"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
Dr. Dean's Medicine Show: Jim Miller also has an excellent post that dissects Howard Dean's Vermont heatlhcare record. Dean summarizes his achievements on his website as follows:
In Vermont, where I served as governor for the last 11 years, nearly 92% of adults now have coverage. Most importantly, 99% of all Vermont children are eligible for health insurance and 96% have it.
But that's not it. We coupled our success in insuring kids with a new early childhood initiative that we call "Success by Six." As a result, nine out of 10 parents with a newborn baby -- regardless of income -- get a home visit from a community outreach worker who's there to help them with parenting skills and to put those parents in touch with the services they may need or want. Thanks to Success by Six, we've cut our state's child abuse rate nearly in half, and child sexual abuse of kids under 6 is down by 70%.
If Vermont -- a small, rural state that ranks 26th in income in the United States -- can achieve this, surely the country that ranks No. 1 in the history of the world can do so as well.
I'm not so certain that lower child abuse and sexual abuse rates can be completely credited to the Success by Six program. There could also be tougher reporting laws that account for it, or stiffer penalties for abusers. And as Miller points out, Vermont actually lags behind other New England states with lower taxes in indicators of children's health such as infant mortality and vaccination rates. Vermonters just must not be using the services they've been handed.
But here's Dean's plan for the nation:
1. He'll expand Medicaid to cover everyone, rich and poor, under 25 years of age:
First, and most important, in order to extend health coverage to every uninsured child and young adult up to age 25, we'll redefine and expand two essential federal and state programs -- Medicaid and the State Children's Health Insurance Program. Right now, they only offer coverage to children from lower-income families. Under my plan, we cover all kids and young adults up to age 25 -- middle income as well as lower income. This aspect of my plan will give 11.5 million more kids and young adults access to the healthcare they need.
2. He'll also expand it to cover everyone making up to 185% of the federal poverty level:
Second, we'll give a leg up to working families struggling to afford health insurance. Adults earning up to 185% of the poverty level -- $16,613 -- will be eligible for coverage through the already existing Children Health Insurance Program. By doing this, an additional 11.8 million people will have access to the care they need.
3. He'll also establish another federal health insurance program:
Many working families have incomes that put them beyond the help offered by government programs. But this doesn't mean they have viable options for healthcare. We'll establish an affordable health insurance plan people can buy into, providing coverage nearly identical to what members of Congress and federal employees receive.
And subsidize the premiums with a tax credit:
To cushion the costs, we'll also offer a significant tax credit to those with high premium costs. By offering this help, another 5.5 million adults will have access to care.
4. The government insurance program will be offered to employers at a discounted rate, and it will cover COBRA premiums for the recently unemployed:
With the plan I've put forth to the American people, we'll organize a system nearly identical to the one federal workers and members of Congress enjoy. And we'll enable all employers with less than 50 workers to join it at rates lower than are currently available to these companies -- provided they insure their work force. I'll also offer employers a deal: The federal government will pick up 70% of COBRA premiums for employees transitioning out of their jobs, but we'll expect employers to pay the cost of extending coverage for an additional two months.
5. And finally, he'd require all employers to provide health insurance to their employees:
The final element of this plan is a clear, strong message to corporate America that providing health coverage is fundamental to being a good corporate citizen. I look at business tax deductions as part of a compact between American taxpayers and corporate America. We give businesses certain benefits, and expect them to live up to certain responsibilities.
Those are, in many ways, laudable goals, but they're also very expensive ones. At a time when national defense is of utmost importance, it's hard to justify spending so much on so many who don't really need the help. Then, too, how do you make all of that new federal health insurance program "affordable"? You could ration care, and only pay for a limited number of services. But everyone cries foul whenever an insurance company - be it private or Medicare - takes that approach. The only alternative is then also an inevitable one - pay for everything but control the prices. Which means that doctors and hospitals, already pinched by inadequate reimbursement, would be driven into further economic losses.
But the biggest drawback to his healthcare plan is that it insists on maintaining the status quo of having a third party bear the brunt of healthcare costs. The actual consumer and his provider continues to be divorced from the financial reality of their healthcare decisions - which aren't always matters of life and death. In this day and age of expensive cosmetic pharmacology and minimally beneficial, but expensive preventive drugs and procedures, that's just asking for trouble.
Evolutionary Psychology, Burgers, and More: Excellent reader email lately on a variety of topics. For example, on evolutionary psychology:
I would like to point out that it is meaningless to:
(1) "prove" that some sort of behavior is genetically determined and
then
(2) recommend that people therefore allow this behavior, because such recommendations are inconsistent, arbitrary and selective.
Most of us went through a fairly difficult piece of training when young, to replace genetically determined behavior with something judged to be socially acceptable. I refer of course to toilet training. I would be happy to go to the home of any of these people who recommend following genetically determined behavior, getting their permission to act "genetically determined" and then dispensing, in their living room, with my toilet training. I believe that "genetic studies" would even support a desire to aim aggressively.
On odd burgers:
I spent some years of my adolescent in a small Missouri town called Sedalia. The Wheel-In Drive-In (privately owned and still operating XXX years later) served (and still serves) a delightful burger smeared with peanut butter, know, of course, as the Goober Burger. Not to my taste, but reportedly a big seller to other Sedalians. Probably as nutritious as a blueberry burger, but then I am not a blueberry fan.
Several years ago I saw reports of a study of women runners that said their times improved slightly after pregnancy, on the average. The authors seemed to think it was the "weight training" part of pregnancy that strengthened the runners.
I don't know about that, but pregnancy does make the ligaments and tendons in the hips and pelvis looser. Wouldn't looser hips improve stride? posted by Sydney on
8/07/2003 09:10:00 AM
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More Traumatized Children: There's a reason so much of today's news is dominated by injured children. This week's JAMA is devoted to the subject. And it includes this interesting, freely-available article on predicting post-traumatic stress disorder in traumatized children.
The paper involves the development of a questionairre that can be used to predict which child, or parent, is most likely to go on to develop post traumatic stress disorder after a traumatic injury. Actually, what it ends up doing is predicting who won't develop it. Only 14% of those predicted by the questionairre to be at risk for the disorder actually went on to develop it. Which proves once again that the human spirit is more resilient than pop psychology would have us believe.
posted by Sydney on
8/06/2003 09:28:00 AM
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Baby Dreams: There's a new theory being floated about that Sudden Infant Death Syndrome is caused by baby dreams. Nice theory, and one that can never be proven, nor disproved. But it can be ridiculed: "
Dr Robin Campbell, a lecturer in psychology from the University of Stirling, whose research interests include dreaming in children, described the theory as 'potty'."
Shaken Babies: A study in today's JAMA says that 1300 babies were maliciously shaken in the United States last year:
If the rest of the country reflected what happened in North Carolina recently, an estimated 1,300 U.S. children experienced severe or fatal head trauma from child abuse during the past year, a new study concludes. Of those, 1,200 were in the first year of their lives.
That's quite a claim. And it has no basis in fact. The only thing the study can say with any certainty is that over the past two years 80 children in North Carolina were shaken hard enough to require hospitalization in an intensive care unit:
"Keenan and colleagues identified all N.C. children ages 2 years and younger admitted to a pediatric intensive care unit in the state or who died from a brain injury in 2000 and 2001. Members of the team contacted charge nurses at each of the state's nine pediatric ICUs three times a week over the span, checked medical examiner and other records and even queried the three closest out-of-state pediatric ICUs about N.C. patients. They considered the injuries to be inflicted if suspects confessed or if a medical or social service agency determined abuse.
'We found 152 cases of serious or fatal traumatic brain injuries over the two years,' the physician said. ''Out of 230,000 children under age 2 in North Carolina, 80 were injured from shaken baby syndrome.'"
Apparently it isn't as widespread a problem as the headlines would have us believe. Thank goodness.
posted by Sydney on
8/06/2003 09:03:00 AM
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King Makers: Stay-at-home moms are making huge contributions to the Edwards Presidential campaign. Who would have thought that stay-at-home moms had so much financial clout:
"The nearly $1 million they've given so far this year tops campaign donations from bankers, physicians or business executives.
Here's why:
Many of those homemakers are married to lawyers, who have contributed more than half of the nearly $12 million Edwards has raised this year, or other supporters who already have contributed the $2,000 legal limit."
Lawyers. They're so good at finding and exploiting loopholes.
Public Health: The National Academy of Sciences wants health insurance plans to pay for all vaccines and the federal government to subsidize them:
"The federal government should require all health insurance policies to pay for vaccines, should reimburse insurers for the costs and should subsidize vaccines for uninsured people, an expert panel from the the National Academy of Sciences said Monday."
Of course, doing that would drive up the cost of health insurance. But, as things stand now, doctors are the ones subsidizing vaccines. You'd be surprised at how expensive some of those childhood vaccines can be. Ten doses of the chickenpox vaccine (the smallest amount I was able to find from suppliers) cost $600. The Comvax, which combines Hib and HepB is $360 for ten doses. And those are only three of the seven recommended immunizations for childhood. Yet, reimbursement from insurance companies is often so poor, it doesn't cover the cost. A friend of mine who opened her own practice recently doesn't offer immunizations because she can't afford them.
Myself, I'm struggling with the decision. I believe I have an obligation to provide the immunizations to my patients. But frankly, I, too, am having trouble finding the funds to buy them. The cost of buying the smallest supply of childhood immunizations possible is more than all the rest of my medical supplies for the start-up of my practice. I'll probably compromise and only offer those that are required for school.
Since most of the vaccines are required for public school attendance, and since they're given for the greater good of the general public, it actually makes sense to have the federal government subsidize them for everyone. Right now, they do that only for the poor, those without insurance, and those whose insurance plans don't cover immunizations. (Evidently the National Academy's panel never heard of the Vaccines for Children Program.) The only ones left to subsidize are the insurance companies. A better solution would be to leave the insurance companies out of it altogether and just have the same government-subsidized immunization program for all citizens. posted by Sydney on
8/05/2003 07:22:00 AM
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Zeroing in on Kids: I wasn't going to comment on the news that the American Academy of Pediatrics wants us all to measure body mass index in kids so we can point out to them that they're fat, because I'm getting rather sick of this whole obesity thing, but this email summed things up fairly well:
Here we go again. This one takes the cake. The American Academy of Pediatrics is now recommending that physicians treating children take serial measurements of BMI so that they can pick up early increases in growth that might indicate obesity. Please. How stupid can you be?
Shouldn't a pair of eyes and common sense be sufficient to tell whether somebody's getting a little chubby? This is not rocket science. And then here's the ultimate question. What are they going to do about it? When the AAP comes up with a fool proof plan of treatment of obesity or prevention of obesity, that will work for the vast majority of patients( and let's face it, we all know that telling patients to eat less, exercise more, and carefully pick the kinds of food you eat, does not work ), then maybe perhaps it may be useful, though even then I doubt it.
I will tell you what it will do though. It now provides the attorney with a hard number that can be used in court to sue or blame physicians for the their patients' obesity. I can just hear it now, " Doctor, you did not measure the BMI in this poor, unfortunate, roly poly child, who is harassed in school , in the playground, and I can't even describe, what happens to her in gym?" "Doctor, here is a picture of this child at 2, 3, 4, etc, you measured her BMI and didn't successfully treat her obesity?"
What this pathetic recommendation is , is a feeble PR response on behalf of the American Academy of Pediatrics to all the press regarding the so called obesity epidemic, because let's face it they can't do anything more meaningful for this problem, than p*** in the wind!
Never fear. Turns out they have a treatment plan up their sleeves. They're coming up with guidelines for pediatric weight loss surgery:
"Gastric bypass surgery has long been a dramatic solution for obese adults, but more doctors are operating on teen-agers, too. Now the first pediatric guidelines are due out soon, and they'll urge doctors to put more limits on teens' surgery than on adults' -- because nobody yet knows the long-term outcomes of such a radical operation on a still-developing body."
This is a most worrisome trend. Here you have a group that is particularly vulnerable to other people's opinions feeling pressured into a drastic surgery to change their appearance. What will their feelings be when they're young adults with dumping syndrome, nutrional deficiencies, or compression fractures from osteporosis thanks to their teen-age surgery? Very angry, I'm guessing.
And the most ludicrous aspect of the whole thing is the reliance of the guidelines on oracles, er, I mean "experts" to predict who is best suited for the treatment:
Once patients recover, they must follow stringent rules: They eat small servings, carefully counting to get enough protein. They take vitamins and calcium to counter nutrient deficiencies, including bone loss.
Such changes are hard enough for adults. So the pending pediatric guidelines stress having experts evaluate if a teen is mature enough to follow the rules before surgery is offered.
Extreme Prejudice: A father with AIDS has been banned from coaching his 7-year-old son's football team. I guess it shouldn't come as much of a surprise that in this day and age the primary reason for the decision was fear of a lawsuit:
Gable said some of the concerns were the liabilities of the situation, although he acknowledged he had been waiting to no avail for a call from a lawyer. He also said even the slightest risk was too much.
But the reaction of the parents to the decision is astounding, and illustrates how far we've come as a nation in understanding this disease:
But nearly all the parents in attendance said the board made a bad decision without any knowledge of how AIDS is transmitted. Only about four people raised their hands when asked if they supported ousting Derrig.
There were accusations of prejudice, discrimination and even shouts about stupidity -- especially when one of the board members tried to create a scenario of Derrig bumping heads with an injured, bleeding football player and possibly transmitting the disease.
``You can't get it that way,'' several of the parents screamed.
``Are you going to test all your coaches for this?'' another one yelled out.
Renee Schram, whose 7-year-old son plays on the team, pleaded with the board to consider the example it was setting for the children of Ellet.
``This man is a part of our community. We're turning our back on a part of our community, and we're teaching our kids that,'' Schram said.
Post Partum Hurdles: Think coming back to a desk job after maternity leave is tough? Consider what it's like for athletes. posted by Sydney on
8/04/2003 08:41:00 AM
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The AcceleGlove is a wearable computer with super-small electronic circuitry. Sensors in the glove work with a micro-controller attached to the wearer's arm, mapping the placement and movement of the arm and fingers. That information is turned into data a computer can read and convert to words heard from a loudspeaker or read on a computer screen.
Predictably, some in the deaf community object. They feel it threatens their unique culture. posted by Sydney on
8/04/2003 08:34:00 AM
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Ephedra: Michael Fumento argues that ephedra should be left alone. While it may not be necessary to ban it, the drug should at least be subject to the same set of regulations as other drugs. And that's the problem with its current use. It's sold as if it's as safe as coffee - but it's not. posted by Sydney on
8/04/2003 08:15:00 AM
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Sunday, August 03, 2003
Scrutinizing Elderly Drivers: A reader's analysis of the impaired elderly driver study:
John at Number Watch would love this type of digit twiddling.
1) Although the number of 70 and older killed increased by 27% the number of drivers 70 and older increased by 32%
2) The average daily mileage of 70 and older drivers also increased by 20%.
By my calculation:
1) The accident RATE per driver changed by 1.27/1.32 or 0.96, DOWN 4%.
2) The accident rate per mile changed by 1.27/(1.32*1.20) or 0.80, DOWN 20%.
How to Discourage Tourism: Health officials plan to monitor the health of Lake Erie beach visitors this summer:
The EPA will have about 20 interviewers posted at the beach who will ask a few basic questions when visitors arrive and leave, such as whether they swallowed any water.
Researchers also will follow up 10 to 12 days later to see if beach-goers came down with any illness or symptoms.
Not a bad idea, considering the following:
Huntington also faces several potential sources of possible contamination: a drain pipe near the beach dumps storm water into Lake Erie; and nearby Porter and Cahoon creeks, which also could carry contamination, empty into the lake near the beach.
I've never been brave enough to swim in Lake Erie, although we used to like to have family picnics on its shores. But the dead fish and birds became such a problem that the kids made us promise never to take them there again. It was a promise easily made, since at the time we were parked near a man reading this book, which has a very prominent cover illustration. Not that the heterosexuals behave any better there. Beats me how Ohio gets its reputation for being drab and dull. posted by Sydney on
8/02/2003 11:26:00 PM
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To Our Health: Lawyers may have all the money, but doctors have all the health: "
Although the precise cause is unclear, a study of thousands of former students of Glasgow University found that arts and law students were most likely to die early.
Science, engineering and medical students lived longer, although medics were most likely to die from alcohol-related causes."
Clueless: That pond in Maryland that was of such intense interest as a possible breakthrough in the anthrax cases has turned dry:
"The FBI spent about $250,000 and three weeks draining 1.45 million gallons of water from the pond in a search for evidence -- including clothing and soil samples -- that might lead to the culprit who sent the deadly anthrax bacteria in the mail that killed five people and sickened 17 others in the fall of 2001.
But the search netted nothing more than a hodgepodge of items -- a gun, a bicycle, fishing lures -- none of which appeared to be linked to the case, sources said."
Discouraging Exercise: All of those mirrors in health clubs are turning women off exercise, which means the mirrors may just have to go:
"The findings may provide insight into how best to encourage sedentary women to get physically active. Currently, standard guidelines for exercise promotion recommend that workout rooms have mirrors on at least two of four walls.
'As such, the recommended practice of placing mirrors in exercise centers may need to be reconsidered, especially in centers that are trying to attract exercise initiates,' researcher Kathleen A. Martin Ginis says in a news release. 'Certainly, if a woman leaves the gym feeling even worse than when she arrived, she will not be particularly motivated to continue exercising in the future." posted by Sydney on
8/02/2003 10:01:00 PM
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Viagra Marriage: Andrew Sullivan has dug up some weirdly clinical reflections on marriage and male sexuality by the Catholic Church. Here's his source. Given the dearth of sexuality in the life of Christ, you would think the Church would realize that the minutiae of sex isn't all that important in the larger spiritual scheme of Christianity. posted by Sydney on
8/02/2003 07:56:00 PM
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Men Behaving Badly: A recent study by "evolutionary psychologists" claims that male promsicuity is genetically determined:
Schmitt's study, which was published in the July issue of the Journal of Personality and Social Psychology, involved 16,288 volunteers from 50 countries in the Americas, Europe, Africa and Asia, as well as Australia. Asked how many partners they desired over the next month, men on average said 1.87, while women said 0.78. Men said that over the next 10 years they wanted 5.95 partners, while women said they wanted 2.17.
More than a quarter of heterosexual men wanted more than one partner in the next month, as did 29.1 percent of gay men and 30.1 percent of bisexual men, the study said. Just 4.4 percent of heterosexual women, 5.5 percent of lesbians and 15.6 percent of bisexual women sought more than one partner.
Or maybe it just shows that there are a lot of men out there across all races and nationalities who are in unhappy relationships. (Looked at that way, it doesn't speak so well for the world's women, does it?) But, even if you buy the claim that the study proves a genetic basis for male infidelity, the fact remains that men of all nations have the capacity to choose to do the right thing:
"'I have heard people say, 'I can't help it, I am a man -- I have to spill my seed,' ' said Regan. 'That's using science to justify your bad behavior." posted by Sydney on
8/02/2003 07:41:00 PM
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Friday, August 01, 2003
E-Med School: Brown University and a few other medical schools are planning to offer the first two years of medical school over the internet. I've got mixed thoughts on this. On the one hand, you can't overestimate the value of interacting with fellow students in the crucible of medical school. And certainly, virtual education could never take the place of interacting with real patients. But in most medical schools, students are kept from real patients until their third year. The first two years are nothing more than lectures. And at least in my medical school, a lot of people never attended them. They would rely on "note services" to get the lecture content and spend the lecture time studying or sleeping. So, for the first two years of medical school, anyways, the e-school probably wouldn't make much of a difference. posted by Sydney on
8/01/2003 08:39:00 AM
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Good News: The American College of Osbstetricians and Gynecologists says that most women don't need yearly paps. Low risk women can now space out the most humiliating and awkward of exams to every three years. posted by Sydney on
8/01/2003 08:19:00 AM
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Gray Highway Menace: Elderly drivers are an increasing danger on American highways:
"An increasing number of older Americans are dying in car crashes as an aging population of licensed drivers stays behind the wheel, a study released Thursday says.
Nationwide, the number of people 70 and older who died in car crashes increased 27 percent between 1991 and 2001. During that same time, the number of licensed drivers 70 and older increased 32 percent, according to the report by The Road Information Program (TRIP), a nonprofit group that researches information about highways.
To be fair to the elderly as a group, however, the absolutenumbers aren't all that alarming, except for Florida and Texas. TRIP offers an interesting solution, however - the highway equivalent of large print books:
The report calls for more federal funding to increase roadway safety, including clearer signage with larger lettering and pavement markings; brighter lane markings at intersections; and wider lanes and shoulders on streets and highways.”
But the AMA has a different idea. Take away the driving privileges of the impaired elderly.
There will be those - mostly impaired elderly drivers - who will claim that this is ageism, but there’s no denying that there are those among the very old who should not be driving. People with age-related macular degeneration, cataracts, strokes, senile dementia, heart conditions that place them at risk for sudden death. The list goes on and on. It’s no easy thing to take away a person’s driving privileges. Usually it only buys animosity for the doctor or the family member who has to enforce it. Voices get raised, and sometimes fists. Accusations of condescension and deprivation get hurled. And sometimes, tears are shed. No one likes to face the loss of their liberty. It can be heart breaking. Which is why, sometimes, the practice of medicine requires a hard heart.
UPDATE: C. Henry says:
This is never a fun topic, but is common in an ophthalmology practice, especially one that deals regularly with neuro-ophthalmology and disease resulting in visual field defects.
Usually it is in context of a routine examination of a patient who has an existing diagnosis of glaucoma or retinal disease that also needs a routine certification to renew a driving license. I discover some excluding, irreversible defect and have to tell the patient they cannot meet the visual qualification to drive. It can be
heartbreaking. Sometimes the patient is the supporting member of their household, the only one of an elderly couple still driving. Sometimes it is a widow or widower with limited local family and no other practical means of mobility. The loss of driving privileges for them is devastating. But to say nothing is to shirk your public duty (and possibly the requirements of law) and to permit driving by someone who when driving is dangerous to themselves and others.
We have a duty to care for our patients, not to lie for them.
In these cases I tell them plainly not to drive anymore. I carefully
document that I specifically told them not to drive and why. I also
note who was present when I told them that. I don't talk around the subject, or give them the impression that I am only making a
suggestion. Some actually are relieved to be told not to drive; others obviously are not.
Like I said, practicing medicine well requires a hard heart. I don't lie for my patients, either. Which is why some of them accuse me of having no heart. posted by Sydney on
8/01/2003 08:04:00 AM
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