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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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    Monday, June 07, 2004

    Lovely Venus: Venus will move across the sun early tomorrow morning (at least that's when it happens here in Ohio), an event that happens twice every one hundred and twenty years or so. NASA has information on when and how to view it, as well as music to accompany it.

    posted by Sydney on 6/07/2004 08:27:00 AM 0 comments

    Desperate Measures: Treating diabetes with the spit of Gila monsters. And it's "natural"!
    posted by Sydney on 6/07/2004 08:19:00 AM 0 comments

    Better than Aspirin! And over ten times the cost. The cholesterol-lowering drugs, statins, are being hailed as cancer fighters:

    Dr. Stephen Gruber, a cancer researcher at the University of Michigan, found in a study of Israelis that statin medications lowered the risk of colorectal cancer by 46 percent, which is significantly more than aspirin. The study, which was observational, he said, requires additional testing. But if future research proves him right - and he thinks it will - drugs now used to prevent clogged arteries may one day be prescribed to prevent the third leading cause of cancer deaths.

    The study was not a rigorous one:

    His team, working in Israel, looked at 1,708 people who had colon cancer and 1,737 who did not. Those on statins for at least five years had about a 50-percent reduction in the risk of cancer.

    Adjusting for other factors that could possibly explain the difference, such as better health habits, did not change the strong link between statins and lowered risk.

    This sort of study, one which compares one group with a disease to another group without it and then looks for similarities and differences is one of the weakest ways to find causes (and preventives) for a disease. What it really finds is associations. It's impossible to say from this if statins actually lower the risk of cancer. It was studies like this that purported to show hormone replacement therapy reduced the risk of heart disease in post-menopausal women, which we now know it does not do. What's more, the study was reported at a meeting of oncologists, which means it hasn't been peer-reviewed (for what that's worth) and that the data aren't available for scrutiny. That fifty percent reduction in cancer rates could have been the difference between 2 cases and one case, or the difference between 50 casesand 25. We have no way of knowing. So don't buy the hype.
    posted by Sydney on 6/07/2004 08:14:00 AM 0 comments

    Sunday, June 06, 2004

    Passing: Ronald Reagan, at age 93. Reagan's era coincided with my college and medical school days, when I was a knee-jerk liberal. I had no respect for him. But, a few years ago, I heard an interview on NPR with a man - a European - who had made his life's work documenting the atrocities of the North Korean dictatorship. He cited Ronald Reagan as his inspiration. Specifically, Reagan's courage in calling totalitarian regimes evil - and to their faces. He said from that moment, people living under those regimes (the old Soviet Union, most of Eastern Europe) took heart. And I realized that Reagan played more of a role in the collapse of communism than I had ever given him credit. Simply by speaking the unvarnished truth. So to President Ronald Reagan - requiescat in pace.

    posted by Sydney on 6/06/2004 08:33:00 AM 0 comments

    SARS Lessons: The lessons of SARS as learned by Canadians. The numbers are staggering:

    Results Toronto Public Health investigated 2132 potential cases of SARS, identified 23,103 contacts of SARS patients as requiring quarantine, and logged 316,615 calls on its SARS hotline. In Toronto, 225 residents met the case definition of SARS, and all but 3 travel-related cases were linked to the index patient, from Hong Kong. SARS spread to 11 (58 percent) of Toronto's acute care hospitals. Unrecognized SARS among in-patients with underlying illness caused a resurgence, or a second phase, of the outbreak, which was finally controlled through active surveillance of hospitalized patients. In response to the control measures of Toronto Public Health, the number of persons who were exposed to SARS in nonhospital and nonhousehold settings dropped from 20 (13 percent) before the control measures were instituted (phase 1) to 0 afterward (phase 2). The number of patients who were exposed while in a hospital ward rose from 25 (17 percent) in phase 1 to 68 (88 percent) in phase 2, and the number exposed while in the intensive care unit dropped from 13 (9 percent) in phase 1 to 0 in phase 2.

    One person with SARS managed to give the illness to 222 people. Think about that. And just three unrelated infected people resulted in the quarantine of 23,103 others. Even worse, 88 percent of hospitalized people- those least able to fight off infection - were exposed to the virus while in the hospital. The SARS epidemic was a vivid illustration of just how quickly a truly infectious disease can spread. We should consider ourselves warned against complacency when it comes to bioterrorism with highly infectious (and much deadlier ) agents, like smallpox. But our public health officials still continue to insist that things will be fine if we wait until an outbreak. And they still aren't doing anything to educate the masses (we physicians in the trenches) on recognizing bioterror diseases and how to respond.

    My own health department is still devoting all of their resources to educating me about the importance of childhood immunizations (something I learned in medical school) and of convincing my patients to stop smoking (also learned in medical school.) They are completely incapable of shifting their paradigm.
    posted by Sydney on 6/06/2004 08:17:00 AM 0 comments

    Special Niche: Who are the Whiskey Painters of America? A society of imbibing artists:

    The purpose of this most unique organization is:

    (A) To promote the fine art of painting in miniature.

    (B) To promote the good fellowship among imbibing artists.

    (C) To prove to fellow pub habitués that bongo drums and free verse are not necessary adjuncts to good art.

    (D) To permit an artist to enjoy two of the three greatest pleasures in life while sitting on a pub stool or a dimly lit cocktail table any place.

    (E) To add interest to an otherwise dull evening.

    And they have an online art gallery.

    posted by Sydney on 6/06/2004 07:59:00 AM 0 comments

    Friday, June 04, 2004

    Science Spectrum: The new monthly feature from Winds of Change - Winds of Discovery - a monthly round up of the latest in cutting edge science.

    posted by Sydney on 6/04/2004 06:34:00 PM 3 comments

    Hopeless: What do you do when you've been banned from every hospital in the Kingdom?
    posted by Sydney on 6/04/2004 06:24:00 PM 0 comments

    The Best Medicine: Chortle
    posted by Sydney on 6/04/2004 05:09:00 PM 0 comments

    Faith, Hope, and Charity: What the dying would like from their physicians.
    posted by Sydney on 6/04/2004 08:24:00 AM 0 comments

    A Stitch in Time: The BBC says that cervical cerclage - the placement of a stitch in the opening of the uterus to prevent preterm birth, doesn't work:

    Stitches don't stop preterm birth

    A common surgical procedure used to try to stop women giving birth prematurely has little effect, research suggests.

    But that isn't really what the study found. It found that the procedure is only marginally beneficial if used for women whose cervixes appear short on ultrasound examination:

    The Kings team, led by Professor Kypros Nicolaides, used ultrasound screening to identify 250 women with a short cervix. Some underwent cervical cerclage, while others had no surgery.

    Among those who underwent surgery, 22% went on to have a premature birth, compared to 26% among those who had no surgery.

    Premature birth was defined as delivery at or before 33 weeks.

    In both cases, the level of premature birth was far higher than the UK average of 1.5%.

    The researchers say their work shows that women with short cervixes are at increased risk of premature birth - and that for them cervical cerclage seems to have only a limited effect.

    Here in the States, cervical cerclage is not routinely recommended for asymptomatic women with ultrasound evidence of a shortened cervix. It's recommended in women who meet other criteria. This study says nothing about its usefulness in the situations when it's usually used.
    posted by Sydney on 6/04/2004 08:07:00 AM 0 comments

    Less is More: When it comes to Vitamin C, taking too much can accelerate arthritis, at least in guinea pigs:

    "The guinea pig is the ideal animal in which to test this,' Kraus explained, 'because they require vitamin C in their diet, just like humans, and they get an osteoarthritis of their knees that looks very similar to the type of knee osteoarthritis that humans get.'

    Arthritis specialists have long recommended that patients consume an adequate daily amount of vitamin C because the nutrient is both a potent antioxidant and a key player in the formation of joint cartilage. But would higher doses of the vitamin make bones even stronger?

    Not so, Kraus reports. 'More is not better,' she said. 'We found that the more vitamin C given, the more osteoarthritis is apparent in the joints of these animals that are predisposed to getting osteoarthritis.'

    Guinea pigs fed low doses of vitamin C showed the least signs of knee arthritis, Kraus said, but since they also tended to weigh much less than the medium- or high-dose animals, reductions in weight might explain that result.

    Animals fed a medium dose of vitamin C -- roughly equivalent to the recommended daily allowance in humans -- had slightly more signs of knee damage. But it was the high-dose animals that fared worse, with obvious signs of arthritis and an increase of bony outcroppings on the knee called osteophytes or bone spurs.

    So there, Linus Pauling.
    posted by Sydney on 6/04/2004 07:44:00 AM 0 comments

    School Reform: How one school principal has made a difference in the health of her students:

    She ordered sweeping changes. The first priority was to remove the soda machines — but there was a problem: the school district had a contract with Coca-Cola.

    So Butler insisted the vending machines sell only Dasani-brand water, which is a Coca-Cola product.

    Butler then banned fried foods, high-fat foods, and especially sugary desserts. Browns Mill was now a "sugar-free school," which left many parents angry.

    .....She even enlisted the bus drivers to ensure students did not eat sugary snacks on their way to or from school.

    She comes across in the article as a bit of a zealot, but at least she understood her school's complicity in the poor eating habits of her students. I still can't understand why my children's elementary school sells chocolate milk and ice cream in the cafeteria. Not as a special treat, but every day.
    posted by Sydney on 6/04/2004 06:43:00 AM 0 comments

    Pygmy Science: Honey, they shrunk my lab.
    posted by Sydney on 6/04/2004 06:20:00 AM 0 comments

    Gouging: Michael Fumento is skeptical of claims by political activists that commonly used drugs are increasing in price. He's got a point about generics. Most commonly used drugs can be had at a cheaper price in a generic version - or a safe alternative to them can.
    posted by Sydney on 6/04/2004 06:18:00 AM 0 comments

    Poverty Chic: The much talked-about Guardiancolumn by former New York Times editor Howell Raines had this revealing sentence:

    With Gore, you feel that if he could choose, he would have been born poor and cool.

    This says nothing about Al Gore, since it is only Raines' impression, but it says everything about the psychology of Raines. Can he really think it's cool to be poor?
    posted by Sydney on 6/04/2004 05:56:00 AM 0 comments

    Thursday, June 03, 2004

    Hmmm: They say that obesity causes cancer and that we're in the midst of an "obesity epidemic", and yet the annual report to the nation finds cancer incidence and death rates on the decline. So does that mean obesity doesn't really cause cancer? (Expect the next headline to be "Death Rates from Cardiovascular Disease on the Rise." Those of us who don't die of cancer will have to die of something eventually, and it's usually the heart that gives out first.)

    UPDATE: A reader sends this link to a story about treating fat as cancer.

    posted by Sydney on 6/03/2004 10:51:00 AM 0 comments

    Question for the Sages II: Another reader emails:

    Last January I had a client contract me to conduct a communications survey of medical malpractice of Ohio Doctors. The primary conclusion I can share with you is that doctors don’t have single mindedness on this issue. Theirs was a smattering if ideas as to what is the cause and what can be done to help improve the issue of skyrocketing prices. My question to you is this.

    1. Why at this late juncture, do doctors still not have a plan on how to combat the skyrocketing prices of medical malpractice insurance?

    Doctors are an opinionated, and often arrogant, bunch. Getting us to agree on a course of action, especially a political one, is almost impossible. For one thing, not all of us share the burden of the malpractice crisis equally. Doctors who are paying $8,000 a year for malpractice insurance in southern Ohio can't empathize, or sometimes even sympathize, with doctors in northeast Ohio who are paying $50,000 a year.

    I think the medical profession has been working hard on a plan, though. The Ohio State Medical Association has been at the forefront of lobbying for tort reform, and they've made a real effort to reach out to doctors and the public for support. It's getting doctors to tear themselves away from their practices (or what little free time they have) to provide the support that's difficult.

    2. Why are medical professionals afraid to prioritize the issues and combat the dismantling of how they practice medicine?

    We're too distracted by the day to day practice of medicine. And one doctor's dismantling is another doctor's improvement.

    3. Who should lead & speak for doctors in Ohio?

    That's a tough one. I guess the Ohio State Medical Association should, but not every doctor is a member. Professional organizations, like the American Medical Association and its sister organizations in each state, are widely perceived as being too narrowly focused on the needs of sub-interests within the organization. Primary care doctors think they cater to the needs of specialists over primary care, and vice versa. Which makes it difficult to unite all of us, contributing to the problems noted in questions one and two.

    4. It was clear from my interviews with doctors, that the independent practitioner is being squeezed out. Eventually we will see a few large corporations running the medical profession. Why are doctors allowing this? In the end the doctors will be charged back for expenses and told this is how much the corporation is willing to pay. Take it or leave it! Why are medical professionals allowing corporations to define how they will practice medicine is such an intimate way?

    I'm not sure it's true that the independent practitioner is being squeezed out. It was the trend about ten years ago, when HMO's were all the rage, and "economies of scale" the buzzword. Doctors were selling their practices to hospitals and management corporations to reap the benefits of bargaining power with insurance companies and supply companies, and to gain market share in a tight HMO field. But, then, just as the question states, they found they were "charged back for expenses and told this is how much the corporation is willing to pay," and that the corporation wasn't willing to pay much. The corporations, on the other hand, found that medical practices don't make a lot of money, at least not enough to support several tiers of management at anything above minimum wage. So the trend in the past few years has been for these corporations to kiss the doctors good bye.

    Actually, in the past two years, I've known more colleagues who have gone out on their own than I did in the years immediately after my residency. Part of that may be because we're older now, and more confident in our business abilities, but I think most of it is because the two major hospitals in our area who used to own a lot of practices have been dissociating themselves from outpatient medicine.

    5. Doctors have been too nice for too long and accepted the fall-out. Why hasn’t anyone suggested a “united public relations effort” to prioritize how their patients can assist them in the crisis? A simple leaflet on the table top of each doctors office title “10 things you can do to reduce your medical expenses” Patients want to help if only they know how to help. Something like this leaflet would make a world of difference – extending beyond the doctors morale.

    That's a good idea. Maybe I'll write a pamphlet like that and see how it's received.

    6. Any thoughts? I have lots more but it will immobilize you.

    I'm almost immobilized now, or at least late for work. Readers are welcome to email me with any thoughts or suggestions, and I'll add them to the post as updates.

    UPDATE: One readers' thoughts on how to reduce medical expenses - take a more active role in your health:

    I would love for a community to get this going: Persuade local pharmacies to offer discounted BP cuffs and stethoscopes, or perhaps some drug reps could donate a few. Announce a "How to Take Your BP" day at various areas, such as Walmarts, or the Northside pharmacy locations here in town. Have volunteers (I would be happy to do this) at a couple of areas in the store, teaching people how to listen and take BPs. Then have a second volunteer check they're doing it properly.

    Put a note up in your office that a filled-out daily (weekly?) log of BP will be good for a $10 discount on office visits. (Or some such inducement.) If I knew my husband had high BP....he might not be in Adams Lane Care Center now, following a big bleed 5 years ago.
    Think what we could do.....

    Even something as simple as opting for generic medications instead of brand names helps reduce expenses, although many people don't see it that way because they don't pay the full cost of their drugs, their insurance companies do.

    And a comment about the pamphlets:

    Re your comment about writing a pamphlet -- saw a poster for an org called, I think, fightingdocs.com, that is putting out materials. The poster said 'Save Pennsylvania Physicians' to which I asked 'collect the whole set?' The receptionist, at least, was amused.

    UPDATE II: Bard-Parker, surgeon extraordinaire, has some thoughts on why doctors have trouble getting behind their medical associations - it's a generational thing.
    posted by Sydney on 6/03/2004 10:36:00 AM 0 comments

    Questions for the Sages: A reader and frequent contributor to post ideas asks:

    What is your plan for our fractured and soon to collapse health care system?

    Well, if I had an easy answer I'd be running for office. But, my correspondent answer his own question:

    I think Brad DeLong's is correct that Kerry's proposal to effectively offload catastrophic health care coverage onto the government is a good one. I'm more skeptical about its workability in practice - the stakeholders with their snouts in the health care trough are rather powerful. I worry frankly that any non-nuclear health care reform (which would likely fail unless the people had taken to the streets or the rest of big bizness had finally gotten smart) will just get loaded up with more and more pork for the lovers of the free market as it sails through congress.

    A rather smart person recently clarified the whole health insurance issue to me -- what we call health insurance in this country has little resemblance to actual insurance, and thinking about it as an insurance problem largely muddies the issue. What we have is a health care delivery industry, with little divide between the providers of health care and the providers of health insurance. It's all one tangled mess, and the incentives are completely skewed across the board.

    An exception is catastrophic insurance, which could be more like traditional insurance if it were chiseled off. Perhaps if a clean bill could get through congress Kerry's plan is a good first step. Still, I suspect that it'll just provide another way for the health care industry, one way or another, to suck some more taxpayer dollars.

    He's exactly right about the skewed nature of our system. I would add, however, that the one thing that skews it the most is the complete disconnect between the consumer and the payer. When insurance companies pay for every screening test regardless of its usefulness, when they pay for every risk-reducing drug, no matter how high the price or how low the risk reduction, then there's no incentive for either the provider or the consumer to choose responsibly. And when the insurers don't pay, there's sure to be some activist group lobbying for a law somewhere to make them pay for it. It's too easy to cast the payer as withholding coverage for greed's sake. The result is that insurance companies (and government programs like Medicare) end up paying for things of dubious benefit.

    For example, Medicare now covers routine colonoscopies to screen for colon cancer (that is, colonoscopies on asymptomatic people), which around here go for $2,000 each. Now, there's no doubt that colonoscopies find small polyps before they become cancer, and therefore save lives, but are they worth the cost? Especially when you consider that the vast majority of them will be normal? That kind of cost/benefit analysis is best left up to the individual, and that kind of cost/benefit analysis only works when the individual has to pay the $2,000 himself. If doctors had to explain to their patients why they needed to pay $2,000 to have a telescope snaked through their colon, then we'd have a better incentive to make sure our evidence for recommending it is solid.

    Colonoscopies are just one example. The medical profession has been on a reckless recommendation spree these past ten to fifteen years (ever since preventive medicine has been covered by insurance companies), making all kinds of recommendations to minimize small risks at astronomical costs - from cholesterol-lowering medication to prevent heart disease in the healthy and cholesterol unchallenged, to stricter diabetic control with more and more medication, to screening for prostate cancer with a badly flawed blood test, to encouraging mammograms in young, low-risk women. And that's just in preventive measures. If you consider the reckless abandon with which some of us prescribe expensive routine medications such as antibiotics and blood pressure medication when cheaper equally effective alternatives exist, the problem is even worse. If we had to answer to our patients for the costs and benefits of the screening procedures and treatments we recommend, we'd make more responsible, and cost-effective recommendations. And in the process, we'd be serving our patients better.

    In the end, I agree with DB. We need a system in which the patient bears some financial responsibility for the routine medical costs. It's the only way we'll ever rein them in.
    posted by Sydney on 6/03/2004 10:12:00 AM 0 comments

    Lines in the Sand: Peggy Noonan notes that California is banning public smoking on beaches, and wonders why legislators only worry about what goes on in some organs but not others:

    I have come to hate the banners. No, I don't smoke. I just believe in the right of people to be human, to be imperfect and messy and flawed. I don't dislike the banners because they're prissy bullies, though that is reason enough. I dislike them because their work forces us to look at the shift in values in our country in our time. As I watched the NBC report, I actually thought to myself: I want to make sure I understand. If you smoke a cigarette on a beach in modern America you are harming the innocent. If you have a baby scraped from your womb, you are protecting your freedom. If you sell a pack of cigarettes to a 12-year-old boy you can be jailed, fined and sent to Guantanamo Bay with the other killers. If you sell a pack of contraceptives to a 12 year old boy in modern America you are socially responsible citizen.

    For reasons that call for an essay of their own, and as we all know, the banners of cigarettes are on and of the left, and the resisters of the banners are on the right. Once the banners of liquor were of the right and its legalizers of the left. The banners of drugs were on the right and the legalizers on the left.

    Why did the left change its stance on what it calls personal freedom regarding cigarettes and cigars? What was the logic? And please, if you are on the left, would you answer this question for me? How come the only organ the left insists be chaste is the lung? What is this pulmocentrism? Why are lungs so special? Why can't you endanger your own lungs? Why don't you care as much about livers? Don't the Democrats have a liver lobby?

    UPDATE: A reader answers (although I think he's confused me with Peggy Noonan):

    I am always amazed and profoundly bored when partisans want to play the "hypocrisy game". It goes like this, a right winger points out a hypcritical stance on the left like "How can the left support the legaization of alcohol and the banning of smoking in the same breath?". Of course, by doing so, the right winger, by being diametrically opposed to the leftie on both issues, is guilty of an equal and opposite hypocrisy. The leftie might respond "How can you right wingers support a ban on alcohol while simltaneously supporting the rights of cigarette smokers?"

    Another example: You decry "How can the left support smoking bans on the grounds that it harms the innocent and still support abortion rights?". Leaving you open for "How can you support harming only those innocents who happen to lie outside the womb?"

    Rush does this all the time. I thought you were better than that.

    The obvious difference between cigarettes and alcohol is this. If somone is drinking next to me at a beach it is entirely inconsequential to me. His drinking has no effect on me or my enjoyment of the beach. If he or she becomes beligerent with drink it becomes another issue, beligerence without drinking would be equally disturbing.

    Smoking, however, blows smoke in my face, ashes onto my blanket, etc. It has a direct and unpleasant effect on those around the smoker. Being more of a libertarian, I would rather not have smoking banned. I would leave it be and have he smoker suffer the social consequences of his or her habit, like having to deal with dirty looks and the occasional "Hey, could you put that butt out?" In this way I think smoking has a lot more in common with playing loud music than it does with drinking.

    As far as your comparison to the abortion debate. I don't think it is fair to accuse the left of "harming the innocent" until both sides have agreed upon an answer to the question "when does life begin?" (I also don't think it's fair of the left to accuse the right of impinging on a woman's civil liberties until that answer is reached) Personally I feel that the answers "conception" and "birth" are both fairly ridiculous, with "birth" being a good deal more ridiculous.

    Good points. But I don't think that linking to or posting Peggy Noonans thoughts makes me a partisan on the level of Rush Limbaugh.
    posted by Sydney on 6/03/2004 08:23:00 AM 0 comments

    Wednesday, June 02, 2004

    A Tale of Two Systems: Galen's Log compares healthcare in Canada and the U.S.

    posted by Sydney on 6/02/2004 03:23:00 PM 0 comments

    Simple Gifts: Something as simple soap and water can cut the incidence of diarrheal illnesses:

    "Giving people soap and hand washing instructions reduced the incidence of diarrhea by more than 50 per cent among children in Pakistan, the team reported in Wednesday's global health-themed issue of The Journal of the American Medical Association.

    Actually, the study's results aren't quite as impressive as the news report makes it sound. Among the households who were nagged about washing their hands, there were 2 episodes of diarrhea per 100 "person-weeks" (That would be 100 people observed over a week's time or one person observed for a hundred weeks, or any variation thereof.) Among the non-nagged households, there were 4 episodes of diarrhea per person-week. The difference is even less dramatic when viewed
    graphically, there being a substantial over-lap between the washed and unwashed when it comes to diarrhea.

    Of course, in Pakistan, there are other issues besides hand-washing to consider. Issues like clean drinking water. Still, there is a slight improvement in diarrhea when hands are washed regularly, and since soap is relatively inexpensive, it wouldn't be a bad idea to promote it more. Too often, the simple interventions get overlooked in favor of the high-tech and expensive, like the importance of clean needles in fighting HIV in Africa.
    posted by Sydney on 6/02/2004 08:17:00 AM 0 comments

    Abusing Privileges: The uses of ambulances in Palestine.
    posted by Sydney on 6/02/2004 08:10:00 AM 0 comments

    Death Becomes Them: Oregon's assisted-suicide law has been given a supporting hand by the Ninth Circuit Court of Appeals, which ruled that doctors in the state can't be prosecuted for over-prescribing lethal narcotics, as long as they do so under these circumstances:

    A patient must make two oral requests for the drugs and one written request after a 15-day waiting period. Two doctors must determine that the patient has less than six months to live, a doctor must decide that the patient is capable of making independent decisions about health care and the doctor has to describe to the patient alternatives like hospice care.

    The law also requires that the drugs be self-administered by the patient, rather than given by a doctor or family member, to avoid involuntary euthanasia. The death certificate, under the law, must state the cause of death as the underlying disease, not suicide.

    That seems to be a prudently written law - on the surface. But the problem with assisted suicide is that it assumes the doctor-patient relationship exists in an emotional vacuum. That doctor's never get weary of hearing a patient complain about intractable health problems, and that patients are never influenced by their doctor's attitude (or the attitudes of family members.) Consider one doctor in England who found it all too tempting to first relieve his patient's suffering, and then to relieve his own.

    Death is scary, no doubt about it. It's the ultimate loss of control. And that, in the end, is what really motivates those who seek physician-assisted suicide. It isn't so much to avoid physical pain, as to insure that they will ultimately be in control of those final days:

    Barbara Coombs Lee, the president of Compassion in Dying Federation, said she saw the suicides not as "an impulse to self destruction," but as "an impulse to self preservation - preservation of the self I cherish."

    That point of view clearly grates on Dr. Stevens. Although he said he did not want to "put people down or label people," he added, "the 'P' word is not 'pain.' The 'P' word is 'pride.' " He explained, "Rather than being death with dignity, it's death with vanity."

    Which also calls to mind the British doctor:

    The only valid possible explanation for it is that he simply enjoyed viewing the process of dying and enjoyed the feeling of control over life and death, literally over life and death.

    One can argue that it makes the world of difference whether it's the patient who enjoys the control over life and death or the physician. But the problem is, that's a distinction that's too easily blurred in the symbiosis that is the doctor-patient relationship.

    Oregonians must sense this on some level. The suicide option is rarely chosen. Which disturbs Dr. Marcia Angell, representative of the medical establishement to the national press:

    But Dr. Marcia Angell, a former executive editor of The New England Journal of Medicine and a supporter of doctor-assisted suicide, said: "He can call it vanity. Somebody else might call it admirable independence."

    If anything, Dr. Angell said, the Oregon law may be too restrictive and may not reach everyone who could benefit from it.

    "I am concerned that so few people are requesting it," she said. "It seems to me that more would do it. The purpose of a law is to be used, not to sit there on the books."

    The nerve of dying Oregonians. Why are they malingering and eating up valuable Medicare tax dollars when they could so easily put us all out of their misery?

    Not coincidentally, Dr. Angell also advocates a single-payer healthcare system. Her attitude, unfortunately, is not uncommon among those who think the state knows best how to run things. And it isn't hard to imagine where that sort of attitude could eventually lead us in end-of-life care, especially in a wholly state-run system: from physician-assisted suicide to state-mandated euthanasia.
    posted by Sydney on 6/02/2004 07:54:00 AM 0 comments

    The Misbegotten: A Federal judge in San Francisco has ruled that the partial-birth abortion ban is unconstitutional. Her logic should give us all pause, regardless of what side of the abortion debate we fall on:

    She agreed with abortion rights activists that a woman's right to choose is paramount, and that it is therefore 'irrelevant' whether a fetus suffers pain, as abortion foes contend.

    ...In her ruling, the judge said it was "grossly misleading and inaccurate" to suggest the banned procedure verges on infanticide.

    The partial birth abortion/dilation and extraction procedure is usually performed late in pregnancy, when the fetus is too large to be removed by just scraping out the uterus. It also happens to be late enough in pregnancy that the fetus would live if delivered intact rather than in little pieces. The only difference between the fetus in the womb and a premature baby is that you can see one and not the other.

    And consider this. When a fetus dies in the womb of natural causes, the preferred method of delivery is not intact dilation and extraction, but conventional delivery, either vaginally by inducing labor, or by cesarean section (last link requires registration.). If it's safer to perform a dilation and extraction, as the proponents of the procedure argue, then why isn't it the procedure of choice for fetal corpses? And why are the proponents so eager to preserve its use on living fetuses? The answer is, because in most cases of natural fetal demise, the babies are wanted. And most parents, given the choice, want to see their baby and have a chance to grieve their loss. But, of course, in abortion, the goal is to deliver a dead baby not a live one. Better to cause the death out of sight than in sight.

    If an infant dies in the woods and no one's there to witness it, did it ever live? According to partial-birth abortion activists and Judge Hamilton, no.

    UPDATE: Donald Sensing has more.
    posted by Sydney on 6/02/2004 07:22:00 AM 0 comments

    Root Causes: Yesterday's local newspaper had this observation (requires registration) on Lyndie England in the letters to the editor:

    On Mother's Day, when I saw the photo of the young woman soldier with the leash around the neck of the naked Iraqi prisoner, I thought that this was not something she learned at her mother's knee but was part of her indoctrination into the military, where the enemy is dehumanized.

    Ah yes, glorious womanhood. One of the advantages of practicing family medicine is that you get a front row seat in the circus of life, and I can assure you that it is far more common for bad behaviors to be learned at a mother's knee than elsewhere.
    posted by Sydney on 6/02/2004 07:16:00 AM 0 comments

    Tuesday, June 01, 2004

    Chocolate Dreams: Is chocolate good for your heart? The evidence isn't very impressive:

    Eleven people were given 46 grams (1.6 ounces) of dark, flavonoid-rich chocolate every day for two weeks, while 10 others received dark chocolate with low-flavonoid content.

    At the end of the trial, the researchers used ultrasound to measure how well blood vessels are able to relax if blood flow increases - called flow-mediated dilation.

    They examined the brachial artery in the arm. How well this artery dilates indicates how coronary arteries are behaving.

    In the group eating flavonoid-rich chocolate, blood vessel dilation increased by a tenth, while it fell by as much in the other group.

    I love chocolate as much as the next person (probably more), but this seems pretty weak. It's a very small study showing very small changes in the caliber of a large vessel in the arm. Any conclusion that it helps the heart is purely speculative.

    posted by Sydney on 6/01/2004 08:43:00 AM 0 comments

    Don't Try This at Home: A do-it-yourself Cesarean section:

    Alone in her one-room cabin high in the mountains of southern Mexico, Ines Ramirez Perez felt the pounding pains of a child insistent on entering the world.
    ....The sun had set hours ago. The nearest clinic was more than 50 miles away over rough terrain and inhospitable roads, and her husband, her only assistant during a half-dozen previous births, was drinking at a cantina. She had no phone and neither did the cantina.

        So at midnight, after 12 hours of constant pain, the petite, 40-year-old mother of six sat down on a low wooden bench. She took several gulps from a bottle of rubbing alcohol, grabbed the 6-inch knife she used for butchering animals and pointed it at her belly.

        And then she began to cut.

        Under the light of a single dim bulb, Ramirez sawed through skin, fat and muscle before reaching inside her uterus and pulling out her baby boy. She says she cut his umbilical cord with a pair of scissors, then passed out.

    Trouble is, if anything went wrong, there would be no one to sue.
    posted by Sydney on 6/01/2004 08:38:00 AM 0 comments

    Occupational Hazards: Green Slime Syndrome.
    posted by Sydney on 6/01/2004 08:33:00 AM 0 comments

    Uncivil Disobedience: The most recent New York Times Sunday Magazine
    had this somewhat disturbing profile of a drug reimportation activist:

    I can be very frail if I need to be,'' Kate Stahl said recently as she unpeeled the ripe banana she carried in her bag for lunch.......''Can't you see the publicity?'' she said, stooping over an imaginary cane. '''Frail old lady put in jail because she couldn't afford her drugs in America and she had to do it in Canada.' I even have an old cane that I got at Goodwill. Can't you see it? 'Gee, Officer, I really can't afford a new one. They're too expensive and I just don't have the money . . . honey.''

    The article never makes it clear whether or not she's actually frail. Only that she's rather obnoxious. It's also never clear whether or not the cost of drugs is really pinching her financially:

    Stahl, whose total income consists of Social Security and her deceased husband's pension of $51.74 a month, counts herself among the many Midwestern widows, ex-stockbrokers, retired schoolteachers -- people with time on their hands and dwindling savings -- who have found a galvanizing political cause in the high cost of prescription drugs.

    Social Security benefits are based on the highest income you've ever earned. And widows who were homemakers get their husband's benefits. (You can calculate what your benefits would be here.) For all we know, Mrs. Stahl could be pulling in five or six thousand a month. You have to suspect her income must not be so meager since the reporter hedged on the full amount. To be sure, there are many senior citizens who are pinched financially by their medication needs. (And there are programs available for the needy, believe it or not.) However, it's been my experience that most people taking advantage of Canadian re-importation are not so needy. They are people who use their extra income to pay for vacation homes, or their kids' mortgages. It's hard to feel sorry for them.

    And if, in the end, drug re-importation only serves to drive up the cost of drugs in Canada, and take away money from research, as the drug companies claim, then what has anyone gained - on either side of the border - from Mrs. Stahl's efforts?

    (There's also the whole issue of counterfeit drugs running through these prescription mills that doesn't get nearly the attention it deserves.)

    UPDATE: On the other hand, looks like re-importation will soon be a non-issue, thanks to election year politics.
    posted by Sydney on 6/01/2004 07:54:00 AM 0 comments

    Medicare Drug Cards: They're already driving down prices. Free markets work!
    posted by Sydney on 6/01/2004 07:44:00 AM 0 comments

    Red-headed Stepchildren: Italian men wondering about the paternity of their children, can test them themselves:

    An Italian businessman has triggered debate in Italy by advertising "do it yourself" paternity testing kits, with which men can check their children's DNA without telling their wives.

    The kit—which Aurelio Coppola has been advertising for 700 euros (£470; $840) each since May—allows suspicious fathers to take a swab from their child's mouth, and their own, and send it to a laboratory for testing.

    The results, which Coppola claims are "over 99.99% accurate," are posted or emailed to the anxious parent about a week later.

    I don't understand Italian, but look at the happy father in the ad. The reliability of DNA testing such as this is very much dependent on the lab and the technique they use. As OJ Simpson's defense team illustrated, it's difficult to prove something beyond a shadow of a doubt with DNA testing alone. And doesn't a beloved wife deserve at least the same margin of error that OJ Simpson enjoyed? But then again, if things have gotten to the point that a DNA test is necessary, the wife probably isn't all that beloved, and won't be regardless of how the test comes out.
    posted by Sydney on 6/01/2004 07:20:00 AM 0 comments

    Recreational Diversions: We watched Bubba Ho-Tep the other night. Hilarious. Elvis finds redemption by saving his fellow nursing home residents from a cowboy-booted mummy. (Rated R for strong language. Not one for the kids.)
    posted by Sydney on 6/01/2004 07:04:00 AM 0 comments

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