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    Friday, September 24, 2004

    Sins of Omission: Bard-Parker thinks things are improving. We're no longer being accused of actively trying to kill our patients, just passively.
     

    posted by sydney on 9/24/2004 09:09:00 PM 3 comments

    Canadians Respond: Evidently, Canadians aren't exactly in agreement about the state of their healthcare:

    Might I take a moment to "fisk" the comments from my fellow citizen. I'm not certain where this individual has been living lately but it certainly hasn't been inside the Canadian health care system.

    I think I can speak from a position of some knowledge. I am a nurse currently working on a PhD in a health related field. My husband is an overworked GP. Between us we have 40+ years of toiling in this system in two different provinces and have a number of family and friends working in various aspects of health care throughout the country. Anyway here goes...

    Canada has an enviable record of providing universal, quality health
    care at a reasonable price for the last half a century. But, as in
    every other country, our health care system is facing several strains:
    While we have a history of providing excellent care, currently we are not living up to expectations.


    The system is not just strained it is about to implode. There are not enough physicians (one town in northern Ontario has put paving its streets on the back burner in order to have money to recruit doctors - 80% of its citizens are without a primary care physician). We anticipate a severe nursing shortage in the next few years and presently do not have enough lab or x-ray techs to fill vacant positions. Why? In short, no one wants the jobs. How come if its such a great system no one wants to work in it?

    Soaring health care costs, driven by astronomical salaries paid to senior medical practitioners by competing private health-care providers in the US.

    Huh?? I simply just don't understand this comment. What private health care providers pay physicians in the US has no bearing on what provincial governments (the only real employer of physicians in Canada) are willing to pay. Government budgets have been under considerable constraint in the last few years and physicians have received only a few meagre increases in renumeration. In fact, their renumeration levels have not kept pace with other health care sector employees. Compared to their counterparts in the US, Canadian physicians are significantly underpaid.

    Disproportionally high usage of the health care system by Canada's
    exploding immigrant population.


    Might have a point here but its anecdotal only. I am unaware of any study that has quantified this. Ageing population needing more health services is a problem everywhere in the western world but particularly salient in Canada as compared to Europe - we had a larger baby boom.

    The answer of US-worshipping Canadian neocons is two-tier health care. Why, cries John Tory, the new leader of the hapless Ontario Conservative party, shouldn't Canadians have "choice" in their health care services? This is classic conservative re-framing of public debate. "Choice" in health care means choice for those who can afford it, which means doctors who want to make obscene amounts of money (including many of the best ones) would work for the higher-paying private-tier system and the rest of us would be stuck with long waits and second-class service, just like we face in every other private sector of the economy.

    Good lord, where do I begin. Let's start with the epithet "neocon". Then again let's not. I'm tired of trying to have a rational discussion with my fellow citizens about how the whole system is just crumbling only to confront the "neocon" argument. Oh, and by the way, reforming the system is not about physicians being able to make "obscene amounts of money". Somehow the argument always seems to return to this as well. Bottom line, Canada is the only country in the world that does not allow its citizens to spend their own money on health care. England, Australia, Germany, France (just to name a few) all have complimentary private systems and yet manage to have public systems that are (in many cases) superior to Canada's.

    Fortunately, and to the chagrin of the Canadian neocons, the vast majority of Canadians aren't buying this Orwellian deceit. Recent polls say support for a public, single-class health care system is as high as ever.

    Really? What polls? Last I saw people were actually warming up to the idea of a complimentary private system.

    So what's a civilized country to do to deal with the three great challenges of 21st century health care bulleted above? I recently listened to a talk show featuring the federal Minister of Health, discussing how these problems should be solved. Caller after caller said the same two things:

    Much of the work done by doctors should be transferred to paraprofessionals and to self-diagnosis and self-treatment. Much more
    information, expert systems and self-service equipment needs to be
    provided to enable this. [I spoke to two doctors who said they would
    love to do this, since the majority of the work they do does not
    require a licensed professional to do it competently -- but that the
    lawyers wouldn't let them do it.]


    Which paraprofessionals? I'd really like to know what he/she means by this. For instance, I would consider a nurse practitioner to be a professional not a paraprofessional and while they are a good idea there are a number of limitations. Remember that nursing shortage I mentioned previously? Well, if we turn more nurses into nurse practitioners who's going to take their place? Robbing Peter to pay Paul. Besides, it takes 5-6 years to create a nurse practitioner (4 years for a BScN then 1 to 2 years post grad training) so, we're not exactly going to have a glut of them anytime soon. Oh, and then there is the little problem of their scope of practise. Currently, most NP's do well baby care, prenatal care, uncomplicated diabetes management, uncomplicated HT management, colds, flu, etc. But, as we have already noted, the population is ageing. When was the last time you saw a someone over the age of 65 who needed well baby care or for that matter had uncomplicated diabetes? What the ageing population is going to need are more physicians with good internal medicine knowledge not more people who are limited to diagnosing otitis media.

    There needs to be a massive shift in the health care system from
    treatment to preventative care.


    Snort! And this pays off when exactly?? What do we do with all the boomers who have already smoked and eaten their way into chronci illness? Furthermore, the last time I looked there wasn't any preventive measure for growing old. In other words, if we sink a lot of money into prevention we might (just might mind you because after all we have to die of something) affect the health care budget in 2060.

    When the moderator asked the Minister whether he had learned anything from these recurring messages, he 'summarized' the discussion by saying that better measurement systems were needed to ensure hospitals were operating as efficiently as possible, and that the government was looking into ways to do public-private partnerships without allowing competition or giving up control over pricing and access. The interviewer was incredulous: Had the Minister not heard the two messages that the public had been bombarding him with for the past hour? Of course these things would be considered, he replied, but the first priority was to find ways to increase access without increasing cost. His deafness to these two obvious solutions to the malaise of the system was astonishing.

    See above.

    What one listener of this talk show said about neoncons' true motivation for wanting two-tier health care was also telling: "The reason rich politicians want a two class system is that they're embarrassed to have to wait in line for health services the same as 'ordinary' Canadians, when their US business colleagues can jump the queue so easily and have their company write off the extra cost as a business expense. They're also embarrassed that, to jump the queue,they have to fly to the US and pay out of their own pocket". So in fact there is a choice for the very rich to jump the queue: Pay for treatment in the private US system.

    Sigh. It's the neocons again (bad neocons, bad). Hate to tell him but, I don't think there is much of a queue to jump in the US. Also, I don't think embarrassment is the motivation here. Stark, cold fear maybe, but not embarrassment. Hell, median wait time to see an oncologist post cancer dx in Canada is 6 weeks. If I had the money, a dx of cancer, and was looking at at least a 6 week wait for treatment...Mayo clinic here I come.

    Is Canada's health care system the best in the world? Far from it. Health care in Canada's cities is much better than in rural areas. The bureaucracy in much of the system (notably the blood collection system and the 'walk-in' clinics) is suffocating, and needlessly so. And because of its zeal to protect jobs in the system, Canada, which ranks first in the world in per-capita patents of medical technology, ranks forty-first in the world in the use of modern medical technology in its hospitals (MRI equipment is as scarce as gold, for example).

    Again, I don't get what he means about bureaucracy and the blood collection system or "walk in clinics". I suspect walk -in-clinics run just the same up here as they do in the US. Child's got an ear ache and you don't want to wait 8 hours in emerg (or three weeks for an appointment with your overworked family physician) go to the walk-in.

    Canada is in thelower 1/3 in OECD countries when it comes to providing medical technology and sinking fast. But it's still an excellent system, and one that a two-class health care system won't improve, at least for 95% of the population. If only the politicians and bureaucrats only had the intelligence and vision to listen to the Wisdom of Crowds and make the two changes (more paraprofessional/self-care, and more prevention instead of treatment) that the public is already starting to make themselves, our system would be the best in the world.

    Excellent system? No access to technology, unacceptable wait times for treatment, professional bailing with no one to replace them, can't find a doctor - yep, that's my definition of an "excellent" system.

    Oh -- a word about prescription drug costs: You may have heard that
    many Americans come up to Canada to buy prescription drugs much cheaper than they can buy them in the US. Now, US municipal and state governments are fighting for the right to buy their drugs from Canada, too (and Kerry wants them to have this right). The funny thing is, the companies selling them are essentially all the same companies, since the Canadian pharmaceutical industry is dominated by the same handful of global corporations as the US industry. Why do these companies charge more in the US than the rest of the world for the same drugs? Not, as the neocons and the pharma industry are telling Americans, because Canadian drugs are inferior (perhaps, it is implied, dangerously so) -- they are the identical drugs. They sell them for higher prices in the US because they can. Drug companies charge as much as the market will bear, and in the bloated US health care system where if you have enough money you can buy anything, the market will bear a lot. In the rest of the world money available for drugs is much less, so to sell their products pharma companies lower prices by 30, 50, even 70%, and still make a good margin. This is a case where globalization threatens to backfire on some of the corporations that most benefit from it. Couldn't happen to a nice bunch of guys.


    You're correct on this issue. It's because provincial drug plans (they cover a significant amount of the cost of drugs for seniors, welfare recipients etc) determine what goes on their formularies (the drugs they will cover) they are able to bludgeon the drug companies into supplying the meds at a lower cost. In essence US drug consumers are subsidizing all the R&D that we eventually benefit from. I'm going to say thanks but somehow I doubt your grateful.

    And no, antibiotics aren't available without a prescription up here. My husband was flabergasted when we walked into a pharmacy in Mexico only to see just about every antibiotic he prescribes for sale over the counter. Ticked him off as well. Physicians here get a lot of grief about "over prescribing" antibiotics (implicitly blamed for increasing antibiotic resistence) when in many countries (Mexico obviously and according to his patients, much of Eastern Europe) they are OTCs. To the best of my knowledge about the only difference in prescription vs. non prescription meds between Canada & the US are some of the antihistamines (Loratadine and dimenhydrinate are OTC for instance).

    Anyway, sorry for the screed but I'm soo sick of my unenlightened fellow citizens who feel the need to flaunt their apparent health system superiority. Hate to tell them, but the emperor has no clothes.


    And about that "two-tiered" system, another reader notes:

    A comment from your Canadian correspondent caught my eye:

    Health care in Canada's cities is much better than in rural areas.

    Hmmm, and is that somehow NOT a "two tier system"? Looks like one to me.

    Well, then, what is to be done? Here'a a modest proposal. Let there be a government appropriation of the labor of physicians in the name of the people, and let physicians work for a compensation that the people deem fair. And let physicians, or other health professionals, be prohibited from working for any health care company that pays "astronomical" salaries. And let the government determine where each physician and health care professional will work - urban or rural, in the name of the people. And while we are at it, let laws be enacted to prevent those "high utilizing immigrants" from entering the country, and let us arrange to deport those immigrants who are guilty of high utilization. And finally let us ration the care for our seniors. This solves our cost problems, so we can then proceed building the world's finest health care system with the finest docs and hospitals.

    This reminds me of "The Doctor's Dilemma" - well, not Shaw's play actually, but his lengthy introduction, in which he argued for physicians to become public employees.

    Was Shaw so much ahead of his time, or is the set of proposals above so 100 years ago?


    Maybe the latter, considering Shaw believed vaccinations were dangerous. Oh, wait, that's a modern bugaboo, too. The more things change, the more they stay the same....

     
    posted by sydney on 9/24/2004 08:11:00 PM 0 comments

    Rather Biased: Michael Fumento remembers a similar case involving CBS from three years ago.

    Actually, the fact that the news is slanted is nothing new. It's been that way at least since the late 1970's when "investigative" journalism became the fashion in the wake of Watergate. Since then, it's been the goal of every news team, from local to national beats, to be the Woodward and Bernstein of their area. What local news station doesn't have an "I-Team" now?

    Their goals aren't to discover and report the facts, but to prove that someone in authority is behaving badly - whether that position of authority comes from the government, an oil company, a pharmaceutical company, or the medical establishment. In the process, the media has overlooked the fact that they've become "authority figures", too. And what do you know? They're more corrupt than other parts of the establishment, which at least have some measures of checks and balances in place.
     
    posted by sydney on 9/24/2004 08:22:00 AM 0 comments

    Thursday, September 23, 2004

    Norman the Mutant Poppy: A Tasmanian mutant poppy named Norman is in the news because he's morphine free:

    A mutant morphine-free opium poppy holds the key to producing less addictive pain management drugs, Australian scientists say.

    The poppy, nicknamed Norman and grown in Tasmania, produces no morphine or codeine, CSIRO plant geneticist Dr Phil Larkin said.

    Instead, a block in the biochemical pathways that would normally produce those substances leads to an accumulation of their precursors, thebaine and oripavine.

    Both those substances are already being developed into less addictive painkillers as well as addiction-treatment drugs, Dr Larkin said.
     

    posted by sydney on 9/23/2004 10:33:00 PM 0 comments

    Political Season: There's a great discussion going on over at Roger Simon's blog on the healthcare crisis. I have to agree with Simon, ever since I can remember the system has been "in crisis," and yet it somehow never comes to a head. This comment is also an apt observation on healthcare as a "right":

    If health care is a fundamental right, it is different than other fundamental rights such as free speech, freedom of religion, protection against illegal search and seizure, and the right to bear arms. The other rights do not require that someone else pay for your right out of their pocket.
    (via Grunt Doc.)

    And the debate on tort reform continues over at PointofLaw. Today, Ted Frank explains why we should avoid the use of the word "frivolous."

    MORE: Even the New England Journal of Medicine is getting into the act, with a first in a series of articles on healthcare issues in the election. This week's is a study of opinion surveys on how voters rate the issues. Healthcare is number four, after the economy, the Iraq war, and the war on terrorism. And what about the problem of the "45 million uninsured"? Even the 45 million uninsured don't see themselves as a priority:

    The survey data suggest that voters are not focused heavily on the problem of the nation's 45.0 million people who do not have health insurance. Pre-election polls have shown that although that problem is an important health care issue, it is ranked below the costs of health care and health care insurance, Medicare, and prescription drugs. Surprisingly, even among uninsured voters, the subgroup most affected, this issue is seen as only slightly more important than other health care issues, and it is not significantly more important for these voters than for voters who have health care insurance. (emphasis mine)

    I suspect the uninsured vs. insured numbers are so similar because most of uninsured are transiently uninsured. They're between jobs and expect to get insurance shortly. Or, they're people who have chosen to go without insurance and don't really see it as a problem. The authors of the article see that as a problem, wondering how a comprehensive solution can be had if even the uninsured don't care about their situation. Maybe policy makers should take that as a clue that the problem of the uninsured isn't, in reality, as big a problem as they think. It's more a reaction to a number than it is to a situation.

    UPDATE: One reader's reaction:

    Most people who routinely exercise their "bill-of-rights" rights (like
    the ones quoted above), require organizations to exist that constantly
    fight to keep those rights operative. Paid for by others.

    Most people who exercise their freedom of religion do it by going to a
    house of worship that was mostly paid for by someone else. (That's a lot
    like saying that I exercise my health rights by going to a hospital that
    (including its services) was paid for by someone else. Religious
    building fund costs probably rise almost as fast as health costs,
    definitely ahead of inflation.

    People who exercise their right to bear arms place a terrific cost on
    the rest of American society. We pay for some of the carnage those guns
    produce, and we pay for the extra police who try to keep the playing
    field equal, AND we pay for all the heavy artillery those police need to
    protect themselves about those rightful arms that fall in the wrong
    hands.


    First of all, freedom of religion does not come via the financial generosity of others. Churches are bought and paid for by their congregations, not by tax dollars. Ditto their maintenance. No religious group is guaranteed the right to a building in which to worship. The only thing they're guaranteed is the right to gather and worship. Period.

    The right to bear arms does not include the right to have other people purchase your guns for you. You can argue that an armed citizenry is costlier to society than an unarmed citizenry, but it's an indirect cost. Every right has an indirect cost. Freedom of speech, for one, often comes at a steep price. But no one expects the government to provide everyone with a free soap box, or newspaper, or blog. When people talk about healthcare as a right, however, they are talking about having others pay directly for that right. There's a difference. A huge difference.



     
    posted by sydney on 9/23/2004 10:08:00 PM 0 comments

    Meddling: The downside of government run medicine is the intolerable government meddling.

    And check out the links (especially this one and this one) in the comment section, too, to see the perversities these sorts of mandates introduce to the system.

    NOTE: This was double-posted by mistake earlier. I removed the version I liked least.
     
    posted by sydney on 9/23/2004 09:48:00 PM 0 comments

    Learning: I went to a conference on infectious diseases yesterday and learned about this. The article makes it sound benign, but the case study was a man who developed a severe kidney infection because the piercing obstructed the flow of his urine from his bladder. So consider yourself warned!
     
    posted by sydney on 9/23/2004 01:52:00 PM 0 comments

    Tales from the North Country: A Canadian reader, and frequent contributor of ideas to this site, on healthcare in Canada:

    Canada has an enviable record of providing universal, quality health
    care at a reasonable price for the last half a century. But, as in
    every other country, our health care system is facing several strains:

    Soaring health care costs, driven by astronomical salaries paid to senior medical practitioners by competing private health-care providers in the US

    Disproportionally high usage of the health care system by Canada's
    exploding immigrant population

    Ageing population needing more health services

    The answer of US-worshipping Canadian neocons is two-tier health care. Why, cries John Tory, the new leader of the hapless Ontario Conservative party, shouldn't Canadians have "choice" in their health care services? This is classic conservative re-framing of public debate. "Choice" in health care means choice for those who can afford it, which means doctors who want to make obscene amounts of money
    (including many of the best ones) would work for the higher-paying private-tier system and the rest of us would be stuck with long waits and second-class service, just like we face in every other private sector of the economy.

    Fortunately, and to the chagrin of the Canadian neocons, the vast majority of Canadian's aren't buying this Orwellian deceit. Recent polls say support for a public, single-class health care system is as high as ever.

    So what's a civilized country to do to deal with the three great challenges of 21st century health care bulleted above? I recently listened to a talk show featuring the federal Minister of Health, discussing how these problems should be solved. Caller after caller said the same two things:

    Much of the work done by doctors should be transferred to
    paraprofessionals and to self-diagnosis and self-treatment. Much more
    information, expert systems and self-service equipment needs to be
    provided to enable this. [I spoke to two doctors who said they would
    love to do this, since the majority of the work they do does not
    require a licensed professional to do it competently -- but that the
    lawyers wouldn't let them do it.]

    There needs to be a massive shift in the health care system from
    treatment to preventative care.

    When the moderator asked the Minister whether he had learned anything from these recurring messages, he 'summarized' the discussion by saying that better measurement systems were needed to ensure hospitals wereoperating as efficiently as possible, and that the government was looking into ways to do public-private partnerships without allowing competition or giving up control over pricing and access. The interviewer was incredulous: Had the Minister not heard the two messages that the public had been bombarding him with for the past hour? Of course these things would be considered, he replied, but the first priority was to find ways to increase access without increasing cost. His deafness to these two obvious solutions to the malaise of the system was astonishing.


    What one listener of this talk show said about neoncons' true motivation for wanting two-tier health care was also telling: "The reason rich politicians want a two class system is that they're embarrassed to have to wait in line for health services the same as 'ordinary' Canadians, when their US business colleagues can jump the queue so easily and have their company write off the extra cost as a business expense. They're also embarrassed that, to jump the queue,they have to fly to the US and pay out of their own pocket". So in fact there is a choice for the very rich to jump the queue: Pay for treatment in the private US system.

    Is Canada's health care system the best in the world? Far from it. Health care in Canada's cities is much better than in rural areas. The bureaucracy in much of the system (notably the blood collection system and the 'walk-in' clinics) is suffocating, and needlessly so. And because of its zeal to protect jobs in the system, Canada, which ranks first in the world in per-capita patents of medical technology, ranks forty-first in the world in the use of modern medical technology in its hospitals (MRI equipment is as scarce as gold, for example).

    But it's still an excellent system, and one that a two-class health care system won't improve, at least for 95% of the population. If only the politicians and bureaucrats only had the intelligence and vision to listen to the Wisdom of Crowds and make the two changes (more paraprofessional/self-care, and more prevention instead of treatment) that the public is already starting to make themselves, our system would be the best in the world.

    Oh -- a word about prescription drug costs: You may have heard that
    many Americans come up to Canada to buy prescription drugs much cheaper than they can buy them in the US. Now, US municipal and state governments are fighting for the right to buy their drugs from Canada, too (and Kerry wants them to have this right). The funny thing is, the companies selling them are essentially all the same companies, since the Canadian pharmaceutical industry is dominated by the same handful of global corporations as the US industry. Why do these companies charge more in the US than the rest of the world for the same drugs? Not, as the neocons and the pharma industry are telling Americans, because Canadian drugs are inferior (perhaps, it is implied, dangerously so) -- they are the identical drugs. They sell them for higher prices in the US because they can. Drug companies charge as much as the market will bear, and in the bloated US health care system where if you have enough money you can buy anything, the market will bear a lot. In the rest of the world money available for drugs is much less, so to sell their products pharma companies lower prices by 30, 50, even 70%, and still make a good margin. This is a case where globalization threatens to backfire on some of the corporations that most benefit from it. Couldn't happen to a nice bunch of guys.


    Actually, I thought the prices were so much lower in other countries because their governments force lower prices. They'd rather take the lower prices than do without the market, but, because our government doesn't set prices for drugs, we in the U.S. have to pay the higher cost. If drug importation becomes the norm, you can bet the prices in Canada will go up to meet the prices in the U.S.

    The safety issue isn't because the drugs come from Canada. It's because many people send for them from big warehousing operations whose integrity is unknown. There have been cases of counterfeit drugs being passed on this way. Of course, that can happen with the big mail-order warehouses in the U.S., too, I suppose.

    I wouldn't put so much hope on "self-treatment" and preventive care to reduce costs. Preventive care costs a lot of money, and it doesn't guarantee that more money won't be spent further down the line. Providing colonoscopies for everyone over a certain age will cut down on the number of colon cancers in the future, but those same people will live to have other diseases that can't be entirely prevented- arthritis, emphysema, heart disease, other cancers. And self-treatment? Well, if you treat yourself for the wrong diagnosis, you're going to be a lot sicker than you were to begin with. (I thought Canadians are already allowed to self treat. Aren't antibioitics available without a prescription up there?)
     
    posted by sydney on 9/23/2004 01:32:00 PM 0 comments

    TLC: The human touch can add a lot to the treatment of depression:

    Today's treatments for depression can leave a lot to be desired, but new pills or modes of therapy are not necessarily the answer. Rather, simple changes in how existing treatments are delivered can yield significant improvements.

    A new study, published in this week's issue of the British Medical Journal, found that inexpensive enhancements to care by primary care physicians, such as follow-up phone calls to patients, could boost response to treatment by almost 30 percent.

    Perhaps as significant as that finding, however, is that the five large U.S. medical groups involved in the study, including Highmark Blue Cross Blue Shield, have decided to make the changes permanent.

    'It's not a complex intervention,' said Dr. Alan Axelson, Highmark's medical director for behavioral health, and it costs little more than the standard care already provided by primary care physicians.'


    And they don't have to pay the phone bill, an added benefit, I'm sure.
     
    posted by sydney on 9/23/2004 01:29:00 PM 0 comments

    Wednesday, September 22, 2004

    Eat Like an Italian, Walk Like an Aborigine: That's the key to staying healthy and wise according to this week's Journal of the American Medical Association:

    It is never too late to eat well and exercise every day, according to four new studies that found healthy lifestyles can produce dramatic benefits for the body and mind even among the elderly.

    ...One of the studies found that elderly people who ate a healthful diet, exercised regularly, drank alcohol moderately and avoided smoking slashed by more than half their risk of dying from any cause, while another found that the same diet improved blood-vessel function and reduced inflammation. The two other studies produced the strongest evidence yet that simply walking every day goes a long way toward keeping the mind sharp and warding off dementia, including Alzheimer's disease.


    Actually, the data aren't as impressive as the news reports are making them out to be. The first study followed 2,339 European seniors ages 70 to 90 for ten years. Forty-percent of them died during that time. Periodically, they would answer questionairres about their eating, drinking, smoking, and exercising habits.

    A "Mediterranean" diet was a diet higher than average in legumes, fruits, vegetables, monounsaturated fatty acids, nuts, grains and fish, but lower than average in meat and dairy products. It was healthier to drink than to teetotal, healthier to never smoke or to have quit fifteen years ago, and healthier to walk the equivalent of thirty minutes every day. Assuming that the study subjects answered their questionairres truthfully and accurately, which is a big assumption, they were rated on a score of 0 to 4 in terms of health, with one point for each category. The higher the score, the healthier the lifestyle.

    The absolute mortality rates over the ten year period in this very elderly population were 66% for those with the lousiest lifestyles (a score of 0 to 1), 60% for the moderately lousy (score of 2), 56% for the moderately healthy (score of 3) and 56% for the healthiest lifestyles of all (a moderate non-smoking drinker who exercises daily and eats Italian-style.) The most important factors influencing longevity during this ten year period were cigarette smoking and exercise. Diet and alcohol were a little less influential. And while the difference between the 66% mortality rate for tobacco-puffing, couch-potato teetotaling cheese-burger eaters and the 56% mortality rate for athletic, non-smoking, pasta and wine afficionados is significant, it's impossible to tell from the study what contribution the diet makes. It also isn't "dramatic" - the word I heard used on NPR this evening to describe the results.

    The second study took 180 patients diagnosed with the metabolic syndrome and put one half of them on a "Mediterranean diet" and one half on a diet of their choice. The biggest difference between the two groups was that those on the Mediterranean diet were given detailed instructions, counselling, and encuragement in their diets. Those in the control group were just given general instructions about healthy food choices. After two years, those on the Mediterranean diet had lower average blood sugars, lower trigycleride levels, (by twenty points), lower insulin levels, and smaller waists. The diet had their metabolic syndrome symptoms, at least by a little bit. But the study didn't look at mortality at all.

    And what about dementia and exercise? There were two studies that looked at that relationship. One was devoted to elderly men, the other to elderly women. The study in men involved 2257 Hawaiian men who reported their physical activity from 1991 to 1993. They were then examined for dementia from 1994 to 1996 and again in the time period from 1997 to 1999. The study didn't find out if their activity levels had changed since the intial evaluation, but among those who walked less than one quarter of a mile a day from 1991 to 1993, eight per cent developed dementia. Among those who walked over two miles a day, four percent developed dementia. It's not a huge difference, but it does show a small benefit for those who exercise.

    The women's study looked at the physical activity and mental dexterity of 18,766 elderly nurses (ages 70 to 81) from 1986 to 2003. Unlike the study in men, the researchers asked the women about their physical activity every two years during the study. They then performed mental status tests over the telephone on two occasions at two year intervals in the final four years of the study. The women had to do such things as recall parapgraphs, name as many animals as they could in 1 minute, and count backwards. The researchers gave the women scores based on their performance and combined them into their own scoring system which only they completely understand. The women who exercised the most vigorously performed better on the telephone exams than those who did not exercise, but we have to take their word for it when they tell us the results were significantly different.

    There's no doubt that staying active is important in living a satisfying life in the twilight years. Joints stay nimbler, balance is better, and overall satisfaction with life is better for those who make an effort to keep moving. Spending your old age in front of the television (or computer) causes joint stiffness and social isolation. But does it stave off Alzheimer's? If it does, not by much.

    P.S. For those of you who are interested, here's some information on the the Mediterranean diet. For the metabolic syndrome study the diet consisted of the following:

    50-60% carbohydrates
    15-20% protein
    <30% total fat (saturated fat <10%)
    cholesterol consumption <300mg/day

    And more specifically, eat at least:

    250-300g fruits each day
    125-150g vegetables
    25-50g walnuts
    400g whole grains (legumes, rice, maize, wheat)
    Use olive oil

    Personally, that seems like an awful lot of mental effort to put into eating.


     

    posted by sydney on 9/22/2004 07:40:00 AM 0 comments

    Debate Goes On: The very interesting and informative debate of the candidate's tort reform proposals continues at PointofLaw. Just keep scrolling down to September 21 and 22 for the most recent back and forth.
     
    posted by sydney on 9/22/2004 07:26:00 AM 0 comments

    Tuesday, September 21, 2004

    Grass, Greener: As is so often the case, this advocate of a single-payer system sings the praises of Canada, but this Canadian ex-pat says things are better here.
     

    posted by sydney on 9/21/2004 10:51:00 PM 0 comments

    When Enough is Enough: You think you had to wait long at the doctor? Listen to this:

    Mr Milne was in his workshop on Friday afternoon when a colleague accidentally drove the nail into his finger using an pneumatic gun.

    With the nail embedded in the middle finger of his left hand Mr Milne, 54, went to the hospital's A &E department, arriving at about 2.30pm and was seen by a doctor at 3.40pm.

    He said he was then sent to Ward 39 at around 5.30pm, examined and X-rayed.

    He said he was then told that he would need to be operated on by a plastic surgeon who would not be able to do it until later that night.
    When the doctor made his last round at about 7pm, Mr Milne claims he was told that he would not be operated on until 9am the following morning.

    After spending the night in a hospital bed, he said he was seen by a consultant who told him that there would be a further delay until lunchtime. At 12.30pm, he was told that it would be a further few hours.

    'After I heard that, I decided to leave. They ran out after me but the doctor had had his chance,' said Mr Milne.


    He drove home where his local GP removed the nail in the office. He probably wishes he had just done it himself.
     
    posted by sydney on 9/21/2004 10:43:00 PM 0 comments

    Interesting Question: From a reader:

    Do we know of a Culture that only pays the doctor if the Patient get well or healed?? If so, is this a new or ancient culture??

    I don't know of any society that pays doctors only if their treatment is successful. For one thing, since so many treatments are less than perfect, such a payment structure would mean that doctors would rarely get paid. No one would ever want the job.

    The closest thing I could think of to this was the HMO-era of the 1990's when doctors were given bonuses by insurance companies for keeping the costs of patient care down. The assumption was that if less money was being spent on patient care, then the patients must be healthier. But of course, that's not the way the patients saw it. They saw it as a conflict of interest - the doctor sacrificing their care for a cash reward. It didn't make for very good doctor-patient relationships.
     
    posted by sydney on 9/21/2004 10:20:00 PM 0 comments

    Reform: A reader wonders if there's any hope at all for health insurance reform that divorces healthcare insurance from employment. I often wonder the same thing myself, and have to confess I'm not optimistic. Changes in healthcare benefits, along with wages, are usually some of the most contentious issues during labor negotiations with unions. Whether those unions are representing nurses, teachers, or steelworkers, they fight tooth and nail to keep their health insurance benefits. Ironically, when the inevitable lay-offs come so the company or school system or hospital can purchase those benefits, it's the (now former) union members who suffer.

    It's short-sighted of them, really. Wouldn't it be much better for workers to have the wages to help pay for their own policy so they wouldn't be left high and dry when the company folds? Of course it would. But there are so many special interests whose interests are best served by the current system, it would take a shake-up of major proportions to change things.

    Insurance companies like the current system because they can negotiate prices with pre-determined risk pools (large employers) rather than working with large, population-based risk pools. Employees of large companies (and their unions) like the current system because they don't have to think too much about their healthcare insurance alternatives, and the premiums feel like they're free since their employer does the paying.

    I'm not sure what the answer is. Maybe when all the large employers have moved to Mexico and we've become a nation of shopkeepers, then individual policies will catch on - but only from necessity.
     
    posted by sydney on 9/21/2004 10:01:00 PM 0 comments

    Polling 52 to 17: According to the Wall Street Journal, a recent Harris Interactive poll shows doctors and scientists beat lawyers and journalists hands down when it comes to prestige:

    Fifty-two percent of adults surveyed say they feel doctors and scientists have "very great" prestige. Other professions that are seen as having very great prestige include: firemen (48%), teachers (48%), military officers (47%), nurses (44%) and police officers (40%).

    The 10 occupations seen by the fewest people as having very great prestige were: real-estate agents (5%), stockbrokers (10%), accountants (10%), journalists (14%), bankers (15%), actors (16%), union leaders (16%), lawyers (17%) and business executives (19%).


    Journalists were less popular than lwyers and business executives. And that was before Rathergate. Ouch.
     
    posted by sydney on 9/21/2004 10:00:00 PM 0 comments

    Mind Games: The Weekly Standard has devastating review of the book Bush on the Couch: Inside the Mind of the President. According to the review, the book's author is practicing psychiatry from another place and time:

    Frank's 'clinical findings' might be put another way: How can someone who disagrees with me not be crazy? The author of Bush on the Couch sounds like a Soviet psychiatrist around 1950.

    In those days, when Stalinism was a cosmology, political dissidents were often sent to psychiatric hospitals as schizophrenics--the substance of their mental illnesses being their divergent political beliefs. Having recently interviewed a series of psychiatrists in Russia and the Baltic states, I came away with the impression that the psychiatrists who diagnosed and treated these people really believed their patients had psychiatric disorders. They never seemed to question the fact that all the criteria of illness were political rather than medical ones. And neither does Frank. The president dissents from Frank's view of the political world, and therefore science tells us that the president is insane.

    ...Mostly, though, Frank is blind to the underlying silliness of his enterprise. As an analyst and a psychiatrist, he has presumably learned to be forbearing, not judgmental, and not prejudicial. But his diagnoses in Bush on the Couch are nothing more than moral and political indictments that he offers as "scientific determinations." The election will prove a better diagnosis of President Bush.



    As I've said before, playing "pin the diagnosis" is great fun, but it's only fun if you play it with people you don't like, which means it's never fair and balanced. Even Freud couldn't resist the temptation.
     
    posted by sydney on 9/21/2004 09:25:00 PM 0 comments

    Texas Gets Results: Texas tort reform is bringing down malpractice premiums:

    Texas' largest medical liability insurance provider said Monday it will cut its rates by 5 percent starting in January.

    The drop by the Texas Medical Liability Trust, or TMLT, comes on top of a 12 percent decrease the company implemented last January, after a new law and state constitutional amendment allowed a cap on jury awards and limited insurance companies' liability.

    'If you think about it, that's a 17 percent reduction in rates in just a year, and I think what's more important than that, that's over $34 million of savings to TMLT's Texas physicians in a single year,' TMLT president and CEO W. Thomas Cotten said during a Capitol news conference.

    TMLT had raised its rates by 147.6 percent between 1999 and 2003, according to the Texas Department of Insurance.


    Remember that the next time someone tells you tort reform won't solve the medical malpractice insurance crisis.
     
    posted by sydney on 9/21/2004 06:36:00 PM 0 comments

    Picture Eyes: Why those portraits are always looking at us.
     
    posted by sydney on 9/21/2004 06:33:00 PM 0 comments

    Monday, September 20, 2004

    World Turned Upside Down: PointofLaw is featuring a debate this week about Kerry vs. Bush tort reform proposals. A doctor is arguing for Kerry, a lawyer for Bush.
     

    posted by sydney on 9/20/2004 06:39:00 PM 0 comments

    Ohio Activism: There's no doubt that Ohio is in the midst of a malpractice insurance crisis. In some parts of Ohio, malpractice insurance premiums are twice the amount of less litigionous neighboring areas. Doctors in my town have been forced to close their doors because they can no longer afford malpractice insurance. Some of my colleagues have bitten the bullet this year and are paying out over $50,000 for a one-year policy. I suspect that next year, a lot of them will close their doors, too.

    Our legislature has passed tort reform measures, but this isn't the first time they've been passed. In the past, the reform measures were cut down by the Ohio Supreme Court, which interpreted them as unconstitutional. The reason? The court was laden with judges who believe strongly in judicial activism - liberally interpreting the law so that it can be used an instrument of social reform. They believed in litigation, not legislation.

    Right now, we have a State Supreme Court that is tilted toward judicial restraint, but only by a margin of 4 to 3. That could change on Nov. 2, when we vote for four of the seven seats on the Ohio Supreme Court. This election could easily swing the court in favor of judicial activism by 5 to 2, which would mean our legislature's efforts at tort reform will have been, once again, for nought.

    I urge my Ohio readers to consider the choices for Supreme Court Justice carefully before voting. Justice Thomas Moyer, Justice Terrence O'Donnell, and Judge Judith Lanzinger are all candidates known to favor judicial restraint over activism. A non-partisan guide to the judicial race can be found here. A more detailed, although admittedly medically partisan, explanation of the importance of the race can be found here. Remember, your vote does count. You can stop the exodus of doctors from Ohio.
     
    posted by sydney on 9/20/2004 08:05:00 AM 0 comments

    It's a Choice, Not a Baby: Parents in India are increasingly choosing not to raise baby girls:

    The methods used in rural areas to kill unborn or newborn girls are varied and shocking. Opium is used, as well as oversalted milk, both of which cause the baby to die a slow and painful death. Midwives are known to hit newborn girls on the head or choke them.

    More modern methods are no less disturbing. Despite being outlawed in 1994 in an effort to stop the practice, ultrasound to determine the sex of a baby is also used to destroy the child in the womb.

    In cities and even rural areas across the country, tens of thousands of ultrasound sex-determination centers and abortion clinics have appeared. Although sex-determination tests have been banned in India since 1994, the ultrasound centers flourish openly throughout the country, often by bribing corrupt police and health officials.

    A doctor in the town of Aligarh, 70 miles southeast of New Delhi, said that many single-room ultrasound centers and private hospitals in the area earn more than three-quarters of their income from sex determination and abortions.


    In a society that still relies on the dowry, girls are only a burden. As they say, "Grooming a girl is like watering a neighbor's garden." So why shouldn't parents have the right to choose? That's the reasoning of at least one or two doctors:

    Dr. Aniruddha Malpani, a top in-vitro fertilization specialist who runs the flourishing Malpani Clinic in Bombay's upmarket Colaba neighborhood, defends freedom of choice for his patients regarding the sex of babies.

    "I have treated about 75 patients, and all of them chose to have sons. In a democracy, people should be allowed to choose the sex of their children," another physician said. "Activists say families should sacrifice themselves for the good of the country. That's nonsense," said the doctor, who insisted on anonymity.


    UPDATE: A reader:

    Just wondering -

    At what point does a market economy kick in and place the burden of dowry on the males? If the next generation really has 8-10% fewer females than males, then wouldn't men have to pay when there is a shortage of women?


    Good point. But I think what happens is, they just do away with dowries.
     
    posted by sydney on 9/20/2004 08:01:00 AM 0 comments

    Sugar, Sugar: Apparently, there's an amazing amount of placebo dispensing in Jerusalem:

    According to the report published in the British Medical Journal, 60 percent of medical professionals prescribe placebos to their patients.

    For their findings, researchers questioned 89 members of the medical profession, including 31 doctors working in hospitals, 31 nurses, and 27 family physicians working in Jerusalem.

    Among the 89 participants, 60 percent reported using placebos, and 68 percent of the participants said they told their patients that they were receiving real medication.


    Maybe I'm dense, but I couldn't find any article like this in the BMJ. It 's certainly a jaw-dropping finding. In the U.S., this is unequivocally unethical. I couldn't find the article with a Google search or in PubMed, either. Could it be a hoax?

    UPDATE: Not a hoax. The link is here (in pdf). It was one of the early online releases. Thanks to a helpful reader for passing it along.
     
    posted by sydney on 9/20/2004 07:58:00 AM 0 comments

    Satisfaction: Sometimes, when my hospital caseload is high, I find myself drifting toward the temptation to give up my hospital practice and hand it over to hospitalists. It would make my life so much easier. I could sleep later. My working hours would be more reliable, my on-call days easier. But then, something happens that reminds me why I hold on to my hospital practice.

    Like this morning. One of my patients has spent the past two weeks in intensive care with an infection so toxic it left her in shock. It was touch and go for many days for her. But she's much better now, and out of the intensive care unit. When I saw her today, the first time she's been able to talk to me, she apologized for "being disrespectful." I couldn't fathom what she meant. Then she explained. She remembered her first day in the hospital when she grabbed my hand and said, "Dr. Smith, my friend!"

    Except that never happened. Until today, she was on a ventilator, deeply sedated, her hands tied down to keep her from pulling out her endotracheal tube. I went to see her every morning, but the intensivists were running the show. I made no contribution to her care. In fact, I did so little, I can't even charge for those visits. All I did, from a medical standpoint, was review her chart every day so I would be prepared to take over when - and if - she left the intensive care unit. But there was one other thing I did every morning. I would touch her hand and call her name. I never got a response. Not the slightest flicker of an eyelid or twitch of a finger. She was too sedated. Too ill.

    But obviously, something got through. On some level of consciousness she must have heard me, recognized me, and been profoundly relieved and grateful to hear a familiar voice amongst all the strangers. And I, in turn, am honored to be called "friend." I think it will be a long time before I give in to that hospitalist temptation.
     
    posted by sydney on 9/20/2004 07:36:00 AM 0 comments

    Sunday, September 19, 2004

    Garden Blogging: This weekend was exceptionally fine here in Ohio - clear skies and cool, crisp air. Unfortunately, it also marks the end of vegetable gardening. The tomatoes and peppers are starting to show the effects of the cold,so we gathered in the last of the fruits.

    Harvest


    We turned this into salsa - the hottest we could stand. The recipe follows, but caveat chef. The jalepenos give off volatile fumes, something like pepper spray. It sent my kids running out of the house, and made my husband feel like a protester in New York during the Republican Convention. Consider yourself warned.

    Medpundit Jalepeno Salsa
    2 tbsp. olive oil
    1/4 to 1 1/2 cups chopped jalapenos, depending on your tolerance.
    1 minced clove elephant garlic
    1 large chopped onion
    3 cups chopped tomatoes
    1 tbsp. balsamic vinegar
    3 tbsp. lime juice
    1 tbsp. chopped fresh parsley
    Salt to taste

    Heat the oil in a skillet. Add the jalapenos, garlic and onion. (Watch out. The fumes are nasty. Make sure your kitchen is well-ventilated.)
    Suate until the onion pieces are transparent, but not brown, about 3-5 minutes.
    Add the tomatoes and cook until they're soft, about 5 minutes more.
    Add the remaining ingredients and cook for a few more minutes.
    Add salt if desired.
    Best served after standing and cooling for about an hour or more.


    Enjoy


    Morning Glory, Heavenly Blue

    (Don't eat the seeds)


    Note: I came back and corrected my spelling of "jalepeno." Was typing too fast, too late, I think.
     

    posted by sydney on 9/19/2004 10:01:00 PM 0 comments

    History Lessons: The story of Zappel-Philipp, an early 19th century children's book character, written by a psychiatrist, and casebook example of ADHD.
     
    posted by sydney on 9/19/2004 09:52:00 PM 0 comments

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