rates.

    In Tallahassee, Cline said he heard lawmakers say doctors make lots of money and they should be able to handle the rate hikes. "Legislators are not listening to us any more," Cline said.

    But, as another doctor points out, without tort reform those high-risk specialists are likely to leave the state:

    "It's a free country," Himmelstein said. "No one is going to swim in a pool of sharks if they don't have to."
    posted by Sydney on 5/19/2003 07:49:00 AM 0 comments

    Tort Reform. Now!: More proof that trial lawyers are running amok. They're going after drug companies because their drugs have side effects. All drugs have potential side effects. The question is whether the side effects are worse than the disease.

    Cases like that involving the cholesterol-lowering drug Baycol may have some merit, but the Paxil case is silly. Paxil isn't addicting by any means, although some people do get a little dizzy when they discontinue it. The dizziness isn't permanent and it doesn't cause any long-standing damage. On the other hand, Paxil is a good drug for depression, obsessive compulsive disorder, and anxiety. And it has far fewer side effects than the older anti-depressants.

    But, then, it isn't really about protecting people from bad drugs. It's about the money:

    Medical trends aside, plaintiffs' lawyers acknowledge that much of the momentum behind the suits comes from the increasing aggressiveness and wealth of the trial bar. These days, the battle between drug companies and plaintiffs' lawyers is no longer one between corporate goliaths and individual advocates on a shoestring budget...

    ....Plaintiffs' lawyers can now finance enormously complicated suits that require years of pretrial work and substantial scientific expertise, in the hope of a multibillion-dollar payoff. Scores of firms collaborate on a case, with some responsible for finding claimants, others for managing the millions of documents that companies turn over, others for the written legal arguments, and still others for presenting the case to a jury. Some 60 firms have banded together, for example, in the Baycol litigation.

    They sound like the Borg. In fact, they are like the Borg. They’re devouring every profitable company in sight:

    In addition, the plaintiffs' bar has refined a technique in drug lawsuits that it has used effectively against many asbestos companies. Lawyers file a few cases with very sick plaintiffs in states and counties considered favorable to plaintiffs, while building big "inventories" of less seriously ill patients, or so-called pill-taker cases, even people who have used the drug but are not sick.

    If the lawyers can win large verdicts in the early cases, they then refuse to settle the claims of their other very sick clients unless the defendants also agree to pay the claims of people who are less sick. Under those circumstances, the companies face a difficult choice. If they go to trial in a case that includes a few seriously injured plaintiffs and hundreds more who are less affected, they risk losing hundreds of millions of dollars in a single case, frightening Wall Street and spurring more suits. But if they settle cases without a trial, they risk being perceived as an easy mark for lawyers.

    That’s one sure way of stifling innovation. Sue the pharmaceutical companies into bankruptcy or into paralysing fear. God save us from the lawyers.
    posted by Sydney on 5/19/2003 07:43:00 AM 0 comments

    Waiting Room Reading: While waiting for my children to have their hair cuts, I learned how to buy a SARS mask and what kind of mom I am:

    [51-75] Sergeant Mom
    As a Sergeant Mom, you take parenting very seriously. Discipline is your friend, and your household is run like a military operation — where actions and consequences go hand-in-hand.

    No wonder my kids sometimes respond to me with “Aye, Aye, Captain,” or “Yes, Sir!”
    posted by Sydney on 5/19/2003 07:39:00 AM 0 comments

    The Morning After: A study in last week's Canadian Journal of Medicine found that California women on Medicaid who had abortions had higher rates of psychiatric illnesses afterwards - specifically depression and adjustment disorders. It isn’t clear, though, that abortion is the cause. Although the authors controlled for previous psychiatric illness, it could be that there are other social factors that are responsible both for the subsequent depression and the abortion. Did the women who had abortions have less social support than women who delivered their babies? Meaner boyfriends (or spouses)? More financial strain? Hard to tell. But, in the long run, perhaps it doesn’t matter. Perhaps in those situations the decision to end a pregnancy isn’t the clear-cut cost/benefit analysis that most abortion proponents make it out to be. Perhaps, there are elments of coercion involved - both implicit and explicit. That’s a study I’d like to see - a survey of abortion clinic clients asking whether or not the abortion was their idea, or their boyfriend’s or parents’. That would tell us someting about the state of abortion in this country - and the amount of personal choice involved in it.
    posted by Sydney on 5/19/2003 07:34:00 AM 0 comments

    Sunday, May 18, 2003

    Stroke Sunday: Today is Stroke Sunday. (If you had gone to church this morning, you'd know that.) Or maybe you wouldn't. It isn't clear if this was a local outreach or a national one, but the American Heart Association has joined forces with Northeast Ohio churches to promote stroke awareness. (Apparently, this isn't a new concept.)

    According to the local paper, some churches will incorporate a message about stroke prevention in their sermons. Others will have mini-health fairs with blood pressure checks and cholesterol screening. Ours just put a flyer in the bulletin with a reminder that "you are the temple of God," and a stroke warning sign book mark. Unfortunately, it also coincides with the diocese's efforts to increase legacies from parishioners, so the stroke flyer was accompanied by a "make a will" flyer. It was the "make-a-will" message that got mentioned during mass, not the stroke message. We know where their priorities lie.

    posted by Sydney on 5/18/2003 12:38:00 PM 0 comments

    Seasonal Changes: I can tell that summer's nearly here. The snowbirds have all returned from Florida and have been coming in for their return check-ups and medication refills, and there's been a minor epidemic of poison ivy/oak/sumac rashes in my patients the past week.

    Two of my patients insisted that there was a shot I could give them that would help prevent future episodes, but there isn't. There isn't even any immunotherapy for poison ivy allergies. Although I did find a source that claims that spraying deodorant on your skin can neutralize the plant's chemical irritant, the best preventative is avoidance. So, as a public service announcement, here are some links to help you identify those itchy poison plants:

    Poison ivy
    Poison oak
    Poison sumac (only mentions Canada, but it's present throughout the Eastern United States, too.)

    When in doubt, remember the old saying: "Leaves of three, leave them be."
    posted by Sydney on 5/18/2003 12:25:00 PM 0 comments

    Absence: Sorry for the lack of posts yesterday. The short explanation is that I’ve been busy with work. The long explanation is that my practice has been liberated from its hospital-owned network. Luckily, it’s a liberation born of diplomacy and not of force, so things are going a lot better for my partner and myself than they have for many of our colleagues whose liberation preceded ours.

    A decade ago the trend in healthcare business was for hospitals and physician management companies to buy up physician practices. Physicians saw it as a chance to have someone else deal with the headaches of running a practice - negotiating with insurance companies, making sure licensing fees and hospital staff dues got paid on time, taking care of payroll and accounting, and managing the practices employee- while still making a decent salary. It was often promoted (and still is) as freeing the physician to practice medicine. Hospitals saw it as a chance to gain a captive audience for their services - not just hospitalization but other ancillary services such as physical therapy, X-ray, cardiac and neurological diagnositcs, etc. There was also a widespread belief that these networks would save money and be more profitable than independent physician practices because of “economies of scale.”

    But economies of scale are only beneficial if they outweigh the inefficiences of scale. And in hospital-run physician practices the inefficiencies are legion. The wages of an entire layer of administrative personnel have to paid - personnel that would not be used at all in a private practice. Many hospitals require their physician practices to buy drugs and vaccines through the hospital pharmacy, often at prices far above those to be had on the open market. Because hospital networks are large employers, they have to provide retirement, disability, and health insurance for all of their employees - benefits which most private practices can’t afford.

    Hospital-owned practices also have to submit to an array of oppressive rules for everyday operation. Hospitals may require their physician practices to use the more expensive single-dose vials of drugs and immunizations because that’s what’s used in the hospital, although the less expensive multi-dose vial would be more appropriate in the office setting. They may accept insurance plans that reimburse well for inpatient care but that are dismal payers for outpatient care. They may prohibit autoclaving of surgical instruments and require a practice to either give up minor surgery (skin biopsies, mole removals, etc.) or to use expensive disposable equipment. In fact, working in a network system is akin to working under the colonial economic system of 18th century America. The mother country (the hospital) makes all sorts of unreasonable economic demands on its colonies (the physician practices) and only offers in return the promise of paternalistic government.

    Now, the tide is turning. Physicians realize that they practice medicine best when they’re in control of those important day-to-day decisions and when their staff answers to them rather than some remote adminstrator. And hospitals, eager to improve their bottom lines in these tough economic times, are divesting themselves of their practices at ever increasing rates. Some call the process “disintegration,” but I prefer to think of it as liberation.

    posted by Sydney on 5/18/2003 12:09:00 PM 0 comments

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