DB’s Medical Rants
Explorations of medicine and the health care system

DB’s Medical Rants

AMA Delegates fighting current P4P

June 28th, 2007

AMA: Delegates Want Principles First with Pay for Performance

Moreover, after five hours of debate — often over the addition or deletion of a single word — the AMA’s House of Delegates said that it will “actively oppose” any pay-for-performance programs that do not meet the AMA’s five pay-for-performance principles.

Adopted in 2005, those principles specify that programs should ensure quality of care, foster the patient/physician relationship, offer voluntary physician participation, use accurate data and fair reporting, and provide fair and equitable program incentives.

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Meanwhile, Dr. Rohack, speaking for the board of trustees during the House debate, repeatedly urged the delegates to refrain from putting too many limits on what the AMA leadership could do in attempting to negotiate pay-for-performance plans with payers.

Too many restrictions, he said, would mean that the AMA would “lose our seat at the table” during crucial negotiations with CMS, which is on track to fix its flawed sustainable growth rate (SGR) physician payment formula by switching to a pay-for-performance model.

“We don’t want a seat at the table,” responded, Marcy Zwelling, M.D., a delegate from Los Alimitos, Calif. “We want to stand on the table.”

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The delegates also instructed the AMA leadership to collect data on the efficacy of pay for performance, including data on special populations that may have increased health risks.

Bravo! Physicians have an ethical responsibility to fight those who propose untested incentives. I have written often about the problems of P4P. But I am not a leader here, just a member of the chorus. The AMA delegates are taking the correct position on this issue.

Popularity: 2% [?]

A review of DTC advertising

June 28th, 2007

Direct-to-Consumer Advertising of Pharmaceuticals

This American Journal of Medicine article is free.

Of significant concern to the medical community is the criticism that direct-to-consumer advertising undermines the physician-patient relationship.19 In studying this issue, the 2002 FDA survey showed mixed results. For example, 73% of patients did not believe direct-to-consumer advertising minimized the role of physicians in making product decisions. In fact, 43% felt direct-to-consumer advertising helped them have better discussions with their doctor (down from 62% in 1999). However, 10% of respondents were hesitant to talk to their doctor about a drug because of fear of creating the impression of distrust with the doctor (up from 7% in 1999).14Prevention magazine in 2001 found 27% of respondents felt their visit with their physician was better because they discussed an advertisement.15

When polling physicians, a similar mixed picture emerges.14 Forty-one percent of physicians reported direct-to-consumer advertising exposure led to benefits such as better discussions with patients and greater awareness of treatments. Eighteen percent felt direct-to-consumer advertising led to problems such as increased time to correct misconceptions, requests for unnecessary drugs, and requests for a drug therapy when a nonpharmacologic therapy might be as or more effective. Similarly, 41% of physicians felt that the patient was confused about the efficacy of a drug, and only 40% felt that patients understood the risks of a drug after seeing a drug advertisement. Overall, advertising led to tension in a quarter of patient interactions, and primary care physicians were more likely to report problems than specialists.14

This review presents a very balanced view of DTCA. I suspect each reader will focus on the issues that support their own opinion. For new readers, I am strongly opposed to all DTCA and have written widely on the subject.

The one point with universal agreement is that DTCA does influence some patients and some physicians. Do we want the pharmaceutical industry to influence our health care spending with advertisements on nightly television?

Popularity: 3% [?]

Seek first to understand

June 26th, 2007

An article in the Archives of Internal Medicine is receiving attention. I will probably be writing a commentary on the article. The NY Times take on the article - Study Says Chatty Doctors Forget Patients

These physicians probably have not read and absorbed Steven Covey’s 5th rule - Seek First to Understand - Then to be Understood

My longer comments will have to wait for the commentary that I will write.

What do you think?

In short, when talking with a patient it should be primarily about the patient. This does not mean that we cannot share a few of our own insights or experiences - but we should always focus on the patient.

Popularity: 10% [?]

Preserving the profession

June 25th, 2007

Michael Moore is currently attacking the US health care system. He champions any country which has national health care.

I understand the roots of his activism. I have many friends who believe he is championing a just cause. While I will not impugn their beliefs, I will argue that nationalizing health care would have several untoward effects.

Nationalized health care could negatively impact medical school admissions. Money does matter. But in addition to many, medicine affords one more autonomy than many careers. In the US, you can make your own success. You can work longer or shorter hours. You can adjust your career to make more money or enjoy your personal life.

These two articles from GB represent the current problems with the NHS - Doctors fury at government policy and Out-of-hours demand riles doctors.

I have written extensively on the concept of health care as a right. Michael Moore believes that government should provide many “rights” to the population. This is socialistic thinking.

He represents an intellectual constituency. I personally disagree with that political philosophy.

He is using his bully pulpit to influence the political discussion. He has every right to do so. I have a right to disagree.

The externalities of socialistic medicine are many. When the government’s budget impacts health care, then we have an externality.

We do not have a perfect health care system, but I still believe that the proposed alternatives would deliver a worse system. Of course, I am expressing my opinion in this debate. I believe socialized medicine harms the profession.

KevinMD has these comments - Sicko: Do I hear bingo?

Popularity: 14% [?]

Do not marry the diagnosis!

June 21st, 2007

I often stress avoiding premature closure. retired doc referred to this interesting article 2 years ago - Diagnostic Error in Internal Medicine

As I am working on a paper about what makes an outstanding internist, I went back to review the article. The authors examined the phenomenon of diagnostic errors in a systematic manner.

Faulty information synthesis, which includes a wide range of factors, was the most common cause of cognitive-based errors. The single most common phenomenon was premature closure: the tendency to stop considering other possibilities after reaching a diagnosis.

And I would argue that avoiding premature closure takes time. It often comes down to time.

Popularity: 25% [?]

Calling out Matt

June 21st, 2007

Well, I tried to send Matt (our favorite malpractice lawyer defender) an email. Apparently he has fabricated his email address (not cool).

Matt has this untrue line in one of his comments today - “Yet you, a physician who has never seen a trial much less spoken to a jury, have reached a different conclusion about what lawyers do.”

Now I have testified (for the defendant) in a malpractice trial several years ago. As an expert witness, I personally experienced the sophistry and obfuscation that I write about. One classic example (which did not work) came when the lawyer tried to impugn the defendant’s notes because they were typed rather than hand written. I was able to tell the jury that I dictated my notes and had them typed so that they would be legible.

Now I know that I have only this one experience to derive anecdotes, but I have talked with physicians who have been through the process. Lawyers work on behalf of their clients. They work hard to win their cases. I do not blame them - that is their job. I would prefer that malpractice cases were judged solely on merits, rather on the skills of the lawyers. I believe that that represents an underlying premise of special health courts.

Popularity: 26% [?]

What is malpractice?

June 21st, 2007

Standard of Care Remains a Moving Target in Medical Malpractice Cases

Courts in 21 states adhere to a local or community standard of care in medical malpractice cases, slowing implementation of evidence-based, resource-based, nationwide standards.

So said Michelle Huckaby Lewis, M.D., J.D., of Johns Hopkins and Georgetown University, and colleagues in a commentary in the June 20 issue of the Journal of the American Medical Association.

The locality rule was a 19th century concept intended to protect rural physicians from being held to the same standards as physicians working in urban areas or at academic institutions, the authors said.

But, they note, modern communication has removed barriers to standardization — no place is more than a phone call or a mouse click away from the latest evidence-based findings.

As a result, a rule originally intended as a protection now “imposes additional duties and legal risk on physicians. Not only must they remain aware of advances in their own specialty, physicians must also be aware of the standard of care in their locality, whether or not that standard is considered substandard at the national level,” the authors wrote.

For example they point out that Virginia, which is one of the states that follows the locality rule, has a “statutory presumption that each physician knows the standard of care in the state, although it is unclear how a physician may be expected to obtain this knowledge.”

Moreover, physicians who practice in more than one state could be required to heed two or more different standards of care.

Dr. Lewis and colleagues contend that the locality rule is also ethically suspect. In the communities that use it, “basic principles of justice may not be met for patients who have been harmed as the result of suboptimal local care standards,” they wrote.

Should we have different standards for medicine according to state, or worse locality?

Our current malpractice system is not well considered, because it is not a system. Rather it represents inconsistent arrangements judged by juries who are peers of the complaining party, but not of the medical professional.

Our system lacks logic. As my previous posts imply, trying to argue logic here will not work. Trial lawyers eschew logic for sophistry.

I would love to see a national standard for judging malpractice. Of course I would love to see a national system of health courts. I would love to see consistency. But then I am a dreamer.

Popularity: 27% [?]

The fallacy of logic - criticizing Bush on stem cells

June 21st, 2007

As I wrote yesterday, trying to argue religious beliefs leads to frustration. Despite my warnings, several commenters wrote well reasoned criticisms of the President’s position. These commenters are trying to use logic to persuade.

I love logic. I strive for philosophic consistency. I would argue that many religious beliefs fail the logic test.

Clearly Bush is not making this decision for political reasons. He has no more election opportunities, and his vote may damage future Republican candidates.

His reasoning is not based on logic, but rather belief.

I disagree with his belief system - but understand that no “rational” argument will change his beliefs.

As Nietzsche said, “There are no facts, only interpretations.”

Popularity: 26% [?]

The futility of arguing ethical frameworks

June 20th, 2007

Bush Will Pair Veto With New Cell Initiative

I disagree with the President’s position on this issue, but I do understand that he is acting with moral consistency.

When I oppose active euthanasia and support passive euthanasia, I have colleagues who do not understand the difference. I clearly have a moral line which I will not cross. I believe that Bush has such a line on the stem cell issue.

The embryonic stem cell measure has widespread public support, and the veto would be the second time Mr. Bush has rejected it. By pairing the veto with a new scientific initiative, the White House clearly hopes to blunt the inevitable criticism that Mr. Bush will face from researchers, advocates for patients and politicians, including many in his own party.

In interviews on Tuesday, two senior administration officials said Mr. Bush would direct his health and human services secretary to promote research into producing cells with properties akin to those of human embryonic stem cells, without destroying embryos in the process. Mr. Bush has said embryo destruction is a moral line that he will not cross.

This issue really has not right or wrong. Whenever we delve into ethical decision making we involve religion and values. Most adults know that arguing about religion rarely achieves anything but acrimony.

For Bush, this represents a religious issue. I strongly disagree with his interpretation, but I understand that no one can convince him or like minded individuals of my position.

Is this mixing politics and religion? I would argue not. All politics involves applying values to decision making. For some the values are religious; for others the values involve their sense of human rights.

Our democracy allows us to elect leaders. When we believe that the leaders’ values are at odds with our own, we can elect other leaders. Since elections are complicated by multiple issues, we often do not focus on a single issue like stem cell research, but we could.

So be prepared for teeth gnashing and polemics. No arguments will change one who is making his decisions based upon a principle which he holds dear.

Apparently further stem cell funding will have to wait until the next Presidential election.

Popularity: 30% [?]

Comparative effectiveness

June 19th, 2007

In the current New Yorker, an excellent piece reflects on the Avandia controversy - A Drug on the Market. The author speaks of the specific issue of Avandia, but then goes on to lament our lack of high quality information on treatments.

This kind of brouhaha, with volleys of personal attacks and fights for the biggest headline, doesn’t look much like science. But it’s all too typical of the way we measure the safety and efficacy of drugs. The U.S. has no rational system for “post-market surveillance”—the evaluation of drugs after they’ve been approved. Instead, oversight is left to a motley collection of altruists, academics, lawyers, self-publicists, and drug companies, who make their own arbitrary decisions about which drugs to study, how to evaluate them, and what risks to look for. Somehow, the truth is expected to rise to the surface from among all these competing interests and random decisions.

There is currently a proposal in Congress which would take some positive steps to address these issues. Here is the CBO testimony on comparative effectiveness - Research on the Comparative Effectiveness of Medical Treatments: Options for an Expanded Federal Role

Furthermore, hard evidence is often unavailable about which treatments work best for which patients or whether the added benefits of more-effective but more-expensive services are sufficient to warrant their added costs. In many cases, the extent of the variation in treatments is greatest for those types of care for which evidence about relative effectiveness is lacking. Together, those findings suggest that better information about the costs and benefits of different treatment options, combined with new incentive structures reflecting the information, could eventually yield lower health care spending without having adverse effects on health—and that the potential reduction in spending below projected levels could be substantial. Moving the nation toward that possibility—which will inevitably be an iterative process in which policy steps are tried, evaluated, and reconsidered—is essential to putting the country on a sounder long-term fiscal path. But even if it did not bring about significant reductions in spending, more information about comparative effectiveness could yield better health outcomes from the resources devoted to health care.

Our organization - SGIM - provided testimony on this proposal. Our organization supports this concept strongly.

I hope that we see positive action from Congress on the proposal to fund comparative effectiveness research. Other countries support such studies.

Other developed countries also face challenges financing health care costs and have taken various steps to assess the comparative effectiveness of treatments. Many of those countries establish overall budgets for their national health systems and use comparative effectiveness analysis to help determine which treatments and procedures will be covered or how they will be reimbursed. Perhaps the best known example is the National Institute for Health and Clinical Excellence (NICE), which was established in 1999 as part of the United Kingdom’s national health service. It provides guidance on the use of new and existing medicines, procedures, and treatments and on appropriate treatments for specific diseases. With a staff of about 200 and an annual budget of about 30 million pounds (roughly $60 million), NICE does not fund new clinical trials or other forms of primary data collection but, rather, bases its determinations on systematic reviews of existing research.

Other countries such as Australia, Canada, France, and Germany have similar review processes. Discussions have sometimes focused on those countries’ procedures for reviewing prescription drugs, but all of them have systems in place to evaluate medical and surgical treatments and technologies as well. It is therefore worth noting that, for all the attention that prescription drugs receive, they currently account for less than 15 percent of total U.S. health spending. Therefore, if additional research in the United States on comparative effectiveness focused only on medications, the impact would probably be much smaller than if that research encompassed the whole spectrum of medical care.

I believe that we will see funding for this proposal. As I understand, both conservatives and liberals are supporting this concept. This is a much better strategy for understanding and perhaps decreasing health care costs than any other proposal of which I am aware.

Popularity: 32% [?]

An important interesting presentation

June 18th, 2007

Lisa Sanders hits another home run - Full-Body Failure

It was early evening by the time Walerstein got to see the patient. She was young — the chart said 22, but the slender figure surrounded by life-support equipment appeared even younger. She looked tired and sick and very, very yellow — highlighter yellow. He introduced himself and asked her to tell him when all this started.

It began, she told him, with a root canal, maybe a month ago. The tooth kept bothering her, even after two different antibiotics. Then she started noticing blood in her stools. At first it was just an occasional episode, but then, a few days before she came to the hospital, the trips to the bathroom became more frequent and the blood more obvious. She felt feverish and tired. She had a headache; she was nauseated. She spent a couple of days in bed and felt well enough at least to take a shower. When she looked in the mirror, she barely recognized the yellow face that looked back. Even the whites of her eyes were yellow. That scared her. That’s when she came to the hospital.

At first, the doctors thought it was viral hepatitis. But tests indicated that it wasn’t. Walerstein examined the patient. She was febrile, her skin hot and dry. Her lips were parched and cracked. Her abdomen was distended but soft, and he could feel the firm edge of an enlarged liver a couple of inches below her rib cage.

This is a classic internal medicine zebra case. It is a “great case” because making the diagnosis helps the patient.

Please read and enjoy.

Popularity: 35% [?]

The woman in 508

June 18th, 2007

She lay in bed with stringy blond hair.
She had multiple crude tatoos.
She lay in obvious pain.

The intern had told me her story.
She had abdominal pain and a tender cervix.

She was agitated and tremulous.
Her urine drug screen was positive for cocaine and barbituates.

Her urine showed and infection.
Her cervix had a lesion.

We reassured her and started her on antibiotics.
We treated her pain.

Her biopsy was negative.
Her pain improved.

We asked about her sexual activity.
She had multiple unknown partners.
She tested negative for HIV, hep B, syphilis, gonorrhea and chlamydia.

She had 3 children - but had lost custody.

We offered to help her end her cocaine dependence.

On her last day, feeling better and pain free she thanked us.
She particularly thanked us for treating her and not judging her.

Popularity: 35% [?]

Experts urge us to not underestimate TB threat

June 15th, 2007

Experts Call for More Research and More Vigilance Against TB

In the wake of a worldwide scare caused by an American who traveled abroad with a highly dangerous strain of tuberculosis, the country’s top experts on the disease called Thursday for a vast increase in federal research dollars. They also asked for expanded authority to restrict travel by infected persons and a heightened explicitness in counseling patients on the risks of infecting others.

“I think we’ve been too mealy-mouthed in our communication of risk to patients,” said Dr. Kenneth G. Castro, director of the division of tuberculosis elimination at the federal Centers for Disease Control and Prevention. Dr. Castro spoke at a three-day annual conference of tuberculosis physicians and nurses from across the country. The Thursday session was devoted to the emerging global challenge posed by multidrug-resistant tuberculosis, known as MDR, the most lethal form of which is defined as extensively drug-resistant tuberculosis, known as XDR.

We should not underestimate this threat. TB has caused suffering and death for centuries. Fortunately it is only modestly infectious. Nonetheless, it does represent a serious health threat.

Tuberculosis experts at the Thursday meeting said they were perversely grateful that Mr. Speaker had revived the public’s focus on the disease. They called for an increase in federal financing for domestic tuberculosis programs, to $300 million a year from $137 million, while raising spending on global programs to $450 million from $90 million.

There is an urgent demand for new drug development, the experts said. And because the disease could spread quickly from abroad, there is a particular need for more laboratories overseas.

We must attack TB on a worldwide basis. To not invest in worldwide TB is penny wise and pound foolish.

Popularity: 40% [?]

The ongoing debate over rights

June 13th, 2007

What is a right? I have tried to search the dictionary for a good definition - but all the definitions that I see are non-specific.

What does the debate really imply? I believe that we are debating the role of government. This is a classic debate between libertarianism and socialism.

The libertarian view argues that health care is not a right - nor is food or shelter. This viewpoint does not imply that physicians and health care systems will not care for those who are disadvantaged. At least in this country, we have a long tradition of providing such care.

This view argues that we need not provide a single class of health care to all. We do not criticize different levels of food or shelter. We do not expect one class of legal advice. We have differing access to transportation.

The socialistic school argues that health care is so important that we should deliver one class of health care to all. Some in this political camp would argue the same for food and shelter. The implication of this thought is that government should fund that health care because they define it as a right - and thus it is a government responsibility.

We have a debate which we cannot resolve. No logical argument will suffice when we engage in a philosophical debate.

I obviously favor the libertarian approach. I believe that moving towards a socialistic approach will have a negative impact on the supply of high quality physicians.

Matt has raised an interesting point in one of his comments -

Isn’t the key to reforming how you guys get paid simply you guys refusing to accept the current payment model?

It would seem that until enough doctors decide to do this, not much will change. The majority of physicians DO work in a free market. They CHOOSE to enter into the contracts that result in them being reimbursed in the manner they are. They do not have to choose this. They can go out there like professionals of every other stripe and market their services if they want.

Changing physician pay models has nothing to do with whether health care is a right. It has to do with changing physician behaviors and getting them to think outside the box and be willing to take the risks that comes with truly competing for the publics’ dollar.

Matt is partly right. Physicians have complied with the insurance companies as a default. Surgeons created the insurance model many years ago. It has expanded to include most medical care. The creation of Medicare has greatly enhanced physician income - but TANSTAAFL. Along with increased income have come increased rules and red tape. Since Medicare pays for office visits, so do other insurance plans.

Some physicians have gone to retainer plans or cash only plans. Many physicians criticize these pioneers for philosophical reasons. We have difficulty separating our desire to help patients from the necessary finances.

But money does matter. We do need new models. I hope that we have the courage to reject the insurance companies. I believe (hopefully some readers will help here) that many physicians are opting out of Medicare - because of payments which barely cover costs.

Those who believe that health care should be a right are philosophically honest. I hope they understand the tax implications of that belief. I hope they understand how such a system constrains health care (please follow the never ending struggles of the NHS.) I hope they understand that such a system leads to rationing of services.

Popularity: 46% [?]

No right to health care - the case for retainer medicine

June 11th, 2007

At least according to this editorial (link noted by KevinMD) - Escaping the medical bureaucracy

Drs. Duckham and Taylor decided to become “concierge” doctors. They collect a flat annual fee from their patients, who in return get an annual physical exam and wellness plan. They also get half-hour, same- or next-day appointments when they get sick.

Dr. Taylor charges each of his patients $1,500 per year, or $125 per month. Most of his clients are people with modest incomes who “are sick and tired of being bounced around” by insurance companies in rushed appointments, not “rich, old sick people.”

More and more physicians are choosing this path, not because it makes them rich, but because it allows them to provide better, personalized health care. Rather than have for-profit insurance companies dictate their hours, patients, practices, staffing and salaries, doctors are deciding to let the open market determine what their time and services are worth.

I have written about retainer medicine periodically for at least 4 years. The more I consider the concept, the more I believe that such a system would create real medical homes.

Of course, there is no universal “right” to health care. A true right doesn’t impose an obligation on others. And when people such as Mr. Smith insist that health care be “free,” they conveniently forget that literally trillions of tax dollars would be required to convert the country’s semi-private system into a public one.

But even more revealing is the hostility from many who favor socialized medicine toward consensual transactions between physicians and patients.

Those who start with the premise that health care is a right logically reject free market influences to solve our health care problems. They argue that the free market has failed. But au contraire - the majority of physicians do not work in a free market. Those who adopt retainer medicine must deliver high quality service to their patients. That model only works when one attracts a sufficient number of patients.

Most of us take what work we can get, and accept fees that insurance companies determine. Many physicians play games with the fee structure (some legal, some not.)

What other profession has its fees regulated? Why should we put all physicians in the same financial reimbursement structure?

I believe the problem stems from how we view health care. We need to reconsider the intended and unintended consequences of our assumptions.

Popularity: 49% [?]

Drug resistant TB gaining attention

June 8th, 2007

So this cloud has a several lining. While I wish Mr. Speaker well, I have disdain for his selfishness. Likely he did not infect anyone else because he does not seem to have a highly infectious form of TB.

From a public health perspective, we may have to thank Mr. Speaker. Through his actions we are now focused on a problem which I have highlighted many times on this blog - the problem of MDR (multiple drug resistance) and XDR (extremely drug resistant) TB.

This NY Times article summarizes the issue well - Agency Warns of Surge in Drug-Resistant TB

Health officials say that Mr. Speaker’s was not an isolated case because the extremely resistant form has been reported in 37 countries. With the growth of international travel, health officials say that TB anywhere is TB everywhere. About 420,000, or 5 percent, of the estimated 8.8 million new cases of tuberculosis in the world are now resistant to many standard antituberculosis drugs, Dr. Mario C. Raviglione, who directs the W.H.O.’s tuberculosis department, said in an interview. About 30,000 of the 420,000 cases are extremely drug-resistant, meaning they are resistant to first-line and a number of second-line drugs.

Dr. Raviglione said the organization had begun to undertake statistical modeling studies to estimate how prevalent drug-resistant tuberculosis might become. Outcomes from such studies depend on a number of variables and none have been published. “It is possible that in some settings drug-resistant tuberculosis could completely replace standard tuberculosis,” Dr. Raviglione said.

Popularity: 52% [?]

On Avandia

June 8th, 2007

I clearly have no dog in this fight. I have never used Avandia - primarily because I now restrict my clinical work to the inpatient side.

So I will not give opinions on right or wrong in this situation. I will opine that the debate is ugly and unfortunate.

Medscape has a nice review today - A House Divided: No Clear Answers on Rosiglitazone Safety or Political Backstory.

Roy Poses has tried his best to provide an objective critique of all involved - More on Avandia: Why We Need to “Call Off the Dogs”.

This should remain a scientific debate. Unfortunately it has become a political debate. Guess what the culprit really is - $$$$$$$$.

As Dr. Kertesz suggests, we might not have this debate were it not for the zealous goals that current diabetes guidelines and HEDIS measures support.

Popularity: 53% [?]

Questioning tight quality targets

June 6th, 2007

A colleague, Dr. Stefan Kertesz, has this interesting commentary on Marketplace - Why so much Avandia in the first place?

This commentary reflects the tension between those who want to use performance measurement to “improve health care quality” and those who question the rationale behind either performance measurement or how the current touted quality measures are selected. A friend and colleague in “high places” assures me that the critics are wrong in criticizing those who select the quality measures.

We all want to improve health care quality. Many, especially payers, have developed a religious belief that we improve health care quality through performance measurement and then P4P. They have no data that this approach really improves health care quality.

Many researchers find the rationale behind the expert based guidelines (which are generally used to select the performance targets) irrational. This debate is becoming quite bitter. Now we are talking academic debates. They do become bitter because we live for such debates.

What do you think? Please comment. I personally believe that this issue is extremely important.

Popularity: 56% [?]

More conflicting guidelines

June 4th, 2007

My latest Grand Rounds topic is “Guidelines - A Skeptics View.” I have had excellent evaluations on this talk thus far (of course I have only given it twice - but have at least 2 more scheduled.) retired doc gives me another great example - Pneumonia guidelines-Europe versus U.S.

In 2007, I believe that we need to radically change our concept of guidelines. Once again we have a nice idea, which no longer works in practice. The problem is that one cannot understand guidelines if one does not understand the many conflicts and values that each panel has. Please read this previous rant - Will stenting decrease?

Popularity: 62% [?]

Is quarantine legal?

June 1st, 2007

I know that you will love this story - TB quarantine raises legal questions

The case of a jet-setting tuberculosis patient might soon shift from the hospital wards to the courts. The patient, Andrew Speaker, an Atlanta personal injury attorney, could sue the federal government for being quarantined on the basis of federal regulations that some scholars see as unconstitutional.

Or Speaker could be sued by fellow airline passengers, especially if any caught the disease from him — which some legal scholars say is much more likely.

“He may be personally liable if someone contracts TB” from being near him on his recent flights to and from Europe, said Peter Jacobson, a University of Michigan professor of public health law. “I can see a jury coming down very hard on someone like that who willfully ignored advice not to travel.”

And he is a personal injury lawyer! Irony is a wonderful thing. “A play is made by sensing how the forces in life simulate ignorance-you set free the concealed irony, the deadly joke.” - Arthur Miller

Popularity: 68% [?]

Why we have a primary care crisis

June 1st, 2007

My successor as President of SGIM - Eugene Rich - has a wonderful detailed article about the financing of primary care. This article is well considered and documented. I commend it to those interested in understanding the problem - Primary Care and US Health Policy

The problems confronting primary care in the United States are longstanding, complex, and not amenable to easy solution, either by policymakers or academics. Thoughtful, articulate, and evidence-based advocacy will be needed to address them. The share of the nation’s wealth evoted to health care may be appropriate, but it has been distributed inappropriately by past and current administrative decisions. It will take courageous leadership to rectify this. Primary care can be saved and expanded by redistributing reimbursement away from technical specialties to the providers at the front lines of continuing health care for the nation’s population. In doing so, the US health care system will mirror other industrialized nations’ health care priorities, as well as provide better outcomes and greater efficiencies.

Bravo!

Popularity: 68% [?]

Right to care versus right to treat

June 1st, 2007
I’m curious how the logic in this case is so at variance with the logic in the case of “right to care.”

If people have no absolute right to care when they are ill … how then do you theorize and absolute right to treat when people’s illness is a threat?

All responsibilities to protect the state with no rights of a citizen therein? Is that what we suggest?

Debating techniques are always fun to analyze. My favorite three are obfuscation, hyperbole, and sophistry. Another technique involves reshaping an argument.

This comment misses the point of the discussion about health care as a right. We who argue against defining health care as a right, still deliver health care to all ill patients. The argument is actually a technical one about what defines a right. Please reread Dr. Huddle’s exposition.

This case is not about treating the patient, but rather protecting the public from a potentially devastating infection. This is not an individual issue but rather a public health issue. I would let this patient refuse treatment, but he must be quarantined.

The implication of health care as a right is (I believe) one class health care - everything for everyone, or severe rationing for everyone. I would love to see a system developed that allows everyone basic health care. Our problem will always revolve around defining basic.

I wish that everyone in our society had access to all the food, clothing, transportation, legal care and health care that they desire. However, all attempts to develop such a society end in failure.

We really want the same thing, we just disagree about how we can best deliver care to those who have less resources. I believe we can make an economic case for providing care to those who are less privileged, but the natural implication of health care as a right is a system which will likely make most health care worse.

Popularity: 67% [?]

When the public health trumps individual rights

May 31st, 2007

Under Federal Escort, Man in XDR-TB Alert Settles in at Denver Hospital

While this unfortunate man is a victim of a bad disease, we must protect others from exposure. XDR-TB scares me greatly. While we may not be able to avoid an epidemic in this country, we might be able to avoid it. We should take every effort to protect the public, even if it requires “arrest.”

Popularity: 63% [?]

A talmudic thought on quality

May 30th, 2007

I am reading the 3 Academic Medicine articles that I mentioned yesterday. The first one has a wonderful quote from a Talmudic comment- “I grew up among wise men and found that … knowledge is not he main thing, but deeds.” I could not find this exact quote on the web but rather found this one which works as well - “What good is knowledge and wisdom if they do not lead to good deeds? ” - The Most Enduring Wisdom

Good deeds are wisdom applied. Without wisdom, we have no moral compass to determine whether our deeds are good are bad. And even the greatest wisdom, without good deeds, is ultimately no wisdom at all.

When evaluating physicians, we must focus on what they do at the bedside. Knowledge is not enough. We must judge their ability to apply that knowledge to the patient’s benefit.

Our current system of certification and testing is incomplete unless we include the observation of master clinicians.

Popularity: 65% [?]

On clinical competence

May 29th, 2007

The same mind set that brought performance measures for practice has championed the clinical competencies. Three articles in the current issue of Academic Medicine challenge the assumption we can measure clinical competency in chunks. Dr. Whitcomb has written a compelling editorial on this subject. I only hope that the “power that be” will heed his advice. The original articles are not available for linkage, but the editorial is - Redirecting the Assessment of Clinical Competence

In the late 1990s, the Accreditation Council for Graduate Medical Education (ACGME) initiated the Outcome Project to ensure that physicians graduating from residency programs are competent to practice in the specialties of their training. In one of the first editorials I wrote for this journal, I challenged the basic premise underlying the design of the project.1 My argument was not with the project’s stated objective but, rather, with the ACGME’s way of achieving the objective. Specifically, I took exception to the notion that one could determine the clinical competence of graduating residents by assessing how they perform in individual domains (defined as core competencies by the ACGME) of specialty or subspecialty practice.

I continue to maintain that documenting that a graduating resident has mastered, at some predetermined level, the knowledge, skills, and attitudes associated with each of the core competencies, while informative, does not ensure that the individual is a competent physician. Something more is needed: graduating residents must be able to translate and integrate their knowledge, skills, and attitudes so they can perform the complex tasks required to deliver high-quality medical care. Determining that residents have taken this last crucial step is the responsibility of the residency program’s faculty, who must find better ways to critically observe the resident’s care for patients in a variety of clinical settings and circumstances.

My colleagues (Drs. Huddle and Heudebert) wrote one of the three articles. I have previously read and commented on their contribution. It looks at medical training in an appropriately traditional manner. Dr. Whitcomb highly endorses their view.

What distinguishes their view from Klass’ is that they do not simply challenge the validity of the ACGME’s approach. They go further and argue that using the ACGME’s framework of core competencies for the accreditation of residency programs and the certification of physicians (as adopted by the American Board of Medical Specialties [ABMS] for its Maintenance of Certification Program) actually threatens to undermine the apprenticeship model of clinical training that has existed in the United States for well over a century. In their view, focusing assessment on performance in individual domains of medicine, rather than on performance in caring for patients, will so distract program directors and faculty from what they should be doing-observing residents caring for patients in a variety of clinical settings and under different clinical circumstances-that it will further erode the quality of clinical training. Indeed, why should program directors and faculty worry about having residents interact with master clinicians if the measure of their residents’ clinical competence and the accreditation status of their programs are to be based on the performances of the residents in individual competency domains? Huddle and Heudebert’s concerns should be treated very seriously, since these authors are on the front line of residency training at a major academic health center.

The whole does not always equal the sum of the parts. In this case it clearly does not. We must worry about the whole rather than the parts.

Popularity: 66% [?]

On transparency

May 29th, 2007

I believe in the Invisible Hand. But the Invisible Hand cannot work if consumers have no idea about prices. One large California group has opted for pricing transparency - Doctors’ list puts a price on care

HealthCare Partners quietly posted on its website last week prices for 58 common procedures.

Patients can go on the group’s website and find that a chest X-ray runs $61 and that a physical examination for a middle-aged patient ranges from $140 to $160. Flu vaccinations are listed at $15, although HealthCare Partners notes that it adds a $31 administrative fee for the first vaccination and $18 for each additional shot on the same visit.

HealthCare Partners’ effort could prompt other physician groups to follow suit, given the competitive nature of Southern California’s healthcare market, some experts said.

“It feels like the right thing to do,” said Robert Margolis, a founding physician and chief executive of the medical group.

The move was motivated in part by the rapid advance of walk-in medical clinics at drugstore chains and discount retailers, such as CVS Caremark Corp. and Wal-Mart Stores Inc., where the prices of blood pressure checks and flu shots are as easy to spot as those for rubbing alcohol and cat food.

HealthCare Partners’ price list also answers calls from President Bush and others to give consumers the information to make better healthcare choices. Proponents believe that shifting medical costs to patients, along with price tags, will blunt the nation’s runaway medical bill by curbing unnecessary care and infusing price competition into the marketplace.

Marketplace discussed this issue on the radio. Two colleagues gave their opinions. More transparency in the cost of health care

Popularity: 63% [?]

The dangers of herbal supplements

May 28th, 2007

Many users think of herbal supplements as something which might help and clearly will not hurt anything. This article points out the problems involved with herbal supplements - Herbal Remedies’ Potential Dangers

As I told a relative this weekend, I do not take anything (pills, herbal supplements or vitamins) unless I know of data that they help me. Herbal supplements have many dangers. Those who rely on herbal supplements and thus do not take medications known to work, put themselves at risk.

Kudos to Sanjay Gupta for this article.

Popularity: 67% [?]

A cousin’s wedding

May 26th, 2007

Actually my first cousin once removed is getting married tonight. We have an interesting family. We have 4 bloggers who each started blogging independently.

My sister’s blog - Funny Business

The groom’s sister has a blog - Squid Knits

And the groom’s blog - Double A Zone

And of course the blog you are currently reading.

Later tonight we will eat drink and yell Mazel Tov!!!

Popularity: 68% [?]

“Better”- a review

May 25th, 2007

Disclaimer - I was sent this book to review.

I have had the book for at least a month. I read much of it, but finally finished it today. The fact that I took so long to finish it is a comment itself.

This book suffers, in my mind, by being released soon after How Doctors Think. The book is really a collection of essays, all related to the subject of how we make medicine better. I did not find the information inspiring or new - until the afterward.

The book has 3 parts - 1. Diligence, 2. Doing Right, and 3. Ingenuity. Each part has 3 stories - I am not certain if they are previously published in the New Yorker (where the author writes regularly). The stories had varying interest to me, but none really gripped me.

Then, this morning I got to the afterward (I was on a plane, traveling to a family wedding). Dr. Gawande has these 5 suggestions for becoming a positive deviant.

1. Ask an unscripted question - My question is what do you do for fun? This question gives me a picture of the patient and also screens for depression. He writes nicely about relating to patients as human beings.

2. Don’t complain - or as my son often tells me - QUIT CRYING!! This section is beautiful - and I will not spoil it.

3. Count something - my academic career succeeded because I decided to count sore throats. We can all keep track of something and explore our counting.

4. Write something - I have written about this often. Obviously those of us who blog have taken this message to heart. Freakonomics on physician writers and Doctors writing

5. Change - Try to avoid a comfort zone. Think about doing things differently and see what happens. Not all change is good, but some change is excellent.

Overall, I give this book a B- (in contract to How Doctors Think which I gave an A+). It is not bad, but it did not grab me.

Popularity: 68% [?]

Too many CT scans

May 24th, 2007

Ask almost any inpatient clinician and you will hear that the ER does too many CT scans. I understand why they do them - but I disagree with the philosophy. They do CT scans in the hopes of decreasing malpractice suits.

Prior to CT scans, we diagnosed appendicitis clinically. Some patients have clear signs and symptoms; other patients have more confusing presentations.

This study suggests that we need not perform CT scans in the obvious group. The study suggests that delaying surgery (to perform the CT scan) impairs outcomes. Routine Use of Diagnostic CT Not Advised for Suspected Appendicitis

The pre-operative use of computed tomography (CT) to make a definitive diagnosis in cases suggestive of acute appendicitis is linked to a poorer patient outcome than a straight-to-surgery approach. In their study, the investigators also observed that diagnostic CT delayed surgery and increased the risk of perforation.

“There has been a somewhat reflexive use of CT since it has become widely available,” Dr. Herbert Chen of the University of Wisconsin at Madison told attendees of Digestive Disease Week 2007, which is underway here.

Dr. Chen and colleagues reviewed the records of 410 adult patients who underwent appendectomy at their institution over a 3-year period. Of these, 62% had pre-operative diagnostic CT, while 38% proceeded straight to the operating room.

Pre-operative white cell counts were similar in the two groups. However, time to surgery was a mean of 3 hours longer in those who underwent pre-operative CT. Patients who did not have a CT were in surgery within a mean of 5 hours, but for those who had a CT, surgery was not performed for more than 8 hours.

The perforation rate was 17% in the patients who had a CT scan before surgery compared with 8% in those who did not. The significantly longer time to intervention with the diagnostic procedure may also account for the more than two-fold increase in complications.

ER CT scans in general increase health care costs. We should use them much more judiciously than they are currently used. I applaud this study and hope that we see much more research on the likely overuse of ER CT scanning.

Popularity: 71% [?]

Financial conflicts in medicine

May 23rd, 2007

This commentary from MedGenMed is sobering - When Medical Care Is Financially Conflicted

As a profession we must address this issue aggressively.

Popularity: 71% [?]

On palliative care

May 22nd, 2007

Over my career in medicine, we have had great advances. Often overlooked is the palliative care movement. I work mostly in 2 hospitals. One has great palliative care, while the other has no emphasis on palliation.

Having great palliative care changes the attitude of a hospital. Our residents think more humanely about end stage disease. Palliative care includes cancer, COPD, CHF, cirrhosis and more.

I have great admiration for palliative care specialists. Please read this beautiful heart wrenching story. At the End, a Duty to Bear Witness

Popularity: 75% [?]

Yes! It is worth it

May 21st, 2007

I worry about Panda Bear. This post has fueled many comments - Is it Worth It?

I will comment on Panda’s angst, then I will link to another outstanding post on the topic. I hope my post complements the #1 Dino post.

I give a regular talk to 3rd year students on picking a career in medicine. Each time I give this talk I stress the importance of picking a specialty which you will love. Many students pick a specialty which is trendy, especially one which their colleagues think provides “good lifestyle and high income.” If one does that, he/she often makes a big mistake.

The phrase that I use is listen to your heart. Do not choose your career unless you love the field?

I admit that I was fortunate. Within the first week of my internal medicine rotation, I knew that I was an internist (just needed the training). I know students who know that they are pediatricians, or surgeons or family docs.

Many students have difficulty figuring out which field of medicine gives them passion. These students do suffer in choosing a field. The students who “like everything” do much better than those who like nothing.

The biggest mistake that I see is students chasing money. While money is wonderful, your career lasts for 30-40 years. Each day you awaken, get dressed and go to your calling. If you choose correctly, you look forward to most days.

Those of us who are fanatics cannot imagine any other career. I know many physicians who feel this way. At age 58, I still regularly get excited discussing a patient situation, making a diagnosis, and helping a patient through conversation.

When I awaken each morning and look in the mirror, I see someone who wants to help.

Many students start medical school with that attitude. Unfortunately, we (medical school faculty) turn eager incoming 1st year students into jaded 2nd year students. I often have stated that 2nd year students are the most undesirable students to teach.

But then the 3rd year comes and most students have their joy rekindled. 3rd year students should learn the humbling power of the white coat. As Stan Lee wrote for Spiderman - “With great power there must also come - great responsibility.” Most 3rd year students come to love medicine.

Note that I say most. Some schools, some attendings, some residents make 3rd year students miserable. I personally find this unconscionable. If we truly love medicine, we have a responsibility to share that love with our students and residents.

Residencies differ greatly. Residents at some programs are happy, learning and excited about their specialty choice. Residents at other programs are unhappy and question their career choice.

Choosing a residency is fraught with hazard. Residencies have personalities, and those personalities can change.

The Panda has chosen (in my opinion) a high risk residency. Emergency medicine, while it continues to attract many students, probably epitomizes a problem specialty. ER physicians see the worst of humanity. They have the greatest challenge in sorting out acute problems. And they do all this with little feedback.

I worked as an ER physician for 4 months (after a year of ER moonlighting.) The problem with ER work is that you never really develop any relationships with patients. Your job is to treat ‘em and street ‘em. Your job is to decide if someone needs admission, and then find someone to take the patient.

Now for me that excludes much of the joy in medicine. I love figuring out the problem, and that often takes several days. I love establishing a relationship with the patient, and that really takes a couple of days (at least.) I love seeing a therapeutic intervention make a difference.

So, I will suggest this to the Panda. Find another field in medicine. I will suggest this to medical student readers - pick your specialty with a long view. Do not let that view become tainted by “expected earnings” or your colleagues opinions. Find a field in medicine that fits your personality and way of thinking. I know happy pathologists, radiologist, surgeons, internists, pediatricians, family physicians, obstetricians, etc. I also know unhappy …

Happiness in your daily vocation trumps money. I could have made more money had I finished a subspecialty fellowship. I could have made more money if I had continued ER work. Fortunately, I understood that I loved general internal medicine.

The #1 Dinosaur also found love - Is it Worth It? A Response

Medicine is more than a job. It is more than a career. It is a calling. (Perhaps that’s what Panda means when he says that fanatics “…hear things that normal people do not.”)

Is it worth it? I would answer, is it worth what?

Don’t pursue a career in medicine because you think it would be a good idea. Don’t do it because you want to. Don’t do it because you love it. Do it because you cannot possibly imagine being happy doing anything else.

Popularity: 80% [?]

5 years of blogging

May 19th, 2007

It was a Saturday, 5 years ago, that I started this journey. Blogging is a journey. Like a 1st year medical student, I really did not understand the implications of starting a blog.

I have learned much over the past 5 years. My writing continues to improve (as does my typing). This blog has changed focus. When I started, I was focused on links. Today, I still link, but often I will spend several days exploring an issue. Thus, I still report, but much more often provide long commentary.

Today I am adding a quote to my list of favorites. I heard this quote recently and loved it “A foolish consistency is the hobgoblin of little minds” - Ralph Waldo Emerson. I never knew that writing a blog would lead me to become a quotation collector.

I believe that the Nietzsche quote, “There are no facts, only interpretations” best informs my blog. I understand that I am giving my opinions. As Groucho said, “Those are my principles, and if you don’t like them… well, I have others.”

What has my blogging wrought? Many loyal readers visit this site regularly. Periodically I will meet someone when visiting another institution who reads my blog. Learning that anyone reads your ramblings must humble one. The many commenters greatly strengthen my posts.

Blogging has made me a more confident writer. Prior to blogging I had modest writer’s block. I would always find excuses to avoid writing. Now I eagerly write articles and columns and submit them well before their deadline.

Blogging made me known to Medscape - I now serve on their Editorial Board and contribute regularly. Blogging has given me opportunities to write for USA Today and participate in an NPR discussion on DTCA. Blogging has helped me sharpen my ideas and is actually stimulating some of my current research.

So once again, thanks to the many readers of my blog. I hope to continue for at least 5 more years. I promise I will continue to learn and improve. My blogging gives me great joy. I hope that it pleases you too.

db

Popularity: 81% [?]

Is medical blogging doomed?

May 17th, 2007

Saturday marks my 5th year blogaversary. I probably will not blog that day, as I am going out of town to celebrate a happy occasion.

Several blogs have pronounced doom for medical blogging - Medical blogging and the tragedy of the commons and Black Wednesday: A dark day for the medical blogosphere. These two rants could cause sadness and angst. However, I believe they miss the point entirely.

The best blogging still champions ideas. I now need to blog to explore my philosophy on many medical issues. As I have written before, blogging represents the same concept as the soapboxes in Hyde Park.

I occasionally do blog about patients who I have seen, or who have been presented at morning report. I go to significant lengths to mask identification.

My patient presentations focus on important lessons that I have learned, and that I think readers will find interesting. I do not blog about their personal quirks or issues of personal sensitivity.

Medical blogs will continue. I will not stop blogging. We have much to say and discuss.

Common sense must always prevail. One should never blog about a patient in such a way that you would be embarrassed for a colleague or any patient to read your entry.

But ideas are my major impetus for blogging. This blog will continue as an outlet for my ongoing understanding of our health care system, what it means to be an internist, and how we can improve health care.

Thanks for reading.

Popularity: 85% [?]

Could multivitamins be bad?

May 16th, 2007

I have always reasoned that a balanced diet trumped taking supplements. Unless I see good prospective data that a supplement improves outcomes or decreases disease, I stick with trying to eat a balanced diet.

It appears that taking multivitamins might be harmful to men - Multivitamin prostate warning

Their study showed taking multivitamins more than seven times a week was associated with an increased risk of advanced and fatal prostate cancer.

There was no link with early cancer or localised prostate cancer, the researchers wrote in the Journal of the National Cancer Institute.

Experts advised men to eat a healthy diet to reduce their risk of cancer.

The findings, based on data on nearly 300,000 men, indicated the risk of advanced prostate cancer is 32% higher in men who take multivitamins more than once a day compared with those who do not take them at all.

Risk of fatal prostate cancer was almost double.

The correlation was strongest for men with a family history of the disease, and who also took selenium, beta-carotene or zinc supplements.

Now to be fair this is an epidemiologic study. It really can only provide hypothesis generation. Nonetheless, this study supports my balanced diet approach.

One expert responded

“And there is conflicting evidence on the pros and cons of vitamin supplements.

“These products don’t seem to give us the same benefits as vitamins that naturally occur in our food.

“We encourage people wanting to reduce their risk of cancer to eat a diet rich in fibre, vegetables and fruit, and low in red and processed meat.”

Popularity: 89% [?]

Doctors writing

May 15th, 2007

Doctors Who Wield the Pen to Heal the Profession

Dr. Abigail Zuger writes a very interesting piece today about physician/writers. Since she includes blogs, she is indirectly writing about physician bloggers.

The strongest voices at the moment belong to Dr. Jerome Groopman and Dr. Atul Gawande, both clinicians at Harvard and writers for The New Yorker, both with articulate new books garnering impressive reviews and climbing in parallel to best-sellerdom. But they are only two of many doctors holding forth these days, in escalating volume.

Readers know that I loved Dr. Groopman’s book. I cannot say the same for Dr. Gawande’s. I received his book for free so that I could review it. I have read his New Yorker pieces. His writing does not grab me like Dr. Groopman’s does. I have not been able to finish reading Dr. Gawande’s book. I probably will not - it just does not draw me back.

Doctors are also filling up newspaper columns (like this one), blogging, submitting work to literary journals and signing up for courses designed to help them break into print.

It all prompts the same questions as a sudden swooping, squawking murmuration of starlings: where are they all coming from? And what in the world are they trying to say?

Some listeners hear a set of new variations on very old songs.

“Doctors are storytellers,” said Kathryn Montgomery, a professor of literature who directs the medical humanities and bioethics program at Northwestern University’s Feinberg School of Medicine in Chicago. “They spend all day long listening to stories and telling stories.”

They tell stories, she went on, even when no one is around to listen — to clarify their own thoughts, to teach and to stimulate research. “It’s not surprising they write,” she said.

And that makes sense. Get a group of physicians together, even as early as the 3rd year of medical school, and we each become raconteurs. We have stories to tell. As I often say, you cannot invent these stories.

Once the writing bug infects one, writing becomes a joy. Writing our stories acts as a release. We feel better when we share our insights, our struggles and our angst.

Dr. Groopman has made it clear, in his writings since then, that medicine has no magic, wizards or geniuses, and very few saints. Instead, there is only uncertainty in an endless spectrum of grays, with doctors whose skills promote an illusion of magic and others who stumble.

Dr. Groopman does not just write, he also teaches medical literature. He has this recommended reading list. Prescribed Reading

Medicine engages life’s existential mysteries: the miraculous moment of birth, the jarring exit at death, the struggle to find meaning in suffering. But medicine is practiced in the mundane world and involves concrete issues like the imbalance of power between physician and patient; the role of quackery, avarice and ego in molding a doctor’s behavior; and the demand for perfection in the face of human fallibility. No insight into its more existential aspects is found in clinical textbooks, properly devoted to physiology, pharmacology and pathology. Rather, it is literature that most vividly grapples with such mysteries, and with the character of physician and patient.

We write because we can. We write because we have intriguing stories to share. We write because others care to read.

Popularity: 88% [?]

Renin inhibitors?

May 12th, 2007

The other day a drug rep started to pitch the new renin inhibitor. I told her that I would wait to read information on my own.

This article raises some interesting questions - Reviewers Question First In-Class Rennin Inhibitor for Hypertension

Aliskiren, the first oral antihypertensive agent in the renin-inhibitor class, is no better at reducing blood pressure than older agents, and in some patients may actually increase blood pressure, claimed two reviewers.

A review of studies involving more than 5,000 patients indicated that aliskiren (Tekturna, Rasilez) was no more effective than angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, found Jean E. Sealey, D.Sc., and John H. Laragh, M.D., of Weill Cornell Medical College here.

“Aliskiren in combination with a diuretic appeared to lower blood pressure more than an aliskiren-angiotensin receptor blocker combination, but still failed to control blood pressure (<140/90) in 50% of the patients,” the reviewers wrote in the May issue of the American Journal of Hypertension.

Others disagree with them.

But a hypertension researcher who has used the agents in clinical trials said that many of the claims by Dr. Sealey and Dr. Laragh are not backed by the evidence at hand, nor are they supported by results of a large study scheduled for publication in the near future by another hypertension journal.

So what is a generalist to do? My general philosophy on new drugs is to wait for a year or so to see what the literature says. While I am often an early adopter of new technology, with drugs I tend to lag a bit.

This class may represent a major benefit … or it may not. We need to follow the literature and learn about this drug over time.

Popularity: 93% [?]

More thoughts on health care as a right

May 11th, 2007

As at least one commenter has stated, the key problem here is in defining what the word right means, and therefore what implications follow from considering health care a right.

Those who consider health care a right will expect universal health care. Many countries treat health care as a right.

Those who do not consider health care a right still believe in providing health care to all. The non-right philosophy does not preclude providing basic health care to all citizens (or even anyone in the country). In fact, by law, we must provide emergency room care to all, regardless of financial status.

The non-right crowd would prefer that we make explicit basic health care. They would accept increasing Medicaid coverage to pay for it, assuming that the politicians provide moneys to fund the program.

I am personally interested in the state experiments currently in process.

Since this debate is a philosophical one, we can have no winner. Your individual feelings on this issue reflect your philosophical view of the world. Who can say which philosophy is the “correct” one?

Discussing the nuance of this argument at least helps us understand why the debate is so heated. Thanks to all who have (and will) contributed to our discussion.

Popularity: 94% [?]

A colleague writes about the right to health care

May 10th, 2007

Dr. Tom Huddle is a colleague in every sense of the word. We have worked together for 14 years. More important we discuss ideas. We have written 2 papers together, and probably will write more in the future. We read each others papers and candidly criticize them.

Last week he participated in a debate on the issue of the right to health care. My other colleagues told me that he did a wonderful job. I asked him to write a few paragraphs discussing why health care is not a right. His contribution follows:

Why access to health care is not a basic human right

We would all like to improve access to health care in this country; and one of the most powerful arguments for doing so is the claim that such access is a basic right which our nation has failed to grant to its citizens. We have a tradition of respect for “negative” rights—the traditional freedoms from interference that are enshrined in our founding documents. Ought we not to similarly guarantee the “positive” rights—to economic goods and services such as food, shelter, and health care—necessary for the enjoyment of the negative rights? Positive rights seem to be prerequisites for the enjoyment of negative rights such as freedom of speech and religion and security of property; and government action is necessary to secure both kinds of right; why not therefore conclude that certain positive rights ought to be guaranteed to us?

The reason why not emerges from a closer look at the structure of rights. The flip side of a right is an obligation. If there are basic, unconditional rights to goods and services, then there are basic, unconditional obligations to provide them. On whom do such obligations fall? On the community of course. But the practical working out of any such positive right (such as a right to health care) involves the community choosing what amount of health care to guarantee and from whom to take the wherewithal for providing such an amount to those having a right to it. The difficulty here is that the potential demands on those with superfluous goods to spare is potentially infinite—as there can be no stinting on the provision of any good or service deemed a basic right, so long as someone lacks something he has a right to. Hence the moral principle behind a doctrine of positive rights: having produced goods and services, we are obliged to give them to those others that have a right to them until either everyone has all goods or services they have a right to or we have exhausted our resources. In any society in which the need of such goods to guarantee positive rights exceeded resources, such a morality would soon extinguish all production.

In addition to being impractical, this principle differs from the common sense morality that we in fact adhere to. We acknowledge an obligation to help the needy, but that obligation is unconditional only in certain circumstances: with family-members, people we have previously agreed to help, or certain kinds of immediate need that appear in our presence—such as the child drowning in a puddle as we’re passing by. If we had more general obligations to aid strangers that were absolutely unconditional—if we HAD to give our money to the street-person asking for it once we confirmed that he needed it to gain something he had a right to—our own negative rights to choose what to do with what is ours would be nullified; a conclusion most of us could not accept. Because there cannot be unconditional duties to provide goods and services, there cannot be unconditional rights to them, however necessary they may be. Our common morality posits an unconditional duty not to harm; but a conditional and limited duty to help.

In what does that duty to help then consist? It involves, I would contend, recognizing that decisions about public provision of goods and services to the needy are moral but also prudential decisions; we ought to help the needy but we must choose what and how much to provide so as not to endanger production and nullify the negative rights of producers; and, because need will inevitably exceed supply, we must make hard choices among competing goods. We cannot do everything that we would wish to do. While advocates for health care as a right press their case for public provision on that basis, their audience listens only because in 21st century America, public provision of some level of health care is thinkable without the consequences that positive rights doctrine would demand in a less wealthy country. That such provision is prudently possible is the real reason why we should now find a way to offer it, given our obligations to the needy. But the decision to do so must be taken in the political arena in which access to health care must compete with other public goods whose advocates scramble for the public purse—it cannot be made by simply appealing to an unjustifiable doctrine of positive rights.

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I agree with Tom. Both he and I look forward to your critique.

Popularity: 100% [?]

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