Monday, September 29, 2008

Local medical news

In the debate over national health reform, there's been a lot of discussion about state-level health care innovations. Whether it's good, bad or indifferent, local governments do seem to be busy legislating health care lately. A few examples culled from a single day's news:

Illinois is now requiring hospitals to offer discounts to uninsured patients. Consumers will spend no more than actual cost plus 35% for care, and cannot be forced to pay more than a quarter of their annual gross income to a hospital.

The city of Boston has had to give up its Canadian drug-importation program for lack of interest. Problem was that the program targeted at city employees who would pay the same copay regardless of how much the drugs cost, so why bother signing up for imports just to save your employer money?

Michigan is looking at legislation that will protect physicians who report their patients for driving when they shouldn't (because of medical conditions or medications). Trial lawyers are pushing for the reporting to be mandatory rather than optional. Michigan is among 18 states that don't have laws on the books regarding the issue, the article says.

Nebraska will be hastily revising its new child abandonment safe harbor law, after droves of parents started relinquishing custody of their teenage children at local hospitals (including one guy who left 9 kids ages 1 to 17!). Warms your faith in humanity, doesn't it?

Medical news of the obvious

Apparently, we weren't all born with little chips in our brain that direct us to binge drink at age 17 when the 'rents are out of town. Nope, drinking is actually influenced by our cultural environment.

Also, cancer is stressful and poor balance increases fracture risk.

And from the world of psychology, a headline that made us giggle:

"Facebook profiles can be used to detect narcissism," University of Georgia researchers report.

Quoth the press release: "'We found that people who are narcissistic use Facebook in a self-promoting way,' said lead author Laura Buffardi, a doctoral student in psychology."

People who choose glamour shots (vs. snapshots) as their main profile pix are more likely to be narcissists, as are people with a whole lot of friends-- because narcissists tend to have "numerous, yet shallow," relationships, the study found.

Don't worry, though: Having a Facebook profile in and of itself does not mean you are a narcissist. Having a blog, on the other hand...

(A very special thanks to our reader, tantheman, for submitting the Obvious item about fractures. Keep those suggestions comin', folks! )
Friday, September 26, 2008

The fountain of youth...but at what cost?

Thus far, calorie restriction (low calories, balanced diet) is the only scientific intervention we know about that appears to increase people's life span. So what's the catch-- besides having to be extremely strict about what you eat? Might a person, for example, live a long time but have fragile bones that have been compromised by a low-cal diet?

Nope, according to a new study in the Archives of Internal Medicine. A 6-month study of 46 young, non-obese adults found that the bones of those who practiced 25% calorie restriction from baseline energy needs, as well as those who had a 25% energy deficit through diet and exercise, were in fine shape bone-wise at the end of the intervention. All groups took pains to preserve their calcium intake through diet, not supplements. The researchers acknowledge, of course, that a test of longer duration is needed.

What do you think of this practice? Do you have patients who practice calorie restriction, and if so, how do you counsel them about staying healthy? Does this study ease your mind at all about potential adverse effects to the practice?

(For more interesting reading on calorie restriction, check out this profile of a couple who practice it in Philadelphia Magazine, and this article in Slate which argues that calorie restriction is an eating disorder.)
Thursday, September 25, 2008

Whole body CT scans are SO last year...

What do Rupert Murdoch, Ivanka Trump and Harvey Weinstein have in common?

All have recently attended a "spit party" according to the New York Times.

"What's that", you ask? Well, it seems that, in a natural progression from whole-body CT scans, folks are now gathering in festive huddles so they may spit into test tubes, then have their DNA tested to see if they are predisposed to develop various diseases and conditions.

Now that's my idea of a good time.

The company behind this idea, 23andMe, drastically lowered its price in September to an affordable $399, so the average Joe or Jane can have the chance to spit into a tube, drop it in the mail, and get their results back about a month later. ("23andme Democratizes Personal Genetics," the Web site declares proudly).

All kidding aside, I'm thinking this could have big implications for physicians if panicked patients start coming in with genetic profiles that show they are doomed for such and such disease-- or alternatively, that they have nothing to worry about, so why bother with those statins, that diet, that exercise plan?

Then again, perhaps if you find out early that you are predisposed to a condition, you can change your habits to help ward it off-- like Google co-founder Sergey Brin, who plans to donate much of his substantial wealth to medical research since he now knows he's prone to Parkinson's.

What do you think, readers? Is this development a positive or negative one for patients? For you?

Are there any undecided voters out there?

If you haven't gotten your fill of the presidential candidates on health care in my Campaign Trail columns (here, here, here, here, here, here, here and here), you might be interested in the current issue of the New England Journal.

Barack Obama and John McCain each wrote a piece about their health care plans, and while they both spout a lot of platitudes (According to McCain, "every American should have access to quality and affordable coverage of their choice" while Obama believes "all Americans should have high-quality, affordable medical care that improves health"), they do eventually explain the basic precepts of their plans. And if you prefer your campaigning negative, operatives (er, I mean, health experts) have written attack pieces on the Republican and Democratic plans.

And if you still haven't made your decision after that, there's some kind of video on the NEJM Web site with more health care campaigning. If you watch it, let me know how it ends. I was afraid my head would explode if I had to hear or read the words "high quality and affordable" one more time.

Update: The Kaiser Family Foundation (who must know more about the candidates and health care than anyone else on earth) just released an online tool that compares Obama and McCain on a whole series of health-related issues going far beyond insurance coverage.

Saying no to generic doughnuts

A new study by Medco reveals some interesting data about how seniors work around the Part D doughnut hole.

It's no big surprise that a chunk of them stop taking their statins once they have to pay for them. But did you know that--among those who stay on their meds--many seniors switch from brand-names to generics while they're paying out of pocket, and then switch back again when they reach the other side of the gap?

In an ACP Internist discussion of these stats, one staffer attributed the finding to the penny-saving, coupon-clipping habits of the Greatest Generation. But, as it turns out, these thrifty seniors may actually be costing themselves (as well as all of us taxpayers) in the long run, because if the patients used generics while they were covered by Part D, they would delay, or even avoid, arrival at the doughnut hole.

According to the Medco press release, the company deals with the problem by offering their members forms to talk to their docs about prescribing generics. But if they're already switching back and forth, it doesn't seem like these patients are scared to ask for the drugs they want. The real issue seems to be how do you convince them that generics are just as good as brand names? Any strategies out there?
Tuesday, September 23, 2008

Americans taking fewer drugs

According to stats from IMS Health Inc., prescriptions dropped almost 2% in the second quarter of this year compared to the year before. The lede of this Philly Inquirer article attributes the drop to economic problems, but also cites several other potential causes of the first drop in drug sales since 1996:
  • fewer new drugs being introduced
  • heavy publicity for some nasty side effects (e.g. rosiglitazone)
  • a slowdown in FDA approvals

Physician visits were also down 1.2%. But medical workers shouldn't worry about unemployment quite yet, experts said. The American population is still expected to get older and sicker in the future, so we can expect business to pick back up. What a relief.

Monday, September 22, 2008

Medical news of the obvious

Four items that need no explanation or comment:
  • People who have steady, dependable jobs are more mentally healthy that those whose jobs may be in jeopardy, according to a new WHO report.
  • Women who binge drink are at greater risk of unsafe sex, according to the journal Alcoholism.
  • Women who are bulimic in pregnancy are more anxious and depressed than pregnant women without eating disorders. At least in Norway.
  • People with a family history of cancerous brain tumors are at higher risk of developing those tumors than people with no family history, Neurology reports.
Friday, September 19, 2008

New CDC testing recommendations for Hep B

The CDC just issued new testing recommendations for chronic Hep B virus infection, which affects more than 1 million in the U.S.

In addition to testing all pregnant women, infants born to infected mothers, household contacts and sex partners of infected individuals, and people with HIV, providers should now test:
  • People born in Asia, Africa, and other regions with 2% or higher prevalence of chronic HBV infections. (It was formerly 8% prevalence)
  • Men who have sex with men and injection drug users.
  • People with abnormal liver function tests not explained by other conditions
  • People who require immunosuppressive therapy

A diabetes therapy from the future

Rather than putting patients with type 2 diabetes through the pain and risk of gastric bypass, physicians may soon be lining diabetic intestines to induce weight loss and control blood sugar. Researchers at the First World Congress on Interventional Therapies for Type 2 Diabetes reported on a cool new device (with a slightly less appealing name--the EndoBarrier Gastrointestinal Liner) which is inserted endoscopically and then alters the way food is absorbed by the digestive system.

As reported in the Washington Post, a trial of 18 patients (the device has been put into 118 people total) resulted in an average weight-loss of 27.5 pounds by 31 weeks, and improved glucose control as soon as a week after surgery. The studies were, of course, funded by the manufacturer and need more confirmation. And yes, having a plastic bag put down your gullet sounds gross, but it sure beats having your stomach stapled.
Wednesday, September 17, 2008

Your patients may not listen to you...

...but they remember every piece of advice that Dr. House offers. A new Kaiser poll (reported in USA Today) found that a substantial portion of TV viewers (45% to be exact) remembered that HIV transmission from mother to child could be prevented in 98% of cases after they heard Dr. Izzy Stephens of Grey's Anatomy tell a patient the statistic.

Meanwhile, Newsweek reports that more pharma companies (perhaps those who read the Kaiser study) are trying to get the names of their drugs worked into TV plotlines. The article's author suggests that similar techniques could be used to promote the use generic drugs. Interesting idea, although I'm not sure I can picture the guys from Scrubs cracking jokes about sildenafil citrate.

Either way, this research appears to confirm that the best way to get your patients to absorb health information is not reminder postcards, waiting-room posters, or teachback, but having a sexy celebrity explain it.
Tuesday, September 16, 2008

Patient weight loss tool

I've stumbled upon an online weight loss tool I really like, and some of your patients might like it, too.

It's "Calorie Count Plus", a food and activity tracker on With minimum effort on the user's part, the site keeps track of the daily calories you burn as well as those you consume, and will chart the results over time. (remember, this strategy works: an August study in the American Journal of Preventive Medicine found keeping a food diary can double the chances of losing weight.)

The site also has a feature where you can look up the calorie and nutrition information of the foods you eat, and it will give you a nutrition analysis and grade (A-F) according to how balanced your diet is. You can also keep a journal, participate in message boards and make "friends" through the site, if you choose.

My favorite feature: The "calories burned" counter resets to zero at midnight and updates throughout the day, using a projection based on your weight and height, plus any activities you tell it to include. It's kind of fun (and motivating) to watch that number climb.

Heck, I burned 10 calories just sitting here writing this blog post.

Acronym fatigue

Do you know your EHR from EMR from PHR? How about whether you're dealing with an HIE or an HIO?

The EHR vs. EMR issue seems to be one of the most perplexing and commonly confused. According to a report which The National Alliance for Health Information Technology (or NAHIT, if you needed another acronym) put together to explain the terms to the government (comforting to know they're so on top of it, isn't it?), an EMR is a electronic record that is confined to a single office's computer system, and EHRs are interoperable with other health care providers/facilities.

Presumably then what most people would want is an EHR. But, according to this article from a software advice firm, more web searches are conducted for EMRs than EHRs. Guess a lot of us are confused about this. Check out the NAHIT report for the full explanation of these terms and other confusing HIT (sorry, health information technology) terminology.

Now if only we could get our Microsoft Word to stop auto-correcting EHR to HER, we'd be all set.
Monday, September 15, 2008

Medical News of the Obvious

Our theme this week is obesity. There are lots of interesting questions on this subject, but these studies aren't answering them.

Physical activity is associated with reduced risk for obesity in people who are genetically predisposed, the Sept. 8 Archives of Internal Medicine says. But, wait, there is a suprising part of the study--it was conducted among the Amish. Who would have guessed that there even are inactive, obese Amish? Apparently cars and fast food are not entirely to blame for the obesity epidemic, as 30% of female study participants were obese.

Another Archives study (a little old, but profiled in this week's Journal Watch) provides more evidence on the new weight-reducing properties of exercise. "Women who maintained a 10% weight loss during a 2-year study had better eating habits and more leisure-time physical activity than did those who regained weight." Got it? Diet + exercise = weight loss

And why should we care? Because obesity has some relationship to cardiovascular disease, according to a study in the Journal of the American College of Cardiology, reported in the Washington Post under the headline "Heavier People Have Heart Attacks Earlier." This study author wins the quote-of-the-week award for telling the Post, "If you had your choice, you would choose not to have a heart attack in the first place."
Friday, September 12, 2008

Do we need a talking cure?

The New York Times has just launched a new blog, "Doctors and Patients Start Talking," with the goal of healing the confidence and communication gap between physicians and patients. It's a laudable objective that has attracted a lot of web traffic, and maybe I'm being too cynical, but I don't see how airing more complaints from both sides (patients and docs) is going to fix a problem whose causes are systemic.

A new article on Slate gets at this issue, by pointing out that the cause of ER overcrowding is not illogical misuse of the emergency room. Rather, people are using it for non-emergent problems because it is, for them, under the current system, the most efficient and cost-effective way to get care. The authors rightly conclude that structural changes are in order, although they, too, make some odd suggestions of individual solutions to the problem ("Next time you call the dermatologist and they say, 'We'll see you next summer,' you could cry foul." Good luck with that!).

What do you think? Are there things that you'd like to tell all patients that would improve overall health care? And do they have any complaints that you haven't already heard?
Thursday, September 11, 2008

MRSA mutterings

In case there's anyone who hasn't already heard all about the disease, the CDC is launch a MRSA awareness campaign. The project aims to teach parents how to reduce their children's risk of acquiring community MRSA--basically by maintaining proper hygiene. According to the press release, they'd also like health care professionals to get involved in the education effort.

More glamorous MRSA-reduction projects were unveiled at the recent meeting of the Society for General Microbiology. A British study found that a paint which contained particles of titanium dioxide killed MRSA when it absorbed ultraviolet or infrared light, reported the Washington Post. And, cited in the same story, another piece of preliminary research determined that putting a certain green dye in infected wounds killed off the bacteria.

But for now, the experts said, the best way to not spread MRSA is still the simplest--wash your hands.

New 9/11 PTSD estimates

September 11-linked asthma has gotten a fair amount of press, but here's something that hasn't: PTSD.

The NYC Dept. of Health released an estimate yesterday that as many as 70,000 New Yorkers may have PTSD due to the terrorist attacks on their city, the Washington Post reports. These are folks, like rescue and recovery workers, commuters, and lower Manhattan residents, who were heavily exposed to pollution from the disaster (up to 12,600 of whom may have asthma, by the way.)

For tips on how to spot, and treat, PTSD in patients, see our cover story in the September ACP Internist, which focuses on returning veterans. Combat-related PTSD-- which often involves multiple exposures to traumatic events-- differs in some ways from PTSD borne of a single event (like 9/11), but they still have much in common. And, unfortunately, PTSD itself is a lot more common than most people know.
Wednesday, September 10, 2008

Dress for success or sterility?

You may think that your quality of care and adherence to guidelines are crucial measures of medical performance, but physicians' clothing choice, of all things, seems to be the quality issue that won't go away. (At least not until something more entertaining comes along for medical journalists to write about.) We first analyzed patients' preferences related to doctors' dress back in April 2007.

Now, the Brits are taking action on the subject, according to the New York Times. The National Health Service has banned ties and encouraged docs to wear short-sleeve shirts, with a goal toward reducing the spread of infections. Debate has ensued, as apparently evidence is mixed (and limited) on whether ties are overall good or bad for patient care.

One reader came out definitely against ties in a response to our article. What do you think? Is it more important to gain that little bit of patient respect garnered by a tie? Or would you rather reduce the possibility that your clothes are spreading germs?
Tuesday, September 9, 2008

Medical News of the Obvious Part II

Maybe because we spend a lot of time talking to students and residents, the press releases for this week's issue of JAMA, which has a medical education theme, particularly struck us with their obviousness.

First up, "white medical students who attend schools with greater racial and ethnic diversity among the student body are more likely to rate themselves as highly prepared to care for minority populations." That seemed a little obvious, but the really depressing part was how an accompanying editorial concluded that even putting evidence behind a concept so intuitive will have no impact. "However, even with an increasing evidence base, many medical schools are unlikely to prioritize increased URM [underrepresented minority] diversity. For such schools, improvements may come only through changes in leadership or external pressure by community and political forces."

Then we learn that "interns who experience an increase in their on-call workload are more likely to get less sleep while on call, have longer shift durations and participate less in educational activities." We, too, are looking for one of those jobs where more work means more sleep and shorter hours.

And, finally, for anyone still mystified by the primary care shortage, med students explain why they are not going into internal medicine. "Compared with other specialties they had chosen or considered, students perceived IM as requiring more paperwork (68.0% of respondents), requiring a greater breadth of knowledge (62.1%) and having a lower income potential (64.6%)."

More kinks in quality reporting

Practice managers are reporting more trouble with the Physician Quality reporting Initiative (PQRI) results, citing a lack of data, administrative burdens, and an 18-month delay in learning results.

Nearly 70% reported low or no satisfaction with how the program's results improved patient care outcomes. Nearly 93% reported problems accessing their results, according to a survey conducted by the Medical Group Management Association.

Specific complaints cited by the MGMA survey include the lack of data for improving patient outcomes and difficulty accessing and downloading the 2007 feedback reports. On average, respondent practices spent five hours downloading their final 2007 PQRI feedback reports from the Web site. In addition, 63% of respondents reported difficulty capturing and submitting data.

ACP members had previously reported their own difficulties. ACP is collaborating with a survey being conducted by the American Medical Association to assess physician experience with PQRI to further bolster arguments that Medicare needs to improve the program quickly. Look for details in upcoming issues of ACP InternistWeekly.
Monday, September 8, 2008

Medical News of the Obvious

What is it about research on kids that all the findings always seem so darn obvious?

This week, one study found that college students who don't believe that prescription drug abuse is very risky are 10 times more likely to abuse prescription drugs than those who believe it is highly harmful. (Special kudos to this obvious study for an author actually telling the Washington Post, "But what we're talking about here is not rocket science.")

Also, children of stressed, low-income mothers have weight issues (Post quote on this one: "The last thing you're going to worry about is whether your child is obese if you're busy trying to take care of physical needs first, like simply putting a roof over your head.").

And playing active video games burns more calories than doing nothing or playing a passive game, but fewer than actually being active away from the TV. (Also from the Post.)

Stay tuned tomorrow afternoon for a special Part II of Medical News of the Obvious, featuring JAMA's medical education issue.
Friday, September 5, 2008

Click here for important new guidelines!

Our analyses of InternistWeekly email readership have revealed that our subscribers are particularly interested in any news involving guidelines. Thus, we are embarrassed to report that the Labor Day holiday caused us to miss a new set of guidelines on that most glamorous of topics...ear wax.

Under the headline "Leave that Ear Wax Alone," the Washington Post reports that the American Academy of Otolaryngology--Head and Neck Surgery Foundation has issued the following not-so-surprising advice:

Ear wax is good. ("Cerumen is a beneficial, self-cleaning agent, with protective, lubricating (emollient), and antibacterial properties.")
Q-tips are bad. ("Inappropriate or harmful interventions are cotton-tipped swabs, oral jet irrigators, and ear candling.")

as well as some more specific, clinical recommendations:
Appropriate options for cerumen impaction are (1) cerumenolytic (wax-dissolving) agents, which include water, saline, and other agents of comparable efficacy, (2) irrigation or ear syringing, which is most effective when a cerumenolytic is instilled 15-30 minutes prior, and (3) manual removal with special instruments or a suction device, which is preferred for patients with narrow ear canals, eardrum perforation or tube, or immune deficiency.
Individuals at high risk (e.g., hearing aid users) should consider seeing a clinician every 6-12 months for routine cleaning.
Thursday, September 4, 2008

Flat bellies sell, bees not so much

Direct-to-consumer drug advertising may not work as well as is commonly believed, a study in the British Medical Journal found.

Canadian researchers looked at three heavily advertised drugs--Zelnorm, Nasonex and Enbrel--and compared prescription rates in English-speaking regions (which were subjected to U.S. TV ads) and French-speaking areas (which weren't). The Zelnorm ads caused a big jump (42%) in prescribing right after the ads started in English areas, but the other ads appeared to have no effect. And prescriptions for the IBS drug soon dropped off, even though ads continued.

Researchers speculated that the award-winning effectiveness of the ad (Remember those trim female abdomens with happy messages written on them?) and the lack of competition for the drug (no alternatives were approved) may explain its unique success, and the dropoff could be attributed to how the drug itself turned out not to work very well and be dangerous.

So what's it all mean? Perhaps some of you already thought this, but the study authors now believe that "a substantial portion of expenditure on such advertising--borne by governments, insurers, and patients in the form of higher costs or by companies as reduced profits--may be better spent elsewhere."

Is it time to say goodbye to the Nasonex bee?
Wednesday, September 3, 2008

The doctor is in...your office.

Several news articles, including this one in today's Philly Inquirer, have covered a new trend of employers opening in-house medical clinics. Some of the statistics are little iffy (Is it really a "trend" when "29 percent of large employers had an on-site health center or planned to open one by 2009, up from 27 percent in 2006"?) but the discussion of cost-effectiveness is interesting.

Although the sources cite platitudes about the savings of preventive medicine (Iffy statistic #2: "An emphasis on wellness can save money, she said, because 40 percent to 50 percent of health-care costs are related to preventable problems."), the companies who have opened the clinics explain that the actual savings comes from cutting deals with their in-house doctors.

As an MSNBC article explains, Toyota, one of the leaders in this trend, is saving money by reducing "referrals to highly paid specialists, emergency room visits, and the use of costly brand-name drugs." All things which, if they actually are unnecessary, it seems like it would be possible to cut back on without adding the cost and privacy issues of a whole in-house medical establishment.

What do you think? Is the return of the company doc a good thing for patients? For physicians? Would you want to be one?
Monday, September 1, 2008

It's that time again

After the traditional summer slowdown, conference season is about to get underway, and that means it is once again time for...Ill-advised Session Titles. Here are a few treasures from the Medical Group Management Association, whose annual meeting I'll be blogging from Oct. 20-22.

"The Ring in the Rubble: Dig Through Change and Find Your Next Golden Opportunity" People, how many times do we have to tell you that metaphors are like fudge--a little bit is amazing, but a lot is unhealthy and nauseating?

"How to Get Your Front End to Meet Your Back End" What do you bet several attendees arrive with absolutely the wrong idea in mind? This is a business seminar!

"I Hate to Wait!" Fair enough, but I'd better not have to sit around while you fiddle with your PowerPoint.

and our nominee for Excessively-Wordy-But-Can't-Miss-Session-Title, "Our Physicians Make More Money, Go Home on Time and Provide Better Care".

Medical News of the Obvious

Medical News of the Obvious won't be published today due to the Labor Day weekend.

Catch two weeks worth of snark on Monday, Sept. 8.