"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
Missing in Action: Posting has been light, very light, because I'm in the process of bringing my office into the 21st century. Having finally put aside my technophobia, I purchased an electronic medical record and am in the process of getting it ready to go live by the end of the month. My apologies for the lack of blogging, but once the system is up, it should make my job a lot less time-consuming, and hopefully free up blog time.
Rashomon: The different spins or recollections that patients sometimes put on our encounters never ceases to amaze me. Sometimes, a patient will tell the nurse that they've come in because they "still have" back pain, or leg pain, or a cough, or whatever's bothering them. But their chart shows no prior complaints of any sort similar to it. They'll swear they told me about it, as if that had been the main reason of their last visit, but I know I would have documented it if they brought it up in any way that needed to be addressed. Sometimes, it turns out they mentioned it only to the receptionist, or to the nurse at the last visit. Sometimes - and this has happened more than once - it was their previous physician they're remembering.
Once, a mother told me that she "didn't like that other woman doctor" in our office. Which I found puzzling, because I was the only woman doctor in that office - ever. I asked her if that wasn't me she meant, but she was adamant that it was another woman. While she went on about how much she despised her, I looked through her daughter's chart. Sure enough, I was that despicable woman. I just nodded my head and said, "Oh, yes. That doctor." We got along just fine in every encounter after that. Nary a whiff of conflict. Although, I'm still not sure what I did, or when, to make her hate me.
Today, I had a patient whose memory was, perhaps, more intentionally selective. I made rounds on an elderly woman who sprained her ankle last night. The emergency room physician didn't feel he could send her home because she has no reliable help at home. Not that she lives alone. She has a grown son. He's just neither reliable nor helpful. I was hoping to send her home today, but she told me that it was just too difficult to walk, that she feared that she would fall at home, that she needed assistance just to walk a few feet. She'd feel better if she could have at least another day in the hospital. I relented. I wasn't sure the home services she needed could be arranged on a weekend, anyway. But, as I stood outside her door, documenting our visit, I heard her talking on the phone to her son. She wanted to go home today, but I told her we needed to watch her for a day or two longer. I guess what she really wanted was a break from her son.
A Food and Drug Administration advisory panel recommended against the over-the-counter sale of a Merck cholesterol-lowering drug, saying that while millions of Americans could benefit from taking it, they should not begin such a regimen without a doctor's advice.
The F.D.A. typically heeds such recommendations, meaning that the drug industry has been at least temporarily thwarted from creating a new segment of the drug market. But Merck and its partner in the application, Johnson & Johnson, said they would continue trying to win approval.
Although their real motive is to avoid patent expirations, they put a patient-friendly spin to their mission:
The companies had sought to sell a nonprescription version of Mevacor, one of the oldest of the class of drugs known as statins. With the support of some cardiologists, the companies argued that over-the-counter statins could benefit many of the estimated 39 million people whose blood cholesterol might put them at moderate risk of a heart attack but who are reluctant to spend the time and money getting a doctor's prescription.
The safe use of these drugs requires monitoring of subsequent cholesterol levels (to get the correct dose) and liver enzyme levels (to check for the not infrequent side effect of liver inflammation), which - suprise - require visits to the doctor, and time, and money. If these are granted over-the-counter status, then every other medication from antibiotics to blood pressure medication to anti-depressant medications might as well be made over-the-counter, too.
UPDATE: UPDATE: Trent McBride disagrees and asks why I would force patients to see a doctor if they want to improve their health. That's not what I said, and that's not the way I view the issue. Certainly, people can do things to improve their health without seeing a doctor.
But, what we can't do, is allow drug companies to sell drugs that need monitoring as if they don't. There's been a lot of hand wringing lately about the safety of prescription drugs. We seem to expect our prescription drugs to be without side-effects. But this is precisely why they're prescription drugs, because they do have side effects and they need close monitoring to insure they do minimal harm. They also need the input of a consultant - such as a doctor - to help a patient decide if the drugs' risks are worth their potential benefit.
Statins aren't as safe as vitamins or antihistamines. They have the potential to cause serious adverse effects, contrary to the claims of their advocates. I've had many more patients develop liver inflammation and myositis from statins than I've had depressed patients attempt suicide because I treated their depression with an SSRI. In fact, it's about a 10 to 0 ratio in fifteen years of practice. It makes no sense to put a drug that requires careful monitoring for side effects over the counter.
posted by Sydney on
1/15/2005 08:35:00 AM
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Yeah, That'll Work: The color coded food warning system is coming to vending machines:
The snacks were scored on a point basis. The system gives a point to foods rich in calcium, protein, fiber, iron and vitamins A and E while taking away points from those high in sugars, fats and calories.
A poster explaining the ratings will be placed on the outside of each machine.
At the vending-machine-association press conference yesterday, green stickers were placed on items such as pretzels, Nutri-Grain cereal bars and Go-Gurt yogurt, advising consumers to frequently choose those items.
Other products like Wheat Thins, Starburst Fruit Chews and SnackWell's cookies were labeled yellow, suggesting to choose occasionally.
Austin crackers, Snickers, chocolate chip cookies and Doritos chips were labeled red, which advises to eat those products rarely.
This movie is a corny, melodramatic assault on people with disabilities. It plays out killing as a romantic fantasy and gives emotional life to the "better dead than disabled" mindset lurking in the heart of the typical (read: nondisabled) audience member.
That's the truth and we need to deal with it. It explains why movies such as Whose Life is it, Anyway? become immensely popular. It explains why The Sea Inside was such a hit with critics. These are the stories about disability that society wants to believe are true. And critics are part of society.
These films don't reflect the typical disability experience, which, for most of us, is just the experience of living our lives. Books and movies about our simple struggle to live life in an oppressive society receive little notice from the public, press or critics. It's only when a disabled person, real or fictional, says they want to die that the movie becomes a hit, the book a bestseller.
I'm not familiar enough with the disability genre to know if that last line is true or not, but maybe some day someone will make a film about Christopher Reeve's life, or Stephen Hawking.
NOTE: A reader on the phrase "million dollar baby":
Great Orwellian doublespeak marketing ploy ...for stem-cell research/funds...! posted by Sydney on
1/14/2005 08:07:00 AM
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Jamie Chavez knew her Richland obstetrician felt strongly about limiting medical-malpractice awards. He bent her ear and offered pamphlets every time Chavez, pregnant with her first baby, visited him for prenatal care.
But she couldn't believe Dr. Mark Mulholland's reaction in November when she refused to sign a petition at the doctor's office for an initiative to limit jury awards in malpractice cases.
"I was kind of fired as a patient," she said.
It has become common for doctors to put out petitions for tort reform in their offices for patients to sign. Usually, they just leave it in the waiting room or at the check-out/check-in desk for people to sign if interested. Discussing it in the exam room is a little much. Patients pay us to focus on them, not to be lobbied for political causes. And firing a patient for having an opposing opinion, well, that's just too extreme for words. But then, we doctors do have a strong totalitarian streak.
CORRECTION: The doctor above isn't anymore "Seattle-area" than Cincinnati is Cleveland:
Actually, he's a Richland doctor, on the other side of the "Cascade Curtain" from Seattle. (And me)
We think the folks from "east of mountains" are really different. They grow wheat and apples, we grow trees. They irrigate their fields, we pump out our basements. They generally vote Republican, we generally don't. ;^)
Richland, Washington is not near Seattle. It is one of the "Tri Cities", the other two being Pasco and Kennewick. All three are on the Columbia in south-eastern Washington state.
The biggest employer in the area is Hanford, which explains the interesting symbol Richland High School uses for its teams.
... four Dollars at Christmas, with which he may be drunk 4 days and 4 nights; two Dollars at Easter to effect the same purpose; two Dollars also at Whitsontide, to be drunk two days; A Dram in the morning, and a drink of Grog at Dinner or at Noon.
Yes, times have changed. But once upon a time alcohol was a wonder drug. THE wonder drug until aspirin came along. posted by Sydney on
1/12/2005 08:20:00 PM
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Under our federal system, each state decides for itself how to balance the interests of patients injured by medical malpractice against the interests of doctors and patients who suffer when damages are too high and too easy to win. If it gets the balance wrong, the consequences can be seen in escalating insurance premiums, defensive medicine (unnecessary tests and procedures motivated by fear of liability), rising health care costs, and specialist shortages. The state becomes a less attractive place for doctors, for employers, and for residents generally.
...Speaking of which, the other reason Bush offered for giving up on federalism was that overly generous malpractice rules raise the cost of federally funded health care programs. "The number of lawsuits, the defensive practice of medicine is driving up the cost to our taxpayers," he said. "Medical liability reform is a national issue, and it requires a national solution."
Leaving aside the fact that Medicare and Medicaid themselves are not authorized by the Constitution, this argument proves too much. It assumes anything that affects health care costs—which would include not only traditionally local matters such as tort law but highly personal matters such as what you eat, how much you exercise, how much sleep you get, and whether you floss regularly—is a fitting subject for federal legislation.
PATIENTS ARE being put at risk -- and Toronto taxpayers are paying the bill -- while paramedics spend more and more time babysitting patients in hospital emergency rooms. At times Toronto EMS has had no available ambulances on the road to react to emergency calls because all the crews are stuck waiting for patients to be seen in the ER, spokesman Larry Roberts said.
The problem soared in the fall as paramedics taking a patient to hospital were forced to continue caring for the person.
"It's more and more often that crews are sitting four, five, even eight hours in an emergency department," Roberts said. "It's a serious problem.
"It affects our availability on how quickly we can get to an emergency call," he said.
Emergency rooms get crowded here in the United States, too, but in cities the size of Toronto, and in smaller ones with more than one hospital, the ER's are able to cooperate when it comes to ambulance traffic. An emergency room with no more beds will close to ambulances and divert them to another hospital. This can cause some problems of its own, such as longer transport times, but it's better than waiting in the ER for hours. If you're sick enough for an ambulance, you shouldn't have to wait hours for medical attention.
UPDATE: An ER resident disagrees:
I am a ER Resident at the Universuty of Michigan, and I have been reading your blog for about a year now. I generally agreee with what you write, but in this most recent post, I have to strongly disagree.
You said "If you're sick enough for an ambulance, you shouldn't have to wait hours for medical attention."
This may be true, but in my experience there are plenty of people who call an ambulance for non emergent reasons (i.e. I have had abdominal pain for 3 days and it isn't getting better, or I twisteded my ankle and can walk, but my friends can't (or won't) drive me to get it checked out)
Maybe where you work this is true, but in our area, our paramedics are excellent and if someone really needs emergent attention, they'll let us know over the radio.
I suppose it depends on the paramedics. Around here, they've been known to check out a person and decline to transport them if it's not an emergency. I suppose if someone insisted, they would do it, but I don't think that happens too much. posted by Sydney on
1/12/2005 07:59:00 PM
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Where have I heard those words before? Oh, yes. That's what I say to all the drug reps when I haven't been listening or am too tired to argue. Their talking points always end with "So, doctor, what do you think?" "I'll keep it in mind....." posted by Sydney on
1/12/2005 07:38:00 PM
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The UK's Food Standards Agency is currently reviewing five food labeling proposals with the goal of picking a system that will help people make better-informed and healthier food choices. The two currently favored proposals are a "simple traffic light" system (with red, amber, and green circles, which supposedly respectively indicate: eat sparingly, eat in moderation, and eat plenty) and a "multiple traffic light system" (indicating low, medium, or high for levels of fat, salt, sugar, and saturates). Other proposals include an "extended traffic light" system containing a range of five colors as opposed to three (I am trying to imagine the confusion that would ensue if such a system replaced all current traffic lights) and a logo to be placed on specific foods deemed to be "healthy."
Only the Corrupt Find it Worthwhile: Honest cab drivers find it hard to get reimbursed for Medicaid cab rides:
Stanley Tapscott, a private cab operator who serves on the D.C. Taxicab Commission, said yesterday that the voucher system long has had problems. He said many cabdrivers in the District are reluctant to participate in the program because of trouble getting paid.
"Some drivers shun it," he said. "The cab business is a cash-money business. If you get one of these vouchers, then you have to go [to the D.C. Department of Health] and find parking, then you go in, then you wait to get paid -- that's been a problem over the years."
But not everyone has a problem with it:
Mr. Tapscott, however, said that in the past the program also has had a reputation as an easy way for unscrupulous drivers to make extra money.
"There were some drivers years ago who went to jail," Mr. Tapscott said. "They'd go down and just get a handful of forms to fill out, then they'd go back and get paid. I hope that's all been cleared up."
....Sandra Seegars, another taxicab commissioner, agreed with Mr. Tapscott and said yesterday that the voucher system was "an easy way to rip off the government." She said changes are needed to improve oversight of the program and to boost participation among drivers. posted by Sydney on
1/11/2005 07:44:00 AM
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Ethics: Regarding coverage responsibilities, from a reader:
Sorry the ice storm has you off the net. Of course, the ethical thing would be for you to refer your readership to a blog that is online or get someone to cover your call.
Well, there is the list of medical blogs over to the left that all provide excellent coverage.
He also sends a link to this paper from last week's New England Journal of Medicine about the role of physicians assigned to military intelligence in interrogation:
In testimony taken in February 2004, as part of an inquiry into abuses at Abu Ghraib (and recently made public under the Freedom of Information Act and posted on the Web site of the American Civil Liberties Union [ACLU] at www.aclu.org), Colonel Thomas M. Pappas, chief of military intelligence at the prison, described physicians' systematic role in developing and executing interrogation strategies. Military intelligence teams, Pappas said, prepared individualized "interrogation plans" for detainees that included a "sleep plan" and medical standards. "A physician and a psychiatrist," he added, "are on hand to monitor what we are doing."
What was in these interrogation plans? None have become public, though Pappas's testimony indicates that he showed army investigators a sample, including a sleep deprivation schedule. However, a January 2004 "Memorandum for Record" (also available on the ACLU Web site) lays out an "Interrogation and Counter-Resistance Policy" calling for aggressive measures. Among these approaches are "dietary manipulation — minimum bread and water, monitored by medics"; "environmental manipulation — i.e., reducing A.C. [air conditioning] in summer, lower[ing] heat in winter"; "sleep management — for 72-hour time period maximum, monitored by medics"; "sensory deprivation — for 72-hour time period maximum, monitored by medics"; "isolation — for longer than 30 days"; "stress positions"; and "presence of working dogs."
Physicians collaborated with prison guards and military interrogators to put such approaches into practice. "Typically," said Pappas, military intelligence personnel give guards "a copy of the interrogation plan and a written note as to how to execute [it]. . . . The doctor and psychiatrist also look at the files to see what the interrogation plan recommends; they have the final say as to what is implemented." The psychiatrist would accompany interrogators to the prison and "review all those people under a management plan and provide feedback as to whether they were being medically and physically taken care of," said Pappas. These practices, he conceded, were without precedent. "The execution of this type of operation . . . is not codified in doctrine," he said. "Except for Guantanamo Bay, this sort of thing was a first."
At both Abu Ghraib and Guantanamo, "behavioral science consultation teams" advised military intelligence personnel on interrogation tactics. These teams, each of which included psychologists and a psychiatrist, functioned more formally at Guantanamo; staff shortages and other administrative difficulties reduced their role at Abu Ghraib.
A slide presentation prepared by medical ethics advisors to the military as a starting point for internal discussion poses a hypothetical case that, we were told, is a "thinly veiled" account of actual events. A physician newly deployed to "Irakistan" must decide whether to post physician assistants and medics behind a one-way mirror during interrogations. A military police commander tells the doctor that "the way this worked with the unit here before you was: We'd capture a guy; the medic would screen him and ensure he was fit for interrogation. If he had questions he'd check with the supervising doctor. The medic would get his screening signed by the doc. After that, the medic would watch over the interrogation from behind the glass."
The Army argues that the physicians and medics in these situations are functioning in much the same way that doctors do in occupational medicine, and that seems exactly right. As described above, their main role seems to be to insure that interrogation techniques cause no harm and that the detainees are physically strong enough to withstand them. They are there, in other words, to make sure their fellow soldiers don't cross the line. posted by Sydney on
1/11/2005 07:32:00 AM
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True Entertainment and Brighter Pictures, production companies owned by international reality giant Endemol (“Big Brother”) in New York and London, respectively, are co-developing a reality series that would pit a group of male contestants against each other for the honor of serving as a sperm donor to a woman willing to be impregnated.
It sure can:
“Mum” isn’t even the only virility-minded program gestating at Endemol; the company reportedly has talked to German broadcasters about a televised contest to find the most potent man, called “Sperm Race.” posted by Sydney on
1/11/2005 06:45:00 AM
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Monday, January 10, 2005
TennCare Saved: TennCare, the most generous state-sponsored health insurance plan in the country, gets reform instead of cancellation:
The plan for “basic TennCare” preserves full coverage for all 612,000 children on the program and maintains a reasonable level of benefits for 396,000 adults who are eligible for Medicaid, the state and federal program for individuals and families with low incomes. As many as 323,000 adults who are not eligible for Medicaid will lose TennCare coverage — although 24% of those enrollees still will be covered under Medicare, the federal program for people who are older or who have disabilities.
...In addition to reducing benefits and enrollment for adults, Bredesen announced TennCare is taking initial steps toward returning to a managed-care model that will require managed-care organizations (MCOs) — more commonly known as HMOs — to assume more financial risk in the delivery of TennCare benefits.
....The State also is pursuing a range of other cost-savings measures, including new care-and disease-management practices that will improve the quality of care while reducing costs.
Inflamed Hearts: C-Reactive Protein as a risk factor for heart disease is in the news again. Two studies, both in the New England Journal of Medicine have put it in the spotlight:
Reducing the levels of a certain protein secreted by the body may be as powerful a tool in slowing heart disease and preventing heart attacks and cardiac-related death as lowering cholesterol, two teams of researchers are reporting today.
One of those researchers is Paul Ridker, the media's favorite cardiologist, holder of a patent for the CRP test, and the most vocal advocate of CRP as cardiac risk factor:
"What we now have is hard clinical evidence that reducing CRP is at least as important as lowering cholesterol," said Dr. Paul Ridker of Brigham and Women's Hospital in Boston, the lead author of one of the studies.
Dr. Ridker's study does show improvement in relative risk, even when he controls for other conditions such as diabetes and hypertension and age which can also increase the risk of heart disease. He does not, however, give us the absolute risk or the raw data for those categories. That should make us supsicious that perhaps the absolute risk isn't so impressive.
Others, with less bias, also urge caution:
But other heart disease researchers cautioned that more work was needed to prove that CRP directly causes heart disease. And most agreed that because the new studies involved only people with severe heart disease, it remained unknown whether healthy people would benefit from reducing their CRP levels.
...Others, though, said CRP could instead be a marker for something else being fought by statin drugs to reduce heart disease risk.
"These are very important papers," said Dr. James I. Cleeman, coordinator of the National Cholesterol Education Program at the National Heart, Lung and Blood Institute. "They are provocative. But we need to recognize that the relationship between CRP and heart disease is a developing story. This adds to the evidence, but I'm not sure it settles the issue."
The burning question is, is CRP a cause of heart disease or a symptom? Chest pain, for example, is a symptom. Eliminating chest pain would eliminate a good number of heart attacks and reduce heart disease. However, not all chest pain is caused by heart disease. The second study, from the Cleveland Clinic, attempts to determine CRP's role:
Dr. Nissen's study, sponsored by Pfizer, examined plaque in the coronary arteries of 502 patients with heart disease, comparing intense statin therapy against moderate and using the same doses of the same drugs as in Dr. Ridker's research.
Intense therapy resulted in lower cholesterol levels and slower growth of plaque, Dr. Nissen reported. But he also suspected that something else was going on, because some patients seemed to be doing much better than others with the same cholesterol levels.
Upon further analysis, Dr. Nissen found that levels of CRP dropped independently of cholesterol and that these reductions were independently associated with a slowing of disease progression. In patients who achieved low levels of both CRP and cholesterol, he found, plaque in the coronary arteries actually regressed.
"I'm looking right at the plaque, and when your CRP level is reduced, you are stopping the disease," Dr. Nissen said. "We are saying that CRP is a direct participant in atherosclerosis."
When he says he's "looking right at the plaque," he means that he's using an
ultrasound probe that's threaded into the artery. It uses sound waves to estimate the diameter of the blood vessel and the size of the plaque. How reliable is the estimate? Hard to say. It's still a rather experimental procedure, not one that's been widely adopted by hospitals or by doctors of varying skills.
A similar technique, however, is widely used to measure the degree of plaque build-up and stenosis in much larger arteries, although it doesn't require the use of an intravascular probe since the arteries in question are so much closer to the surface of the body. That technique is the carotid artery doppler. And, while it's a useful screening test, as an accurate measure of the amount of plaque and stenosis, it leaves a lot to be desired. I have had patients who made absolutely no changes in their smoking or medical regimen but whose carotid artery dopplers vary by as much as 20% from year to year. They may start out with a reading that indicates they have 50% stenosis, for example, but a follow-up ultrasound in another year shows it to be only 30%. The interpretation varies so much from reader to reader, and the technique varies from test to test that it's really only useful as a screening tool, not as an absolute measure of disease. (For that we use the much more invasive angiography which involves the injection of dye into the arteries.)
Granted, the intravascular coronary ultrasound has the advantage of having its probe inside the vessel, but caution is still needed when it comes to interpreting the significance of C-reactive protein as a cause of coronary artery disease, much less a screening test for it. posted by Sydney on
1/10/2005 08:50:00 AM
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Aggressive Intervention: Rosemary Kennedy, the oldest Kennedy sister, died this weekend. I always thought that she lived at the School for Exceptional Children because she was mentally retarded, as most of her obituaries claim, and that she had a frontal lobotomy because that was what doctors recommended in those days to cure intractable behavior problems. However, in the biography of her lobotomist, the real story is a little more nuanced, and not as flattering to the Kennedys, at least not to the patriarch.
It was Joe Kennedy's idea to have the lobotomy, and he sought out Dr. Walter Freeman, the father of American lobotomies, to perform it when the doctors in Boston advised him against it. One has to wonder how mentally disabled she was before the procedure, as she was able to attend school and to travel Europe without a chaperone. But, she was sneaking out at night and returning to her convent school disheveled and drunk. The nuns feared she was picking up men and goodness knows what else. And she threw temper tantrums. All of which got her the lobotomy, and a life of mental disability. Dr. Freeman's records, which are rich with details of his other patients, are strangely silent about the case and its aftermath. One can only marvel at the arrogance and the power of Joseph Kennedy. NPR has more. posted by Sydney on
1/10/2005 08:44:00 AM
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Connected Again: The phone lines are back, and with them internet access. I didn't miss it as much as I thought I would, contrary to these findings. posted by Sydney on
1/10/2005 08:28:00 AM
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