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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Saturday, January 25, 2003

    Medical Economics: A reader says that the reason there are fewer abortion providers these days could just be simple economics:

    There's a very simple reason why there are fewer abortion providers, and why you won't find them in the rural areas of our country. It's the same reason why you generally won't find cardiothoracic surgeons in the rural areas, and why we are seeing a gradual decline in the
    number of surgeons. The overall need for service is down, and the resulting catchment area required is larger.

    ...One could estimate how many abortions an abortion provider has to do in order to have a "successful" practice. As you know very well, for the typical physician in solo or small group private practice, office overhead, malpractice insurance, staff salaries, etc., constitutes about 40 to 50% of collected fees. Add to this the considerable cost of security for an abortion practice. In an abortion practice, as I understand it, it's a cash or almost cash business. For a doc to make $200,000 a year in take-home income, he/she has to collect about $320,000 to $400,000. If the fee per abortion is $400 (about the average, I'm informed), that's 800 to 1,000 abortions per year, per physician. The Chicago Tribune recently ran an article about an abortion clinic in Granite City, Illinois, that did about 7,000 abortions a year.

    ...The abortion rate for 1996 was 22.9 per 1,000 nationally for women aged 15 to 44 (National Center for Health Statistics (Ventura et al., Nat. Vital Stat Rep., 47:29, 1999). That makes the catchment area about 40,000 women age 15 to 44, give or take. And that means the total catchment area about four times that (men, and women under 15 and older than 44, don't count). That's a rough estimate, and some digging in the Census Bureau tables would refine these numbers considerably.

    So realistically, for a county to have a single abortion provider, its total population needs to be about 160,000 or higher. In my home state of Illinois, population about 12.4 million as of 2000, only 12 of 101 counties had a population greater than 160,000. Six more had a population between 100,000 and 160,000, and one might argue that higher payments,higher numbers, etc., might make an "abortion practice" sustainable in these counties. If we grant that, then 18 of 101, or 18%, of Illinois counties would be expected to have at least one abortion provider, and 82% would not. The Maryland NARAL recently said that 84% of U.S. counties didn't have an abortion provider. From my off-the-cuff analysis above, that sounds about right.

    If abortion rates continue to move downward, the catchment area grows. We could run the numbers but the point is clear, and simple economics would suggest that more abortion providers would leave that area of medicine to do something else. This presumes that the providers couldn't raise fees, and I rather suspect that an elective abortion is some price sensitive -- make the fee too high and one could drive poorer women to other providers, including non-MDs.

    While some might question an annual income of $200,000 for a doc, most abortion providers are OBGYN physicians, and their average income is higher than that of family physicians or internists. While I'm sure that some abortion providers are dedicated to the principle, I'm also sure that if didn't pay beans, many of them would find something else to do. My analysis also assumes that an abortion provider devotes almost all of her/his time to such a practice; if one devoted 25% effort to providing abortions and 75% effort to general OBGYN practice these numbers change some, and one might incorporate such a combined practice into a smaller town (as the need for general OBGYN is greater). Practically, this could be difficult given security concerns and, I suspect, some fair general approbation in smaller, more conservative communities.

    Hmmm. Could be, but if most OB/GYNS had no moral qualms about abortion, they would be incorporating it into their practices just as they incorporate other procedures. They all have the skills to perform them. They use the same sort of procedure to take samplings of the uterine lining in women with abnormal vaginal bleeding and to clean out the uterus after incomplete miscarriages and spontaneous abortions. I suspect that this is why abortions came to be the province of special clinics rather than part of routine office practice. It’s asking a lot for an obstetrician to his switch his mindset from one that considers the fetus as much his patient as its mother, to one in which it’s nothing but a bunch of cells or some primitive, unimportant organism.

    That part about the approbation of the community is probably true, though. One would have to feel very strongly and passionately about the rightness of abortion to be able to face other parents at PTA meetings and soccer games if it was common knowledge that you provide abortions. Not to mention facing pregnant patients who expect their obstetrician to have the best interests of both themselves and their babies at heart. How many expectant mothers could trust their obstetrician if they also knew that he dispensed with other pregnancies so easily?

    For when it comes right down to it, most people don't think abortion is necessarily the right thing to do, but they wouldn’t want to tell anyone else they can’t do it. A lot of doctors feel that way to. If asked whether or not they support the right “to choose”, they would probably say “yes.” But if asked if they would actually choose to perform an abortion, most would say “no.”

    posted by Sydney on 1/25/2003 01:01:00 PM 0 comments

    High Risk Behavior: A definitive analysis of the consequences of smoking and drinking, at least in certain populations.
    posted by Sydney on 1/25/2003 08:22:00 AM 0 comments

    Express Warning: So this is why I got an express-delivery from Glaxo-Smith Kline yesterday:

    GlaxoSmithKline said yesterday that Serevent, one of its popular asthma drugs, might pose a risk of death and serious asthma-related illness in some patients.

    The company said it was halting the study it had been conducting since 1996 to evaluate Serevent's safety because the study was unlikely to be conclusive. GlaxoSmithKline said it would work with regulators to design further studies to address concerns about Serevent's safety.

    While the results of the study were not statistically significant, they suggested that people who use Serevent, particularly African-Americans, might be at greater risk for life-threatening attacks or deaths associated with their asthma. People who use Serevent without also taking inhaled steroids to control their asthma may also be at increased risk.

    My express letter said basically the same thing, but left me scratching my head. Why would they go to the trouble and expense to send me news about findings that weren’t even statistically significant? If they aren’t statistically significant, then they could just be due to chance. The cynic in me suspected they just wanted to scare me into switching everyone over to their more expensive product, Advair, which combines Serevent with an inhaled steroid. The Times account does nothing to assuage my cynicism:

    Although the preliminary analysis of the study suggested additional risks, they were not statistically significant because of the small number of deaths and other serious effects, said Dr. Kate Knobil, a research physician at GlaxoSmithKline. The company would soon make public the number of these cases, she said, but was still compiling the information.

    The increased risk appears to be driven by the lack of inhaled steroid use, Dr. Knobil said.

    Despite medical recommendations that patients use inhaled steroids or some other medication, many patients in the study were not being treated with additional medicine. Less than half, or 47 percent, of the patients used inhaled steroids. Whether or not a patient was using an inhaled steroid was determined by that patient's doctor, not the company

    You would think from reading that excerpt that the only anti-inflammatories available were inhaled steroids. But, in fact, for people who have asthma attacks more than twice a week, but not daily, it’s still considered appropriate to use drugs other than inhaled steroids, drugs such as cromolyn sodium or mast-cell stabilizers such as Singulair. In teenagers and children, these alternatives are preferred because they don’t run the risk of slowing growth that is seen to a very small degree in chronic use of inhaled steroids. (Children with daily asthma attacks, however, should take an inhaled steroid. Their asthma poses a far greater risk to their well-being than the small risk of growth slow-down with steroid inhalers.) GlaxoSmithKline didn’t give the details of the study to the media or in their express letter to physicians, which makes it even harder to evaluate.

    According to the Times, though, financial motives aren’t likely:

    Analysts played down the significance of the study while acknowledging that it gives GlaxoSmithKline's competitors some advantage in promoting their own drugs to treat asthma.

    "It's a little marketing nudge here and there," said Todd Lebor, an analyst with Morningstar Inc. in Chicago.

    While the asthma franchise, which includes Advair, is important, Mr. Lebor said, it is a small part of GlaxoSmithKline's nearly $30 billion in revenue. "They don't have a blockbuster portfolio," he said.

    For the nine months ended Sept. 30, the company sold $574 million in Serevent, with $327 million coming in the United States. Advair sales reached $1.7 billion, of which $925 million were in the United States.

    But if they get doctors and patients nervous enough about Serevent, won’t they switch to the costlier Advair to avoid using Serevent, even thouigh it may be used with another anti-inflammatory? Of course they would. Especially when you consider that using the combined product eliminates the risk of patient non-compliance with the anti-inflammatory.

    But my inner cynic is probably wrong. It probably isn’t profit, but fear of litigation that’s motivating them. After all, companies have been sued for less. After all, the FDA is taking the finding seriously and looking into it further. What does it say about us, though, when findings that aren’t statistically significant send a company running away from its product?
    posted by Sydney on 1/25/2003 08:15:00 AM 0 comments

    Friday, January 24, 2003

    Med Mal Update: Overlawyered, has a round-up of all the latest in the medical malpractice debate.

    posted by Sydney on 1/24/2003 08:39:00 AM 0 comments

    Smile: Have a happy day.
    posted by Sydney on 1/24/2003 08:25:00 AM 0 comments

    The Mind's Tangled Web: Derek Lowe explains the difficulty of developing effective psychiatric drugs.
    posted by Sydney on 1/24/2003 08:24:00 AM 0 comments

    Cost Cutting: The Bush Administration wants to fix Medicare by making it managed care. But isn't that strategy already known to be failing? Yep:

    The tilt toward competition among private health plans comes as the administration has been attempting to surmount widespread difficulties with another part of Medicare, known as Medicare Choice, which was created in 1997 to encourage patients to join managed care. Enrollment -- currently about 5 million of Medicare's approximately 40 million patients -- has grown far more slowly than expected, in part because HMOs have dropped out, complaining that Medicare wasn't paying them enough.

    The president's new proposal will try to make Medicare more popular with such plans, although it remains unclear exactly what strategy will be employed.

    Good luck.
    posted by Sydney on 1/24/2003 08:20:00 AM 0 comments

    Risks: Research suggests that in vitro fertilization may be associated with an increased risk of cancer in the children:

    The eye cancer research was prompted when Dutch doctors diagnosed the disease, called retinoblastoma, in five children within a 15-month period. Normally, one child in 17,000 is expected to develop the disease.

    They compared the incidence of the disease in IVF-conceived children with that in the general population. They calculated that the risk in IVF children may be between five and seven times higher, though the disease would still be rare.

    ...The second study, published in the January issue of the American Journal of Human Genetics, looked at a national US registry of patients with Beckwith-Wiedemann Syndrome (BWS). Children born with BWS have an increased risk of developing various cancers.

    Up to June 2001, four of the 279 BWS patients in the registry were known to have been conceived by IVF. Suspecting an association, the investigators began collecting details about conception methods for new patients entering the registry.

    They found that three of the 65 new patients were conceived by IVF. This represents an incidence of 4.6 per cent, nearly six times higher than the 0.8 per cent incidence of assisted births in the general US population. But the researchers caution that, although they did not specifically recruit parents who had used IVF, such parents may have been more likely to participate in the study. And, again, even if their findings are confirmed, BWS would still be very rare even among IVF babies.

    Warrants watching. Modern medicine is very much a novice when it comes to molecular genetics and developmental biology. It wouldn’t be all that surprising if it turns out that manipulating eggs and sperm in a petri dish has consequences of which we aren’t completely aware.
    posted by Sydney on 1/24/2003 08:11:00 AM 0 comments

    Freedom: Another doctor breaks free of the red tape tyranny of today's healthcare system:

    So two years ago, Advani jumped off the modern medical treadmill and started Pearls of Hope, a family medical practice that aims to bring back what he calls the "golden age of medicine."

    He charges just $25 for office visits -- cash please. He's willing to see patients after normal business hours, and he even makes the occasional house call for those who can't get in to see him.

    Advani doesn't take any form of insurance. That would be too time-consuming and raise overhead costs, he says. Buying or leasing a medical office is also expensive, so, like physicians of old, Advani's 17th Street home doubles as his office.

    Another doctor in the story has also stepped away from insurance processing, but he hasn’t lowered his prices much (he’s not working from his home like the other guy):

    San Francisco internist William Andereck, who heads up a committee that focuses on solo and small-group medical practices for the California Medical Association, says more doctors like Advani are searching for a better way.

    "The bottom line is, the health care system in the United States is irreparably broken," Andereck said. "The corporate players, including the physicians, have sucked the money out of the system. Patients have become a means to an end.

    "Doctors are working for the insurance companies, not the patients," he said. "Every patient senses it."

    Andereck says his patients now all pay upfront for their treatments -- and receive better care because of it. But they pay about $65 per visit, and it is left to patients to deal with the insurance company.

    Though Advani does not turn away insured patients, he says he specifically targets the nearly 20 percent of Kern County residents who have no medical coverage.

    When it comes to every day outpatient medical care, smaller really is better.
    posted by Sydney on 1/24/2003 07:52:00 AM 0 comments

    Science Fair: Not likely to see this kind of thing at fairs today.
    posted by Sydney on 1/24/2003 07:44:00 AM 0 comments

    Medpundit Music: Posted some thoughts at Blogcritics on the country and western version of Pink Floyd’s The Wall, called, fittingly,
    Rebuild the Wall
    posted by Sydney on 1/24/2003 07:43:00 AM 0 comments

    Thursday, January 23, 2003

    Medpundit Marshmallows: It was so cold here today that when I left my stethoscope in the car for two hours between making rounds and going to the office, it froze into a U-shape. Now, it’s hovering around 0 degrees Fahrenheit, and snowing hard, and I’m waiting for my husband and sons to return from a basketball game that should have been over a while ago. What’s a worried mother to do? Make marshmallows.

    My friends think it’s stupid to make marshmallows when they’re so easily had at the store, but I love homemade marshmallows. Making them is almost as much fun as eating them. It’s a magical, chemical process that converts sugar and water to a soft cushion of a confection. And homemade marshmallows are more aesthetically pleasing than those uniform cylinders in a bag they sell at the grocery store. Homemade marshmallows are dusted with confectioner’s sugar and cut in squares. When they float on top of hot chocolate they look like chunks of snow.

    The first marshmallows were made by combining the juice of the marsh mallow flower with eggs and sugar and beating it into a foam. But, thanks to modern chemistry, they can be made with powdered pig skin, water, and sugar. Not as pretty as the flower, and devoid of its medicinal properties, but probably a lot easier and quicker.


    1 cup cold water
    3 envelopes unflavored gelatin
    1/2 cup confectioners’ sugar
    3 tablespoons cornstarch
    2 cups granulated sugar
    1/4 teaspoon salt
    1 teaspoon clear vanilla extract (unclear extract works OK, too)

    Mix the 3 envelopes of unflavored gelatin in the 1 cup of cold water. Let sit for 15 to 30 minutes.

    While gelatin is sitting idly, butter a 9x9 inch pan. Mix the 1/2 cup of confectioners’ sugar with the 3 tablespoons of cornstarch. Powder the pan with 1/3 of the sugar/cornstarch mixture. It will look like there are snowdrifts in the corners.

    In a saucepan, combine the 2 cups of granulated sugar with the 1/4 teaspoon of salt. Stir in the gelatin mixture. Bring to a boil over low heat, stirring. When the concoction comes to a boil, cover for three minutes. This washes down any crystals that might be clinging to the sides of the pot. Remove from the heat and allow to cool for about fifteen or twenty minutes. Add the 1 teaspoon of vanilla extract.

    Transfer to the bowl of an electric mixer and beat until it forms soft peaks. (This stretches out the protein molecules in the gelatin, creating molecular stability; and adds air to make it fluffy.) Pour into the buttered and dusted pan. Sprinkle another 1/3 of the confectioners’ sugar/cornstarch mix on top. It will look like a freshly fallen snow cover.

    Let sit overnight at room temperature. Cut into squares and dust the sides with the remaining confectioners’ sugar/cornstarch. Plop into a steaming mug of hot chocolate. Enjoy.

    (And what do you know, kids and husband are home, safe and sound.)

    posted by Sydney on 1/23/2003 11:08:00 PM 0 comments

    Oh Yeah? The insurance industry answers charges that the malpractice insurance problem is caused by bad investments.
    posted by Sydney on 1/23/2003 07:51:00 AM 0 comments

    Seeing is Believing: Don’t miss this traveling health exhibit - coming soon to a city near you.
    posted by Sydney on 1/23/2003 12:25:00 AM 0 comments

    Rights: Fewer doctors are performing abortions. Pro-abortion groups say that this is tantamount to the denial of a women's rights:

    Abortion rights advocates, however, said that in a nation in which 44 percent of women will have at least one abortion, the dwindling number of trained providers is tantamount to a denial of basic health services.

    "Even though the goal is to make abortion less necessary, reproductive health care is totally incomplete without the component of pregnancy termination and abortion," said Kate Michelman, president of NARAL Pro-Choice America.

    So, what is their solution? To force people to learn to do the procedure:

    "We've reached a point in our country where ideology is determining health care," said Jane van Dis, president of the Medical Students for Choice chapter at the University of South Dakota School of Medicine. "It has slipped out of the curriculum."

    The organization is lobbying for mandatory abortion education in medical schools and in residency programs, aiming to return abortion to the realm of mainstream medicine.

    "This has been so politicized there is now an unnatural segregation between abortion care and regular medical care," said Robert Roose, 23, who recently revived a chapter of the group at George Washington University Medical School.

    It’s become politicized all right, but that isn’t necessarily why it’s slipping out of the curriculum. The thirty years since Roe v. Wade has seen a revolution in neonatal technology. Premature babies that would have died at birth thirty years ago are thriving and living today. Heck, now we even have a speciality devoted to maternal-fetal medicine, that specifically views the fetus as a patient. We perform corrective surgeries (warning:graphic photos in both cases) on fetuses while they’re still in the womb. It’s much harder now than it was thirty years ago for physicians to deny the humanity of the fetus.

    I can understand why abortion advocates deny rights to the fetus, despite all of the advances in fetal medicine. They either don’t consider it fully human, or they consider the mother’s rights more important. But I don’t understand why they can’t respect the right of full grown physicians and medical students to defer from doing something they find morally reprehensible.

    UPDATE: Here's a look at a less-than-noble raison detat for abortion:

    But for Roe v. Wade, millions more children would have been born into poverty, where they would be greeted by Congress and the state legislators who failed to provide money for day care, health care, education or job training.

    Millions more would have joined the ranks of welfare recipients and the homeless, the populations of prisons, prostitutes and drug addicts.

    All that, simply to pander to the religious beliefs of a minority who persist in claiming that a collection of cells, without reason or awareness, is human life with something called a soul.

    Jeesh. Margaret Sanger would have been proud.

    UPDATE II: A civil discourse on the topic.
    posted by Sydney on 1/23/2003 12:19:00 AM 0 comments

    Aggressive, Presumptuous, Overbearing: The Canadian Lung Association says that parental smoking is child abuse, and a Canadian law professor agrees:

    A Canadian Lung Association spokesman came out forcefully yesterday stating that smoking around children is tantamount to child abuse. And Richard Bouchard, a criminal law professor at l'Universit de Moncton, said it's possible to argue the case, considering under the Criminal Code of Canada parents are responsible for providing the "necessities of life."

    The necessities of life include food, shelter and medical care, therefore the professor said "it's not a big jump" to say children should be provided with a healthy environment to live in and they should not be exposed to harmful substances and situations that threaten their health.

    "You could, perhaps, make a case that a child living under those circumstances of smoking parents and when the house is constantly filled with smoke and the child is exposed to second-hand smoke, that the parents are failing to live up to the duty which is imposed upon them," Bouchard said.

    God save Canada from their clever people. (Hat tip to The Bloviator.)
    posted by Sydney on 1/23/2003 12:18:00 AM 0 comments

    Bedfellows: Overlawyered has a link to this report from the
    Capital Research Center that details the various financial entanglements between the American Trial Lawyer Association and Public Citizen, as well as a little tiff they've had over the 2000 election.
    posted by Sydney on 1/23/2003 12:16:00 AM 0 comments

    Side By Side: Proof that cloning doesn't produce carbon copies:

    Rainbow the cat is a typical calico with splotches of brown, tan and gold on white. Cc, her clone, has a striped gray coat over white. Rainbow is reserved. Cc is curious and playful. Rainbow is chunky. Cc is sleek.

    Even in cats, genetics isn't destiny.
    posted by Sydney on 1/23/2003 12:13:00 AM 0 comments

    Real Condom Capers: Jim Miller says some men claim that condoms have such low "real use" efficacy because, well, some men cheat when they use them.
    posted by Sydney on 1/23/2003 12:13:00 AM 0 comments

    No Englishman a Slave? I seem to recall Bertie Wooster once telling Jeeves that no Englishman shall ever be a slave, but David at Cronaca pointed out this London Times story that seems to indicate otherwise, at least if the Englishman in question is a physician:

    Dr Pathak has written to his local health authority to complain about
    the problems caused by the large number of asylum seekers being
    allocated to his surgery. GPs are legally obliged to treat patients
    when instructed by their health authority.

    The doctor is complaining because he’s being forced to take on more new patients than he can handle, all of them asylum seekers. Not only that, but his old, established patients are being redistributed to other doctors without their consent or his. Makes our system look like paradise.
    posted by Sydney on 1/23/2003 12:12:00 AM 0 comments

    New Blogs: From the sex education of medical students to the life and times of a family practice resident, it's a medical blog explosion!
    posted by Sydney on 1/23/2003 12:09:00 AM 0 comments

    Wednesday, January 22, 2003

    JAMA's weekly art history lesson.

    posted by Sydney on 1/22/2003 08:23:00 AM 0 comments

    Mysterious Syndrome X: One of my patients asked me to test her for “Syndrome X” after reading this article in our local paper:

    The enemy isn't a box of Krispy Kreme donuts. The enemy isn't a bag of Cheetos. The enemy isn't even super-sized french fries.

    The enemy is their own bodies, which unknown to them are producing far too much insulin, sending the wrong messages to their brains.

    It's a condition called Syndrome X and it affects almost 70 million (one in four) Americans.

    But if it isn’t the Krsipy Kreme donuts, the Cheetos, or the super-sized french fries, how do you explain the success of the treatment?

    Koehler has lost 55 pounds since she was diagnosed in April and went on a high-protein, low-carbohydrate diet. She's now able to wake up at 7:30 or 8 each morning, instead of her old rising time of 10:30 or 11. She runs errands, instead of staying homebound. She can stay up until midnight, instead of collapsing after her last piano lesson at 8 or 9.

    ``What you have to understand is that I'm not doing this to lose weight, I'm doing this to have a life,'' she said.

    That’s right folks, the treatment is to eat less. Reading this story reminded me of the professor I had in medical school who explained that we treat alcoholism as a disease now rather than a personal choice because alcoholics responded better to the disease model than to the moral model. Tell them it’s in the genes, that it’s a disease, and for some reason, they’re more motivated to change. They aren’t fighting themselves anymore, they’re fighting something “other”. That’s got to be why giving some people a diagnosis of “Syndrome X” helps them approach losing weight better. They still have to do the same things - exercise more and eat less - but they’re doing it to conquer a disease now. Instead of grappling with their willpower, they’re grappling with a diseased metabolism.

    There very well may be a physiological and metabolic basis for “Syndrome X,” or as it’s also known, insulin resistance syndrome, but, contrary to the assertions of the newspaper article, there’s no easy way to diagnose it:

    Unlike the diagnosis of overt diabetes, the biochemical diagnosis of insulin resistance syndrome is fraught with difficulties. The most accurate way to measure insulin resistance is the euglycemic insulin clamp technique, in which insulin is infused to maintain a constant plasma insulin level. Glucose is then infused and, as the plasma level falls because of the action of insulin, more glucose is added to maintain a steady level. The amount of glucose infused over time provides a measure of insulin resistance. This and similar methods are useful for research but are otherwise impractical. Use of fasting insulin levels has received some attention. Fasting insulin levels correlate well with the degree of insulin resistance. Unfortunately, measurement of fasting insulin is not widespread. Standard methods for performing the test have yet to be adopted, and criteria for normal and abnormal values have not been established. (You can read more about insulin levels here.)

    Because it's so difficult to accurately measure insulin levels, making the diagnosis of insulin resistance relies on soft clinical findings like symptoms and signs:

    The lack of practical, inexpensive, reliable serum tests means that the diagnosis of insulin resistance can, at best, be made on the basis of strong clinical suspicion. This is reasonable because the goal is to identify a condition whose treatment is neither risky nor expensive because it involves sensible lifestyle modifications and careful monitoring for the component diseases of the syndrome.

    At least, that was true until now. Now, some doctors, such as the one profiled in the newspaper article, are beginning to advocate the use of drugs to treat the syndrome:

    Once diagnosed, Syndrome X patients are put on a high-protein, low-carbohydrate diet, along with medications -- metformin (Glucophage) to increase the body's sensitivity to insulin and wellbutrin (Zyban) to help curb carbohydrate cravings.

    Generic metformin can cost from $33 to $55 a month, and its potential side effects, though rare, include anemia and a dangerous build up of lactic acid. Those are risks that are worth taking when it’s being used to treat a real disease such as diabetes, but is it worth it to lose weight? (Not coincidentally, one of its more common side effects is decreased appetite.)

    The generic version of Wellbutrin and Zyban (bupropion) costs from $49 to $66 a month. Potential side effects include seizures and irregular heart rhythms (also rare). Again, not coincidentally, one of the more common side effects is loss of appetite.

    These drugs may help people lose weight, but we should be cautious about advocating their life-long use for the treatment of a syndrome which owes its existence largely to theory. Advocate diet, advocate exercise, but save the drugs for real diseases.

    Needless to say, I declined to test my patient’s insulin levels or to put her on the drugs. I discussed diet and exercise with her, but she was clearly non-plussed. I should introduce her to my other patient who was given the diagnosis of Syndrome X by an endocrinologist at a tertiary care center. She went on both the drugs, but never has accepted the “eat less, exercise more” part, and has failed miserably. She still blames her body. Her endocrinologist has given up on her. Whenever I see her, she spends most of her appointment complaining that no one can (or will) help her. But until she realizes that the problem lies with her own choices, not the failure of medical science, no one ever will be able to help her.
    posted by Sydney on 1/22/2003 08:10:00 AM 0 comments

    Ever Young: Derek Lowe says we're getting closer to discovering the genetic fountain of youth.
    posted by Sydney on 1/22/2003 07:33:00 AM 0 comments

    The Choices We Make: Teenage pot smokers are more likely to abuse other drugs later in life. A study published this week in JAMA follows the fates of marijuana smoking twins. Out of 3500 pairs of twins, the researchers found 311 pairs in which only one of the twins smoked pot before the age of 17. (They were all Australian.) They then looked at the incidence of other mood-altering substance use throughout the twins’ lifetime. The results show striking difference in the subsequent use and abuse of cocaine, alcohol and hallucinogens. Those who began smoking pot at an early age were far more likely to have problems with other drugs later in life than were their more law-abiding twins.

    It’s neither nature nor nurture that determines who we are, but the choices we make.
    posted by Sydney on 1/22/2003 07:27:00 AM 0 comments

    Tuesday, January 21, 2003

    Smallpox Vaccine Update: Here's the place to get an unbiased report on the risks of the smallpox vaccine - The Medical Letter. (And the download is free!)

    posted by Sydney on 1/21/2003 10:12:00 PM 0 comments

    Welcome: Welcome to the new medical weblog, Psychscape, written by the psychiatry editor of Medscape, which has a list of medical weblogs included on their home page now. Viva la blogosphere!
    posted by Sydney on 1/21/2003 10:01:00 PM 0 comments

    Mercury and Vaccines: Derek Lowe explains thimerosal at Tech Central Station.
    posted by Sydney on 1/21/2003 09:56:00 PM 0 comments

    Misogynists: Doctors are ignoring women again, at least according to recent research:

    Researchers found that beta blockers, which slow the heart rate, were used by only a third of the women who should have been taking them. Only half the women who qualified for cholesterol-lowering drugs took them.

    Even aspirin was underused: Though all of the heart attack survivors in the study should have been taking it, only 80 percent did.

    The research highlights "a terrible discrepancy between what we know and how we treat our sisters and mothers," Drs. Andrew Miller and Suzanne Oparil of the University of Alabama at Birmingham said in an accompanying editorial. "This report confirms previous evidence that women with (heart disease) are being undertreated in the United States."

    Hard to say, truthfully, if women are being treated any differently than men. The study only looked at women, and women who were already known to have heart disease:

    The study, in Tuesday's Annals of Internal Medicine, involved 2,763 postmenopausal women with heart disease. All had suffered heart attacks or chest pain caused by blocked arteries, or had undergone bypass surgery or angioplasty.

    The study found that doctors often fail to prescribe aspirin, beta blockers and cholesterol-lowering drugs to these women, even though the medications have been shown to prevent further heart attacks or other heart trouble.

    I don’t have access to the full article, but the abstract notes this finding:

    At entry into HERS, 83% of participants were receiving aspirin or other antiplatelet agents, 33% were receiving -blockers, 18% were receiving angiotensin-converting enzyme inhibitors, and 53% were receiving lipid-lowering drugs. Women with more risk factors were less likely to be taking aspirin (P < 0.001) and lipid-lowering drugs (P = 0.006).

    The fact that women with more risk factors - diabetes, congestive heart failure, poorly functioning kidneys - received less aspirin and lipid-lowering drugs suggests to me that perhaps they didn’t receive them because of side effects or contraindications. That’s the problem with studies like this that just rely on data from other studies. They don’t take into account the individualilty of the research subjects and the nuances of appropriate patient care. If you put a woman with a bleeding ulcer or renal insufficiency on the drugs they mention, she might not die of a heart attack, but she will die of a GI bleed or acute renal failure or liver failure. Sometimes in our zeal for prevention, we forget that dictum of “do no harm.”
    posted by Sydney on 1/21/2003 08:10:00 AM 0 comments

    Shameless Self-Promotion: My Tech Central Station column is up. It's about dangerous lies.
    posted by Sydney on 1/21/2003 08:07:00 AM 0 comments

    More Condom Capers: Jane Brody discusses condoms:

    A newly published survey of 779 sexually active unmarried women 18 to 24 who were recent condom users revealed that in the previous three months 44 percent had waited too long for the condom to be applied.

    The delay may have exposed them to viable sperm and infectious organisms, including H.I.V. And 19 percent reported that the condom slipped or broke in intercourse, placing them at risk of disease and pregnancy.

    But, taking a page from the lately very vocal condom crowd, she attributes this not to the inherent risk of condom use, but to the stupidity of their users:

    Other studies also suggest that the problem of obtaining maximum protection from condom use is often compounded by inadequate knowledge about the way to apply and remove condoms properly and ways to minimize the risk of breakage and slippage.

    She then goes on to overestimate the reliability and effectiveness of condoms:

    Used properly and consistently, condoms are 97 percent to 98 percent effective in preventing pregnancy and provide the best possible protection, short of total abstinence from sexual activity, against sexually transmitted infections, including H.I.V. and the human papillomavirus, which can cause cervical cancer.

    While condoms may be better than no protection, they in no way approach the 97 to 98 percent effectiveness range in real use. Nor do they protect against HPV, largely because HPV lesions can be on the scrotum, which of course, isn’t covered with a condom. And although, in a perfect world, it might be possible to use condoms perfectly every time, we must face up to their limitations. Even among highly motivated couples who took part in the study of HIV transmission and condom use that Ms. Brody cited, the proper and consistent use of them was astonishlingly low. They began with 304 couples. Some relationships ended during the study. For the rest:

    Of the 256 couples who continued to have sexual relations for more than three months after enrollment in the study, only 124 (48.4 percent) used condoms consistently for vaginal and anal intercourse.

    Not very reassuring, is it? For who among us is so perfect to do everything exactly right all the time?

    posted by Sydney on 1/21/2003 08:04:00 AM 0 comments

    Hubris: In this tragic story of the woman who had a mistaken mastectomy lies this strangest of all suggestions for avoiding medical errors:

    Marc Siegel, an associate professor of medicine at New York University recommended that anyone who is very sick or faces a bad diagnosis should go to a regional medical center that is associated with a medical school.

    "I advise my patients to go to the top place in the region," he said. "There's more scrutiny, there's more structure, there's more vigilance at the top medical centers."

    Yeah, right. Tell that to Libby Zion, and Andy Warhol.
    posted by Sydney on 1/21/2003 07:36:00 AM 0 comments

    Yet More Lawyer Letters: A reader emailed to say that HALT is wrong to claim that clients aren’t allowed to publicize actions they may take against their lawyers for behaving badly:

    There are rules that require that disciplinary proceedings against a
    lawyer be treated as confidential. Those rules are at least nominally
    intended to protect clients by ensuring that when a client brings a
    grievance against a lawyer, the client doesn't lose the protection of
    attorney-client privilege. (They may have the secondary effect of
    protecting the attorney by keeping the proceedings out of the papers,
    and one could reasonably debate whether those rules could be reformed to
    accord greater weight to the public interest in disclosure of the
    proceedings while they are ongoing.)

    However, those rules do not prevent a consumer of legal services from
    speaking about his or her complaints outside of a disciplinary
    proceeding. The suggestion that anyone would ever be fined or
    imprisoned for doing so is absolute nonsense.

    That depends on what the meaning of “confidential” is. Maybe a talented lawyer could find a way to change the meaning of the word to allow public disclosure, but most of us laypeople who take language at its face value would be hard-pressed to do so. The original quotation, from HALT’s website specified that there are nine states that have stiff gag rules. Since HALT is staffed by lawyers, I’ve got to assume they know what they’re talking about.
    posted by Sydney on 1/21/2003 07:35:00 AM 0 comments

    Monday, January 20, 2003

    In Memoriam MLK: I was listening on the way home tonight to the many tributes to Martin Luther King, Jr. on the radio, and I thought about how far we have come in the past fifty years. We've come so far that my Italian/Irish/German/Swiss/English and heaven-knows-what-else daughter often expresses the wish to be African-American. She's learned about Martin Luther King, Jr. in school, read his "I Have a Dream" speach, heard the story of Rosa Parks, the Underground Railroad, Fredrick Douglass, Sojourner Truth, and Ruby Bridges. She's taken these stories of personal courage and triumph over overwhelming odds to heart. To her mind, African-American is the best ethnic group hands down. What better testimony to the success of Martin Luther King, Jr.'s legacy?

    posted by Sydney on 1/20/2003 09:59:00 PM 0 comments

    Canadian Cajones: It takes courage for a physician to say this publicly:

    Preventive medicine displays all 3 elements of arrogance. First, it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy. Occasionally invoking the force of law (immunizations, seat belts), it prescribes and proscribes for both individual patients and the general citizenry of every age and stage. Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them. Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.

    He goes on to make a good point, that we aren’t discriminating enough in the preventive treatments we offer people. Of all the preventive measures we take, colon cancer screening and pap smears are probably the only that are truly effective and worth their cost to the individual. The rest - cholesterol drug therapy, mammograms, osteoporosis prevention , prostate cancer screening - aren’t nearly so clear cut when it comes to cost vs. effectiveness. Yet, we continue to urge them, sometimes force them, on people. I received last week my yearly accounting of preventive services from all the managed care companies that cover my patients. They’re full of names I recognize as people who have been offered but declined health screenings such as cholesterol (“Listen doc, I’m not going to do anything about it anyway so there’s no need to test me.”) to mammograms (“Honey, I’m 90 years old. If breast cancer kills me, it will be a blessing.”). The purpose of the lists is to 1) rate my performance in delivering preventive care and 2) hope that I’ll put pressure on the deliquents to improve my rating. Aggressively assertive, presumptuous, and overbearing.

    I also like the letter from another Canadian physician in support of his position:

    David L. Sackett's commentary on preventive medicine is a breath of fresh air which should become a hurricane in this world where life is becoming increasingly "medicalized." His last paragraph is particularly apt: "Experts refuse to learn from history until they make it themselves, and the price for their arrogance is paid by the innocent. Preventive medicine is too important to be led by them."

    One might add a remark from an essay by Lancelot Hogben, a British scientist and economist, born in Portsmouth in 1895: "No society is safe in the hands of its clever people."

    (via Colby Cosh)
    posted by Sydney on 1/20/2003 06:50:00 AM 0 comments

    Sugar Eyes: A study in The Lancet suggests that diabetics with normal eyes can decrease their eye exams to every three years. The current recommendation is for diabetics to have eye exams every year. Another one of those preventive measures that are more guess-work than science.
    posted by Sydney on 1/20/2003 06:49:00 AM 0 comments

    What Will Monkeys and Children Eat? If the banana industry isn't able to apply biotechnology to bananas, bananas could disappear in 10 years, so says an expert.
    posted by Sydney on 1/20/2003 06:49:00 AM 0 comments

    Amazing Anatomy: I meant to post something about this a while ago, but kept getting side-tracked. The story didn’t get much media attention - it must not have been press released by the New Engand Journal, but it’s fascinating for what it says about how our bodies work. The news is that that some cases (perhaps most cases) of high blood pressure might be determined by the number of nephrons in our kidneys.

    Nephrons are the basic working units of the kidney. They are the places where all the trash left over from our metabolism gets filtered out and dispensed in our urine. In the process they also regulate our water and electrolyte balance. And they also have an effect on our blood pressure.

    There have been clues that something in the kidneys is critical to the development of high blood pressure. People with normal blood pressure who recieve kidney transplants from people with high blood pressure often develop high blood pressure after their transplants, for example. People with kidney damage and disease also often develop high blood pressure.

    But last week’s paper in the New England Journal documented the number of nephrons in people with and without high blood pressure who had died in auto accidents. The numbers were small - only ten in each group, but they were well-matched and controlled for other factors, and the difference in nephron numbers was striking in most of the cases. The people who had high blood pressure had 500,000 to 900,000 nephrons. Those with normal blood pressure had 900,000 to 1.9 million.

    So, what does this mean? Well, for one thing, it helps us understand why the old and cheap thiazide diuretics have proven so effective. Their site of action is at the nephrons. It also may help research chemists come up with other, better medications that reduce the stress on nephrons. It’s been a while since any new blood pressure medications have been developed with a different mechanism of action than the ones that already exist. Perhaps this research will open the door for more.
    posted by Sydney on 1/20/2003 06:45:00 AM 0 comments

    Sunday, January 19, 2003

    More Lawyer Letters: Another email from a lawyer ( a trial lawyer, too) who supports tort reform and who has some objections to comparing the system to the Middle Ages:

    I can't say that voicing the opinion that the legal system is a dated anachronism is remotely close to sanctionable behavior. Heck, we debated it for a full day in my Crim Pro class, and I don't seem to remember being tied to the stake for suggesting that the system is superbly medieval (not that I mind that...)...

    The (first) comment in Ms. McArdle's blog entry to the effect of the real reason for checking footnotes in a law review article is dead-on. Trust me: I was one of the peasants assigned to do exactly that at my journal, and I saw how often those citations were off by a page number or a volume (S.E. instead of S.E.2d). That undermines the value of the work, not for dishonesty, but shoddiness. That's why we check and double-check our cites.

    As for your complaints about the law:

    I'm caught between agreeing with you that the legal profession needs to be better at self-regulating, and thinking we actually do a pretty good job of it on our own. Lemme explain: If you watch the state Supreme Court opinions, you will find *a lot* of sanctions dealt out to lawyers (that's usually where the sanctions have to go). You'll also find a lot of "voluntary" sanctions -- i.e., the lawyer apologized for his conduct, and asked for discipline,(further i.e.), he was scared of what happens if he didn't come up front and apologize. On the other hand, the system relies on reporting. In other words, you get tagged by a lawyer, you need to report it to the Bar; frequently, only you and the lawyer know what he's done wrong. Lousy system, but it's the best we've got right now.

    When the lawyer does something criminal (cough perjury) that's out of the profession's hands, for the most part. Sure, you can (and should) disbar him; but the actual crime (theft, etc.) is best left to the police.

    One last on this: I *like* the fact that there's a cause of action for malpractice against lawyers. Keeps us honest.

    As I've mentioned a couple of times now (on other blogs), the whole medical malpractice system needs a serious adjustment. I've seen both good and bad doctors take a beating. A little back history, though: Our current system is a response, essentially, to a time when it was almost impossible to bring even a battery charge against a doctor, for fear of restraining doctors' practice, and therefore hurting the nation as a whole... There was undoubtedly some wisdom in that. But the system also didn't punish doctors who screwed up, and shouldn't have -- and who just mozied along, happy as could be. The current system, conversely, has the effect of punishing (most) of the doctors who royally screw up, but also tagging doctors (directly or indirectly) who've done nothing wrong. I do not dispute that the system is broken; I just don't want a return to those glorious days of yesteryear.

    I like Bush's new plan (the constitutionality of it is suspect, but I still like it); I'll happily take the cap on punitives (especially if there's an automatic adjustment built in over time, to reflect changes in the real value of money). I oppose a cap on actual damages. In other words, I'm willing to compromise. Especially if there's some way to toss the lousy docs out of the system, too. My wife suggests automatic revocation of license if one is successfully sued three times in ten years; I'm skeptical, but something like that is in order.

    Would that be doctors who are successfully sued because their insurance company or hospital opt to settle to avoid high legal costs, or only doctors who are found guilty by a jury? In our current system, it’s possible for a good doctor to lose three cases in ten years. But maybe there should be a point after so many losses that sends up a red flag and results in investigation by the state medical board of the doctor’s competence.

    posted by Sydney on 1/19/2003 09:58:00 PM 0 comments

    Gaining Ground: According to the New York Times the number of deaths from heart disease has declined precipitously since the 1970's:

    The stereotypical heart attack patient is no longer a man in his 50's who suddenly falls dead.

    "That death rate is so low now that we're no longer able to track it," said Dr. Teri Manolio, director of the epidemiology and biometry programs at the National Heart, Lung and Blood Institute. "It's almost gone."

    The reporter tries to link the decline in mortality to our preventive efforts - our use of statins to lower cholesterol, the
    decline in smoking rates, but as one of the doctors interviewed points out, it's the treatment of heart disease that has improved markedly in the past thirty years:

    "When I look back 25 years ago to when I was a cardiology fellow, many of the things we did were not proven and many are now proven to be wrong," Dr. Goldman said. "Our treatment for heart attacks was bed rest. We put them to bed and we watched them."

    Now, doctors give drugs to heart attack patients to dissolve blood clots, opening blocked arteries. They operate, with much better surgical results. They pry open clogged blood vessels with balloon angioplasty and stents, the wire tubes to keep them open. Recently, device makers developed implantable defibrillators that can shock a fluttering heart into beating steadily, preventing death in patients with damaged hearts.

    And in fact, the graphic that accompanies the article shows the steepest decline in morality in the 1980's, a decade that saw vast improvements in cardiology techniques. The widespread, and aggressive, use of statins didn't catch on until the 1990's.

    While we're on the subject of statins, there was this little nugget of information in the article:

    Tens of millions of Americans are taking them. In the 12 months ended in September 2002, there were 116 million dispensed prescriptions of statins — new prescriptions and refills — in the United States, according to IMS Health, a health information company.

    116 million dispensed prescriptions for drugs that can cost anywhere from $31 per month (the lowest dose generic) to $120 per month (the highest dose of the most expensive). Not to mention the $20 to $100 lab fee to have blood work done every six months to monitor side effects, or more frequently if the drug dosage has to be changed. And we wonder why healthcare costs are so high, and why insurance companies are reluctant to cover drugs.
    posted by Sydney on 1/19/2003 03:03:00 PM 0 comments

    The Power of Rumor: This case of a polio epidemic in one Indian state illustrates the power of rumor. The epidemic has festered largely because of a rumor among Muslims that the Hindus who control the government are out to sterilize them with the polio vaccine. The result has been predictable:

    In 2001, after years of aggressive mass immunizations, there were 239 new cases in the country - down from about 200,000 in the early 1980's. Officials were confident that India could eliminate the disease, as so many countries have, by the end of 2002.

    Instead, India had 1,509 newly diagnosed cases last year - a vast majority, 1,197, in Uttar Pradesh, the country's most populous state, and one of its poorest. Uttar Pradesh accounted for 68 percent of the polio cases worldwide.

    It's amazing how much harm a little disinformation can do.
    posted by Sydney on 1/19/2003 02:45:00 PM 0 comments

    The Ethicist does Smallpox Vaccine: It isn't often that I agree with the New York Times' ethicist, but he hit the nail on the head in responding to a question about smallpox vacccine posed to him by a public health physician who mentioned in his question that he believes “that the policy is primarily an effort to spread fear and build support for a war with Iraq. If I am vaccinated, I will be complicit with a policy I morally oppose.”

    To which the ethicist replied:

    You are not being asked to endorse the president's Iraq policy but to decide if vaccination is called for in your circumstances. Believing as you do that there is no medical necessity, you have no ethical obligation to be vaccinated simply because the president urges it.

    As a doctor, you can judge the risks of vaccination. As a citizen of a democracy, you must decide if the president has made a persuasive case that a smallpox attack is likely enough to justify that risk. If you and your colleagues overwhelmingly reject the president's call, this may indeed be interpreted as a rebuff of his policy, but that should be a byproduct of your decision, not your reason for making it.

    This is precisely what is so bothersome about the campaign that many in the public health field have waged against the smallpox vaccine program. From leaking the IOM report on the vaccine to the media before giving it to the CDC or the HHS, to statements by former CDC head Jeffrey Koplan to the New York Times that “reports that secret stocks of the smallpox virus were held by such countries as Iraq and North Korea were not enough to warrant” vaccinating people, the actions and words of the public health community have been riddled with their personal politics. It doesn’t do much to bolster confidence in them.

    The other thing that’s worrisome about the letter to the ethicist is this: the writer, a specialist in infectious diseases according to his online resume, gives the impression that he needs to be vaccinated to care for people who have had side effects from the vaccine. He seems to suffer from the impression that the vaccine is just as contagious as smallpox. He doesn’t, and it isn’t. There’s a lot of hysteria and misinformation out there about the infectious nature of the vaccine, most of it coming from the public health community. This, too, does little to bolster confidence in them.
    posted by Sydney on 1/19/2003 02:36:00 PM 0 comments

    Condom Casualty: Here's the story of one teenager who relied solely on condoms for birth control.

    One thing that keeps bugging me about this story is the very limited contact the girl had with the doctor before and after her abortion. I can't think of one medical procedure where the patient is sedated and draped before getting to meet the doctor. Don't women undergoing an abortion deserve to know who's going to be operating on them?
    posted by Sydney on 1/19/2003 11:32:00 AM 0 comments

    Defensive Lawyers: Jane Galt linked to the email from a lawyer that was critical of the legal system a few days ago. (He compared it to the Middle Ages.) Judging by her comment section, some of her readers doubt that the writer was a lawyer. Just proves his point. And the point of the post. Whenever someone dares to suggest that the legal system could stand some reform, the legal profession agressively goes on the attack.

    Remember what happened to Dan Quayle when he dared to criticize the trial lawyers? (For that matter, remember Dan Quayle?) The legal profession went on a very highly publicized defensive. If only the medical profession would go on just as vigorous a defensive when we’re unjustly accused of killing 98,000 people a year, or leaving behind 1500 instruments in bodies every year.

    I’m willing to concede that the medical profession could police itself better, although I have no idea how. One of the hospitals in my city tried to remove a subpar surgeon from the staff. He sued them, and the chief of surgery who made the decision, for loss of income and defamation of character. Both the hospital and the chief of surgery lost to the tune of millions of dollars. You can understand why they’d be shy of taking such an action again.

    I’m fully aware of the importance of lawyers. I firmly believe that everyone should have the right to air their grievances in court. But, there is no reason to think that ours is a perfect system or that it doesn’t need reformed. It isn’t right that lawyers can troll for clients from the police accident reports, or records of ambulance runs. It isn’t right that everyone ever involved in a patient’s care can be sued without consideration of their role in that care or of the merits of the suit. And it isn’t right that companies who have never dealt with asbestos are being sued by people who have never been exposed to asbestos.

    Then there are the people who have suffered at the hands of their own attorneys. The son of one my patients went to jail when a prosecuting attorney reneged on her plea bargain agreement - after she discovered that televsion cameras would be in the court room. One of my father’s friends had his inheritance stolen by the attorney managing the estate, an occurence which is all too common. Then, there’s the person whose defense lawyer slept during the trial - without any consequences, except to his client.

    Are these sorts of things disciplined? Evidently not for long, or not often. In fact, according to HALT, an organization devoted to legal reform, in a lot of states people with grievances against their attorneys can’t bring them to the public’s attention the way, say, people with grievances against companies or doctors can:

    HALT's Report Card reveals that nine states still have "gag rules" that prohibit legal consumers from speaking about their grievances. "If the agency finds out that you've spoken to a reporter or even just told your friends or family about your grievance, you could be held in contempt of court, fined or imprisoned. This is a clear violation of the First Amendment right of free speech," stated Suzanne M. Mishkin, HALT's Associate Counsel and Director of the Lawyer Accountability Project.

    Obviously, the legal profession is no more perfect than the medical profession. The difference is, they seem to have no interest in improving the situation.

    (For more about HALT’s lawyer accountability project, click here.)
    posted by Sydney on 1/19/2003 09:56:00 AM 0 comments

    Link Update: I’ve added two blogs to the “personal favorites” category to the left - Cronaca, an archeology/history oriented blog, and Out of Lascaux, an insightful art-oriented blog.
    posted by Sydney on 1/19/2003 07:45:00 AM 0 comments

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