"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
Almost Responsible: The House and Senate both passed a senior drug benefit plan yesterday. And they almost had the guts to act responsibly:
On a procedural vote, senators indicated they would approve an amendment to provide less of a government subsidy for affluent Medicare recipients in paying for doctor visits and other medical services. This prompted a furious response from Sen. Edward M. Kennedy (D-Mass.), who adamantly opposes such means-testing of Medicare.
As 20 or more senators huddled in the well of the chamber, Kennedy returned to his seat and hauled out charts and a lectern -- signaling he had every intention to filibuster the bill until he got his way. The proposal's sponsors finally backed down and the provision was jettisoned by voice vote.
People who closely follow a Mediterranean diet — rich in vegetables, grains and olive oil — live longer than those who don't. That's the conclusion of a new Harvard study that found a dramatic reduction in death rates among those who used the diet's guidelines.
...."Twenty-five percent is a very substantial reduction," says Dr. Dimitrios Trichopoulos, the senior author of the study and a professor in the department of epidemiology at the Harvard School of Public Health.
"It tells you that diet can accomplish that [decreased mortality] over and beyond obesity and everything else. This is an important message because there has been doubt about what you can accomplish with diet," he adds.
The study involved a survy of Greeks and their dietary habits:
For each of the items, respondents were asked to report their frequency of consumption and portion size, with the latter being calculated on the basis of information provided on household units and 76 photographs of usual portion sizes.
Believe me, people are horrible at estimating how much they eat. From what I hear from patients everyday, you would think that fast and abstinence is the rule rather than exception.
Nonetheless, here are the results that supposedly confirm without a doubt that a Greek diet makes you live longer. (The diet score ranges from 0 - 10 with "0" being the least representative of the Mediterranean diet, and "10" being most representative.):
Mediterranean diet score 0-3 overall mortality:
men 74 deaths per 8,869 person-years. (0.008%)
women 45 deaths per 16,115 person-years (0.003%)
Mediterranean diet score 4-5
men: 61 deaths per 13974 person-years (0.004%)
women: 34 deaths per 20,986 person-years (0.002%)(
Mediterranean diet score 6-9 men:
men: 44 deaths per 9774 person-years (0.004%)
women: 17 deaths per 11,421 person-years (0.001%)
SARS Benefit: The Rolling Stones are planning a SARS benefit concert in Toronto:
Let's face it. One has more of a chance of contracting a disease by hanging out with the Rolling Stones as opposed to catching SARS from, say, riding the subway in Toronto, Ontario.
Of Hair and Men:Mixed news on the prostate cancer front. The drug finasteride might decrease the overall rate of prostate cancer, but at the cost of increasing the risk of aggressive prostate cancers.
The National Cancer Institute estimates that if 1,000 63-year-old men are tracked, after seven years, 60 of them would develop prostate cancer, with 18 of those men suffering with high-grade tumors, which spread quickly.
If the same men took finasteride for seven years, only 45 would get the cancer, but 22 would have the more aggressive tumors.
Prostate cancer was detected in 803 of the 4368 men in the finasteride group who had data for the final analysis (18.4 percent) and 1147 of the 4692 men in the placebo group who had such data (24.4 percent), for a 24.8 percent reduction in prevalence over the seven-year period (95 percent confidence interval, 18.6 to 30.6 percent; P<0.001). Tumors of Gleason grade 7, 8, 9, or 10[the aggressive types of cancer - ed.] were more common in the finasteride group (280 of 757 tumors [37.0 percent], or 6.4 percent of the 4368 men included in the final analysis) than in the placebo group (237 of 1068 tumors [22.2 percent], P<0.001 for the comparison between groups; or 5.1 percent of the 4692 men included in the final analysis, P=0.005 for the comparison between groups).
Those are clinically significant differences in the rates of cancer, both for the overall decrease and for the increase in aggressive cancers. One more difficult decision in the prevention of prostate cancer. To screen or not to screen? To take a drug or not? Is it worth the potential harm? One thing for sure, it probably isn’t worth risking the aggressive cancer for a few more hairs:
For young men using the drug to promote hair growth, "I certainly wouldn't want to be taking a drug that potentially promotes cancer of the mean types," Dartmouth's Wasson said. "First, do no harm, that's the bottom line with any drug or treatment ... if you're a young guy, you should really be concerned about finasteride. posted by Sydney on
6/26/2003 08:35:00 AM
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How It Is: The story of one man's battle of the bulge:
I'm not proud to say, I have a weight problem. I've had it since I was a kid, and my whole family has a weight problem. To blame this on the fast food industry is ludicrous. I grew up in urban New Jersey, lower middle class, in somewhat disadvantaged circumstances. I could probably count on one hand the number of times in my first 18 years of life I ate at a fast food restaurant. No money, no access.I ate all my meals and all my additional calories, at home, good , nutritious, solid Italian home cooking, and the pounds piled on.
As an adult physician, I don't recall the last time I ate in a fast food restaurant, unless you want to count Panera's, where I ate a bowl of soup and half a salad for lunch, yesterday. I still struggle. Sometimes, I do eat more than others without a weight problem, however, most of the time, I eat the same or less. My activity level is average. My weight either stays the same or goes up. I've lost significant amounts of weight to achieve normal weight twice in my life. In order to accomplish this, both times required severe restriction of calories, under 700 per day with moderate exercise. To maintain this caloric restriction for long periods of time is extremely difficult. And after normal weight is achieved, it becomes hard to realize that I still cannot eat a normal diet. For me to maintain my weight with reasonable exercise would be around 1200 to 1500 calories.
The bottom line, is that obesity is a multifactorial problem. How simple it would be if by the simple closing of all fast food restaurants( and how are we going to define those exactly legally? Most likely, by the depth of their pockets.) resulted in the resolution of the obesity problem in this country. Anyone that believes that really does not understand the problem as it truly exists( or is too stupid to live), but I am sure the lawyers will find juries of so called average Americans that they can convince. The true threat in this country is that we are being legislated and trialed to death. posted by Sydney on
6/26/2003 08:26:00 AM
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Better Living Through Chemistry: Two physicians think they may have hit upon a solution to cardiovascular disease:
A single pill containing aspirin, folic acid and drugs to lower blood pressure and cholesterol could cut heart attacks and strokes by more than 80%, a newly released study claims.
Researchers, writing in the British Medical Journal, said the "Polypill" would have a greater impact on the prevention of disease in the Western world than any other single intervention.
....They came up with a pill containing six active components - aspirin, folic acid, a cholesterol-lowering drug and three drugs to lower blood pressure at half the normal dose.
The pill would contain these components, according to the article:
The formulation which met our objectives was: a statin (for example, atorvastatin (daily dose 10 mg) or simvastatin (40 mg)); three blood pressure lowering drugs (for example, a thiazide, a blocker, and an angiotensin converting enzyme inhibitor), each at half standard dose; folic acid (0.8 mg); and aspirin (75 mg)
Of course, this is all theoretical, and it's all based on a stastical analysis rather than reality. The doctors looked at the percentage risk reduction that each drug provides separately and combined those reductions to predict an 80% reduction in risk. What they can't tell is how all of those drugs will react with one another when someone takes them all at the same time. Each drug alone has its own potential for side effects, especially in the elderly and the chronically ill who don't metabolize well. Taken together, they have the potential to enhance one another's adverse effects.
The accompanying editorial minimizes the potential risks, pointing out that each drug alone appears to be pretty safe and with few side effects. But that isn't true. I've had to stop statins in patients because of elevated liver enzymes or muscle aches; thiazides and ACE inhibitors because of electrolyte imbalance or renal insufficiency; beta blockers because of low heart rates or pulmonary complications, and aspirin because of bleeding, or gastric ulcers. By combining all of them in one pill, there's a potential for disaster. Imagine if people taking the pill have higher rates of hepatitis, bleeding ulcers, myositis (muscle inflammation), bradycardia, and acute renal failure all at the same time. Can you say "class action lawsuit"?
Of course, the "polypill" won't be approved unless it proves itself safe and effective, but the trend toward pill-popping madness to prevent rather than treat disease is worrisome. As a profession, we're beginning to forget the old maxim "first do no harm." posted by Sydney on
6/26/2003 07:55:00 AM
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Dr. Dean: Some, including me, have wondered if Howard Dean is arrogant because he's a doctor, but Jim Miller points out that Bill Frist doesn't seem to have that problem. And he's a cardiothoracic surgeon - a specialty with no shortage of arrogance among its members. Today, Andrew Sullivan explains the difference:
I didn't see what many are calling a disastrous performance by Howard Dean on "Meet The Press," but I know from observing him and debating him once that he's an intemperate, arrogant bully. Will Saletan is onto something here. It's a trait bad doctors have. They are used to being in such controlling positions vis-a-vis their patients that it goes to their heads. Good doctors resist such an obvious temptation. posted by Sydney on
6/26/2003 07:25:00 AM
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Horrible Hormones: Yet another study came out this week on the horrors of hormone replacement therapy. This time it’s hormones and breast cancer:
“We found that long-term use of combined estrogen and progestin hormone-replacement therapy not only doubles cancer risk, but that the magnitude of this risk increases with duration of use,” said Dr. Christopher Li, a researcher at Hutchinson and lead author of the study, published today in The Journal of the American Medical Association.
Li and colleagues found that women over age 65 who take combined hormone-replacement therapy for five to 15 years or for 15 or more years, whether they take progestin sequentially or continuously, face double the breast-cancer risk of other women.
Double the risk. That sounds frightening. And the authors of the study put it just as alarmingly in their conclusion:
This report provides randomized clinical trial evidence that postmenopausal estrogen plus progestin use significantly increases the incidence of breast cancer within a 5-year period.
But, on closer examination, it’s obvious they mean statistically significant, not really significant. And that claim in the popular press that it doubles the risk is also dubious.
The study participants were divided into two groups. 8506 took a pill that combined estrogen and progesterone, and 8102 took a placebo for five years. In the first group, 245 (2.8%) developed breast cancer by the end of five years. In the placebo group, 185 (2.2%) developed breast cancer. That’s a difference in incidence of 0.6%. To get the “double the risk”, the authors turned to hazards ratios to magnify the difference. Trouble is, even using hazards ratios, the difference isn’t very impressive. Here are the graphs for the hazard ratio data. Notice how the lines representing the placebo and the treatment groups cross? That’s usually a sure sign that the difference between them isn’t truly significant.
There does, however, seem to be a diffference between the two groups in the interpretability of their mammograms. By the end of the study, women who took estrogen and progesterone had higher rates of ambiguous mammogram results. 31.5% of treated women had an abnormal mammogram sometime during the five years of the study compared to only 21.2% of women in the placebo group. Most of those just required a follow-up mammogram to make sure the findings were benign. Suspiciously abnormal mammograms that required a biopsy or were suggestive of malignancy occurred at similar rates in the two groups, the incidence varying by 2% for suspicious lesions (cancer chances = maybe yes, maybe no) and 0.2% for lesions that looked like cancer (cancer chances = higher yes than no).
Which leaves one wondering. Is the very slight increase in cancer incidence among the hormone therapy users due to the hormones actually causing the cancer at a cellular level, or is it because they make the breast tissue denser, thus making mammograms harder to interpret, thus resulting in more biopsies and earlier detection. If the study had gone on for ten or twenty years, would the rates of cancer have been the same?
Either way, the very small difference in cancer rates between the two groups still isn’t enough to take hormone replacement therapy away from those women who want to use it. Yet, you can bet that's exactly how the data will be used.
Fast and Quick: A nice write-up on the new rapid HIV test, and why it's important to have a quick and reliable diagnostic test:
Of the 2.1 million people who were given publicly funded HIV tests in the United States in 2000, the Centers for Disease Control and Prevention (CDC) estimates that 30 percent of those who tested positive -- approximately 18,000 people -- did not return for their results. Neither did 40 percent of those testing negative.
Makes me wonder how many of those patients who tell me they had their test at the health department are telling me the truth about their results. posted by Sydney on
6/24/2003 08:40:00 AM
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Why We Need the FDA: In Brazil, lax standards for drugs have resulted in death and blindness:
The Brazilian authorities are investigating the deaths of at least 21 people, thought to have been caused by a contaminated drug.
The patients died after being given a Brazilian brand of a dye called Celobar - which is sometimes used in radiology examinations.
In a separate case, government inspectors are blaming hospitals for using a gel in eye operations, which resulted in five patient becoming blind.
Doctors are demanding tighter controls of locally-produced medicines.
Both drugs were produced in Brazil by unlicensed manufacturers. The doctors say that pressure to reduce overhead due to low insurance reimbursement makes it possible for the counterfeit companies to prosper. And we thought things were bad here. posted by Sydney on
6/24/2003 08:26:00 AM
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Timing is Everything: Why the 1947 smallpox containment strategy in New York City worked:
But while modern public health officials look to successful campaigns like this to plan how to do it again, historians say the factors that converged to make it possible may not be easy to duplicate. In 1947, the anti-vaccine movement was not powerful. And, despite the end of the war, many people were still in the military or linked to war-effort volunteer organizations. They could be called on to run the clinics. And in the post-war era, people were also more willing to follow government advice.
"If it had to happen and you had to vaccinate a population, the 1940s was probably the right period to do it," said Dr. Lord.
''I find it really bizarre that you can outlaw a plant,'' said Kim Upton, who runs the Starlight Goddess metaphysical store in Louisville. The store sells salvia. ''Even nutmeg taken in large quantities will give you a bigger buzz than LSD.''
Well, marijuana's a plant, and it's outlawed. It's also illegal to sell poppy juice. Others say it isn't all that great a drug anyways:
''It could never become popular like marijuana or Ecstasy,'' Siebert said. ''The effects are not desirable for recreational drug users. It's not something that is fun. It's more of an existential ordeal.''
He sells that existential ordeal for $120 an ounce. He must be quite a salesman.
posted by Sydney on
6/24/2003 08:17:00 AM
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MedMal Alternatives: The Florida legislature is struggling with tort reform issues. Among the ideas being floated - besides capping noneconomic damages, are these:
The group is calling for the creation of medical review panels that would study the legitimacy of liability cases before they go to trial.
"I want my peers looking at those cases, a board-certified surgeon looking at it, not just insurance company [officials], to decide whether I did any wrong and whether a claim should be paid," said Loyola, who said a previous insurer settled just such a claim against him last year.
"A peer would look at the case and say, `You did nothing wrong,' and so you, or the insurance company, would be on stronger ground to fight the lawsuit," he adds.
...The Senate's 78-point plan for dealing with medical liability issues calls for the formation of malpractice review boards. The panels would consist of two physicians, two lawyers and a consumer representative. Alternatively, a malpractice bill in the House calls for only the study of such review boards.
And, in addition, attorneys who file three frivolous lawsuits would be penalized:
... Adding to the lawyers' concerns are proposals to use the screening panels to shut down attorneys who frequently file malpractice claims. That's because the Senate bill, as now drafted, would stop any lawyer who had been shown to have filed three "frivolous" malpractice lawsuits -- as determined by the review panels -- from being able to file any future such malpractice claim in a Florida court. Roth calls the idea "blatantly unconstitutional."
Sounds good to me. And why would it be unconstitutional to punish an attorney for abusing the system?
UPDATE: Thomas Crown sends this explanation of lawyerly objections to the review board:
The answer depends on what they're shooting for exactly, and to which Constitution they're referring.
Assume for the sake of argument that we're talking about the U.S., as opposed to the Florida, constitution. Such a thing would be, off the top of my head, unconstitutional for the following reasons:
* You deprive the attorney of the ability to practice his livelihood without hearing before a court of law. Most attorneys are licensed in only one state; cut them off in that state, and they're at least briefly out of a job. You are taking his property interest without giving him access to the courts. That is a classically unconstitutional act. Kinda. (I'll spare you talk about balancing acts and compelling interests in the desire to make a broad point.)
I’m not an expert on constitutional law, but I’m pretty sure the constitution doesn’t guarantee anyone the right to a job. And the story didn’t say anything about denying the attorney the right to contest its decision in court.
* You deprive his client of access to the courts. Assume for the sake of argument that there is a bona fide case -- either an easy win for the plaintiff, or a close call -- but the client can only find one attorney to represent him, and that one, who is not disbarred, is prevented from filing suit on his behalf: Yet another due process denial.
If a client could only find one attorney to take the case, then I’d have to think his case wasn’t very strong.
* You've created a parallel system to the one that exists to punish attorneys for abusing the system. Ok, this isn't unconstitutional under the Federal constitution (I think), but it's still a bad idea. This is what the Bar and the Florida Supreme Court are for: to kick out the lawyers who abuse the system. (Incidentally, that would make it unconstitutional
under the Florida Constitution: The Supreme Court alone is vested with the power to disbar or otherwise punish an attorney qua attorney.)
That’s part of the problem. It appears as if the system in place for dealing with abusive attorneys isn’t working so well.
* Who sets the standard for "frivolous," exactly? And what is that standard? Unsuccessful? We've had cases that were good -- I mean, those doctors should have had their licenses revoked, and I'm not exaggerating (I'm psuedonymous, after all) -- and we lost. Most were overturned (for new trial) on appeal, but those cases were not frivolous -- we can't afford frivolous suits. That lack of clear standard means that there are, yes, more due process questions wrapped up in this.
Deciding what is frivolous could become rather contentious. The article said that the review panel would be made up of doctors, lawyers, and a “consumer representative,” so there would be a wide variety of viewpoints at the table. But, I suppose a larger question is who appoints the review board? How hard would it be to keep it an impartial panel rather than a politically charged one?
(Side note: Should lawyers who defend doctors, who lose at trial, be kicked out of court after three "frivolous" defenses, i.e., the doctor was plainly in the wrong? There's your equal protection problem right there.)
A lost lawsuit isn’t the same as a frivolous lawsuit. A frivolous lawsuit is one that should never go to court in the first place because there’s obviously been no malpractice. For example, just getting rid of the current practice of suing everyone whose name appears in a medical record, regardless of whether or not their actions caused harm, would cut down significantly on the number of frivolous lawsuits. (Full disclosure: I’m fuming at the moment because my malpractice history includes a claim against me for ordering Tylenol for a patient who died three weeks later of a pulmonary emobolism. Even the most challenged malpractice attorney should be able to recognize that a dose of Tylenol three weeks before a pulmonary embolus didn’t cause the death. The suit was dropped by the attorney because he thought it had no merit. I just wish he had made that decision before filing a suit against me. And the claim remains on my malpractice record - without any explanation of just how little I had to do with any of it, or of how frivolous it was.)
This has the feel of Orrin Hatch's suggestion about blowing up computers: An off-the-cuff, poorly thought-out response to a legitimate problem.
Then maybe we should just put caps on noneconomic damages and call it a day. But lawyers don’t want that, either. In fact, they don’t like any of the suggestions to reform the system. And why would they? They know a cash cow when they see one. posted by Sydney on
6/23/2003 08:22:00 AM
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Shooting for the Moon: The decision of an FDA review panel to approve growth hormone therapy for constitutionally short children seems misguided at best. Studies aren’t very convincing when it comes to its effectiveness, and no studies have been done to document what harm it might do in otherwise healthy but short children. One study, supported by Genentech, found that growth hormone in healthy children increased height by 5 to 5.9 cm, plus or minus 5.2 cm. That hardly seems worth the high cost and potential harm, does it? Other studies have suggested that using it in healthy children may result in a shorter height than they would attain naturally, because it prematurely matures the bones. (When the bones become mature early, they stop growing.)
What seems to be lost in all of this is that predictions of adult height aren’t that reliable:
How accurate is this prediction? Your child has a 68% chance of being within 2 inches and a 95% chance of being within 4 inches of this predicted height. Keep in mind that other factors may influence your child's growth, including his overall health and nutritional status.
And of course, there’s no way to study the effect of growth hormone on actual height. You can’t zip the child back in time to try all over again without growth hormone.
Far better to teach your child to accept who he is:
But the growth hormone boosters believe it goes beyond the cosmetic, and they trot out statistics suggesting that tall folks have better jobs, more money and a greater range of mates. So if I were taller, I would have more money than Ross Perot? Michael Bloomberg? If Michael Bloomberg were taller, would he be mayor of a better city?
O.K., neither Ross Perot nor I will ever be president; the taller candidate tends to win the popular vote. But somehow I think that height is not the only thing holding us back. Whatever the statistics might say, I can't imagine wanting a better job, or a more beautiful wife. I can imagine making more money, but who can't? So I decline the mantle of victimhood. I'm short. I'm used to it.
Full disclosure: I’m short, too. And so are all of my children.
UPDATE: A reader points out that in the long run we all end up drifting toward the mean:
My great-grandfather the Doctor was a very tall man. It's hard to tell from his pictures, but I'd guess he was 6'4" or so: pretty big for a man born in the 1840s. He married a very short woman, and thus began the shrinking of the clan. His son, my grandfather, wasn't more than 5'10", and married a woman maybe 5'4". I come in at 5'10", my wife at 5'3": when our daughter was on a heavier dose of inhaled steroids for her asthma than she is now, my wife used to worry that her growth would be impaired: I said, how could we tell (now 12, she grew 3+ inches last year, so there) posted by Sydney on
6/23/2003 08:18:00 AM
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The Unkown: At last, someone in the mainstream media points out that we don’t really know the full health implications of obesity:
Dr. Reubin Andres, an obesity researcher at the National Institute on Aging, sighed. "As the sage of Baltimore, H. L. Mencken said, `For every complex question there is a simple answer. And it's wrong.' "
In this case, the effort to help fat people help themselves has several implicit assumptions, researchers say. One is that all those overweight Americans would be healthier if they would just shed their excess pounds. "Here is what we know," said Dr. Gary Foster, an obesity researcher at the University of Pennsylvania. "If you have diabetes and you lose weight, it is likely to get better and you will go on less medication." That is important, he stressed, because in addition to causing immense suffering, diabetes is expensive to treat and has expensive complications - amputations, kidney failure, blindness.
But, he added, it is not yet known whether losing weight will help with other medical conditions: "Will it prevent or decrease the risk of heart attack or stroke or will you be less likely to be hospitalized? We don't know that yet." posted by Sydney on
6/23/2003 08:05:00 AM
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Humph: Last week, a psychiatrist who was quoted in the New York Times as saying that family physicians don’t know how to treat depression, apologized for his remarks:
While the lead author of the study, Ronald Kessler, Ph.D., had been quoted in the June 18 New York Times as saying family doctors do not provide quality care for depression, he has issued a correction sent to nationwide news services.
"There is no evidence in our study that family physicians have a lower rate of successfully treating depression than other general medical doctors," Kessler said in his June 19 correction. "I regret having unfairly singled out family medicine specialists in my comments."
Evidently, what he meant to say was that all physicians, other than psychiatrists, mistreat depression. At least, according to the full apology.
But his words, having appeared in the paper of record, have already attained the status of truth, as evidenced by this column from Sunday’s Times:
The JAMA study finding that depression is treated inadequately suggests that family doctors have yet to adopt this view. The cardiac research hints that they may have to - in which case, the cultural standing of depression may change as well. Depression may look ever less like a charming element in the artistic temperament and ever more like a progressive, systemic disease.
The author, Peter D. Kramer, is working on a book about depression, according to the blurb at the end of the piece. What do you want to bet that his slander against family physicians makes it into the book?
Addendum: The study, by the way, based its evidence that depression is undertreated on household surveys. Surveys are a notoriously bad way to collect reliable data. You'd be surprised at how little people know about themselves. We have a nutritional questionaire at the office that asks people if they've lost or gained more than ten pounds in the past six months. The majority of people, especially women, respond that they've gained, but the weights recorded on the chart show that they've remained the same. I've never trusted studies based on surveys since we introduced that questionaire. posted by Sydney on
6/23/2003 07:53:00 AM
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Why Medicare Matters: Hopefullly, Congress will get their act together enough to come up with meaningful Medicare reform. Otherwise, we all might face this again. posted by Sydney on
6/23/2003 07:43:00 AM
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Drug Benefits: I’ve been reluctant to blog anything about the Medicare prescription drug benefit plan before Congress because all of the news reports I’ve read have been confusing. But, TAP has an item online that sums it up succinctly:
Beginning in 2006, seniors could pay an additional $35 a month for partial drug coverage. In most states, the drug benefit would be sponsored by private insurers, and there would be no price controls on drugs.
....Seniors would pay the first $276 a year in drug costs. Then the program would pay half of all costs up to $4,500 a year. The individual would pay everything between $4,500 and $5,800, and the plan would pay 90 percent of all costs above that. This complex formula is just nuts, but it is the best Republicans offered.
An elderly person with $4,000 in drug bills would pay a total of $2,558 out of pocket in premiums, deductibles and co-payments. Many would hesitate to enroll. The formula is intended to hold down costs -- another Republican demand (what with all those tax giveaways to finance). Even so, the program would cost the government $40 billion a year.
Wouldn’t a simple means test be easier? This essentially subsidizes drugs for everyone. Most elderly people’s drug bills come out to be less than $4500 a year. (That’s $375 a month), but if they have higher bills, they have to share more of the burden. Makes no sense. Unless, of course, the goal isn’t so much to provide help for those who need it as it is to curry favor with those who vote.
Explanations: Bill Gates explains why my email wasn’t working:
Already, spam filters built into MSN and Hotmail servers block 2.4 billion messages a day before they reach subscribers' inboxes. We have assembled a vast and fast-growing database of spam, which will be used by a forthcoming version of our Outlook e-mail software to block spam more effectively. And a new version of our Exchange e-mail server will include advanced anti-spam features. Our goal is to do everything possible to secure e-mail systems with servers that monitor and control the points of entry.
But a single company can't stem the tide of spam alone. So we are working with other industry leaders such as AOL, Yahoo! and Earthlink on a range of joint initiatives. For example, we are battling spammers who set up numerous e-mail accounts and move from service to service to avoid detection. To put an end to this shell game, we are sharing information so that we can keep tabs on roving spammers and shut them down more effectively. Spammers also go to great lengths to conceal or "spoof" their identities, so we are partnering with other service providers to identify and restrict mail that conceals its source. And we are creating a system to verify sender addresses, much as recipients' addresses are verified today.
Someone needs to tell them that subaccounts aren’t spam, though. (My email's working now, so maybe they have figured that out.) posted by Sydney on
6/23/2003 07:30:00 AM
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Sunday, June 22, 2003
Blind Sided: Too often, going away means coming back to even more work. That's what happened to me last week. Flight cancellations, lost luggage, returning to a different airport, piles of paperwork and a backlog of patients to be seen at the office, two dying patients in the hospital, an email account that was no longer working, and a changed Blogger system. It was an overload, that I'm only now getting over.
Yet, despite all the distractions on my return, I can't put aside a nagging disquiet about some of the lectures I heard at the conference. It was a family practice review course, designed to give an overview of the latest developments in medicine and clinical treatment, yet some of the speakers went overboard in their enthusiasm for the latest treatment trends. The cardiologists and endocrinologists were the guiltiest. Time and time again they resorted to truncated graphs to exaggerate the therapeutic benefit of a drug. Their ultimate messages? Statins for everyone! ACE inhibitors for everyone! Metforminforeveryone! Not surprisingly, these were the speakers that listed drug company sponsorship under their full disclosure agreements. No doubt, they’re sincere in their belief that drugs are the answer to everything, but I had to wonder to what degree they had been blinded by their enthusiasm for a particular theory of a disease and its subsequent treatment. Blinded to the point of believing that a difference in outcome of 1 to 2 percent is actually significant.
Which made me think about times past when other enthusiasms ruled the day. Take, for example, the treatment of tuberculosis. In 1934, tuberculosis was a common disease about which much was know. It had been around for centuries, so its natural history was familiar to doctors. It was also known to be caused by a bacteria. Nonetheless, treatment was rooted in ideas that fit the theory more than the science. Here’s what the 1934 edition of Cecil’s Textbook of Medicine (a highly respected textbook, by the way) says on the subject:
Of the countless remedies for tuberculosis, complete rest for body and mind is the only one which has proved eminently successful....Even sitting up in a chair or reclining in a chaise-lounge must be regarded as exercise. Since it is undesirable for the patient with fever to walk even as far as the toilet, a bed-pan or commode should be used. The number visitors must be strictly limited, for conversation is tiring. No invalid should be submitted to the strain of talking with a deaf person.
Sounds crazy, but until the discovery of antibiotics, this was the standard of care for tuberculosis patients around the world. And the doctors who practiced it would have said it was based on the best available evidence. The treatment neatly fit their theories of the disease process. Exercise increased the flow of blood and oxygen to the lungs, which in turn fed the tuberculosis germs. Complete bedrest deprived the bacteria of their source of nutrition, and thus provided the cure. So, they gave the credit of the natural regression of the disease to the bedrest on which everyone was placed. Not too much different than the doctors today who believe everyone over a certain age should be on statins regardless of their cholesterol levels. They see in the evidence that which they want to see. posted by Sydney on
6/22/2003 08:58:00 PM
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