Wednesday, March 31, 2010

No End in Sight for Prostate Cancer Screening

This post by Kevin Pho, ACP Member, aka KevinMD, appeared at Better Health.

Is the tide finally turning on PSA screening for prostate cancer? There's no definitive data that PSA screening saves lives from prostate cancer, and it indeed can lead to further invasive tests that can cause men significant discomfort. Medical societies are divided on the issue. Primary care groups like the U.S. Preventive Services Task Force recommend against it for older men, while the American Urological Association continues to recommend screening.

Prostate cancer, adenocarcinoma, from MKSAP, (c) American College of PhysiciansIn a strongly worded op-ed in the New York Times, Richard Ablin, also known as the founder of the PSA test, bemoans how our healthcare system has twisted its use. "The test's popularity has led to a hugely expensive public health disaster," he writes.

Who's responsible? According to Dr. Ablin, it's the drug companies: "So why is it still used? Because drug companies continue peddling the tests and advocacy groups push 'prostate cancer awareness' by encouraging men to get screened."

He's leaving out other culprits. If the public is to be convinced of the PSA test's fallibility, public figures need to get off the bandwagon. That includes prominent prostate cancer survivors like Senator John Kerry, who implores the public to be screened, without explaining the possible ramifications.

And what of the legal consequences? Dr. Daniel Merenstein dutifully explained the risks of PSA screening to a patient, but got sued for his efforts and was forced to settle. Maybe he was ahead of his time.

Until we can better educate the public on PSA's risks, and protect doctors from malpractice, PSA screening will continued to be rampantly ordered.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Health care reform meets resistance

tanning bed by Whatsername? via FlickrWith the final signature in place on health care reform, President Barack Obama now faces an unhappy electorate, displeased large employers, grumbling small employers, and a disgruntled opposition party. Even the tanning bed industry is up in arms. Oh no! Not the tanning salons! (Politico, Christian Science Monitor, NPR, Washington Post, Los Angeles Times, The Hill)
Tuesday, March 30, 2010

QD: News Every Day--"I do the damn test"

Congress controls the nation's purse strings. It can tell the Executive Branch how to spend money. It can regulate all commerce, and by the way, to Congress, everything is "commerce."

Congressional legislation can incent economic behavior--pay for this, but not for that--but it can't change personal decisions. A case in point is Robert Colton, ACP Member, of Boca Raton, Fla., who says he authorizes the tests that his patients demand. His opinion about that is the headline of this piece. He says there's little incentive not to order tests and little in health care reform to make him and others change their habits. More likely is the idea that, once new medical technology is invented, it will find a use.

Another article compiles a wide spectrum of ideas on how to reduce health care spending. Tort reform was one, sure, but many doctors focused on changing patient behavior first. Feel free to offer your ideas in the comments below.
Monday, March 29, 2010

QD: News Every Day--Who will care for the newly insured?

With the prospect of 32 million new patients clamoring for care comes sorting out who will see them all. New med school are opening and students say they relish the prospect of entering a market that will demand their services. ACP Member Manoj Jain, MD, offers a more tempered view of how the fallout might affect primary care. (AP, American Medical News, Fort Worth Star-Telegram, Memphis Commercial Appeal)

Sunset on Hanalei Bay by Alaska Dude via FlickrEven Hawaii has a shortage, especially in primary care, but also cardiology and orthopedic surgery. It's hard to believe recruiters couldn't sell Hawaii as a destination. (Honolulu Advertiser)
Friday, March 26, 2010

When 32 Million New Patients Look for a Doctor

This post by Jonathan LaPook, ACP Member, appeared at Better Health.

With the passage of healthcare reform, an estimated 32 million new patients will try to find primary care doctors. That's not going to be so easy because we already face a shortage of primary care doctors and about 13,000 more will be needed to take care of those newly eligible for insurance.

According to the American Medical Association, there are about 312,000 primary care doctors practicing in the United States. That includes family medicine, general practice, internal medicine, and pediatrics. (In addition, there are 43,000 OB/GYNs who also may serve as primary care doctors.) The estimate that another 13,000 will be needed comes from a study done by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in partnership with the Agency for Healthcare Research and Quality.

Sixty five million Americans already live in areas that don't have enough primary care doctors. And relief is not on the way anytime soon. It takes five to eight years for a first year medical student to be trained as a primary care doctor. And the trend for budding doctors over the past decade has been away from primary care and towards more lucrative specialties.

The new legislation contains some incentives for entering into primary care. Medicare will pay a 10% bonus to doctors spending most of their time giving primary care to the elderly. Medicaid payments will be increased by about 20% in 2013 and 2014 to reach 100% of the Medicare rate. This is important because about 16 million new patients will be eligible for Medicaid and many doctors currently don't accept Medicaid because reimbursement is so low. In addition, primary care doctors will be paid extra for coordinating care among a team of doctors.

The new incentives are a good start but more is needed to increase our supply of primary care doctors. For this week's CBS Doc Dot Com, my producer, Heather Tesoriero, and I traveled to a rural community in Indiana and discussed the shortage with an old-fashioned family practitioner named Dr. Jason Marker. When he started practice eight years ago he was $140,000 in debt from medical school loans. He works long hours and sees about 100 patients a week, but still owes $125,000.

But Dr. Marker isn't in it for the money and he's not looking to heal only the well-healed. The day we visited him, a man walked five miles to his office from a homeless shelter. When I asked Dr. Marker what keeps him going after a rough day, he admitted that sometimes he wondered if it was all worth it. But then he added, "And then you go into the next room and you have a little old lady give you a big hug and you're ready to go again."

Click here to watch my interview with Dr. Marker.

Jon LaPook, ACP Member

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Health reform comes to pass

In the end, health care reform passed not with a bang, but a whimper. The House had to revote on the reconciliation bill after two procedural points were raised in the Senate. But health care reform is the law of the land. Whose wisdom was right, Democrats or Republicans? (NPR, SG2)

--There's still uninsured patients in need of coverage;
--New doctors eschew private practice for hospital salaries;
--President Obama still needs to sell the merits of the plan to businesses, legislators and to the public. (Kaiser Health News, New York Times, USA Today, Washington Post)
Thursday, March 25, 2010

QD: News Every Day--Health reform fixes hit minor snag

Health care reconciliation heads back to the House after opposing Senators found two parliamentary points in debate in the Senate overnight Wednesday into Thursday. These sticking points in the "fix-it" bill involve education grants, are minor, and not expected to permanently disrupt changes sought in health care reform legislation signed into law earlier this week. The Senate is also expected to continue parsing out other amendments today. (Politico, The Hill)
Wednesday, March 24, 2010

Consider a Doctor Who's Not a "Preferred Provider"

This post by Alan Dappen, MD appeared at Better Health. Dr. Dappen founded Doctalker Family Medicine, which is discussed in this article.

Many companies and consumers are turning to higher-deductible health care plans in order to keep their insurance policies more affordable. The rational basis of these plans is that since you're using your money and you are in control, you will pay more attention to what is really being offered to you as well as to the cost relative to value. You will be more likely to challenge your doctor to provide the rationale for an expensive test or drug, and to encourage your doctor to innovate to provide lower-cost alternatives.

A trap of these new health plans, as currently structured, is that you're herded into in-network preferred providers. The rationale of the insurance company is that they can control doctors' prices, thus brokering a better rate for you. They also want to use your loyalty to the network to control physicians' practices. "Preferred," in reality, does not refer to quality; rather, it just means the doctor has signed an agreement with the insurance company, binding them to the insurance company rules, which favor the insurance company, not the patient.

In most cases, there are good reasons to go out of network for your day-to-day health care. First of all, insurance companies place strict rules on their in-network providers. For example, in-network providers can't be paid without an office visit, so you're forced to come to their office for everything, even though evidence shows that office visits are required for less than half of primary care problems. Second, all medical information the in-network provider receives on you is sent to the insurance company. Insurance companies often will use your health information to justify denials of future care. If you want to protect your confidentiality, don't go through your deductible. Finally, if you find a doctor who works outside the network, these providers may be able to work more efficiently, with greater access and convenience for the patient, while charging the same or lower prices than the discounted rate provided by the insurance company.

However, most people are reluctant to go outside the network, because they fear it will result in higher cost. Insurance companies warn that if you go to a physician 'outside the network' the value of your deductible will double, for example, instead of a $2,000 deductible, it could be $4,000. This makes it look like going out of network could increase your costs by $2,000.

But, in fact, for primary care physicians, this logic does not apply. Why is that?

1) There are an increasing number of doctors who are providing primary care at a much lower cost rate than the standard model, either by avoiding the administrative burden of the insurance system, or by finding more efficient ways to provide care.

2) Most out of pocket costs are not actually to see your family doctor or other primary care providers. Most of the expenses go for laboratory tests, medications, emergency room visits and specialist consultants. For these, you may indeed want to stay within your preferred provider network to capture the discounts on these major costs. But your out-of-network physician can order these for you, and you can still get the discounts.

3) Primary care visits with a physician average $400-500 per year; lower-cost innovators like Doctalker Family Medicine, who charge based on time, rather than diagnosis, and avoid insurance-related expenses, and use modern information technology, can provide that service for $300 per year. This is thus a small percentage of the deductible.

4) Out-of-network physicians can provide other qualities worth any small difference in price, like convenience, accessibility, patient education, high knowledge base, tailoring care to your needs, patient control.

5) Many out-of-network providers can use their flexible situation to hunt out low-cost options for other elements of your care, such as X-rays, labs, etc., that may be significantly cheaper than the negotiated rate of your insurance company.

6) In many years, you won't go through your deductible, so you won't move into insurance coverage anyway. When you do go over the deductible, it is usually because you have had some major health problem, an accident, a surgery, etc., and then the difference in deductible qualification won't make any difference. You will go far over the deductible. For example, an ER visit could easily cost $2,000; a typical one-day hospital stay costs $10,000.

7) In many insurance plants, numerous types of care are not eligible to be counted towards your deductible anyway, such as vaccines, travel medicine or weight control.

The bottom line: don't be distracted by the deductible. Your health is too important. The most important criteria for choosing your primary care doctor should be competence, access and trust. Primary care accounts for such a small percentage of your total health care costs, that you shouldn't worry about whether he or she is a preferred provider; this might impact the quality of doctor you choose. Plus, you may even save money by going out of network.

Until next week, I remain yours in primary care,
Alan Dappen, MD

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--The 'single-pen' theory

Counts the pens. News reports said that the president signed health care reform into law with either 20 (The New York Times) or 22 pens (Everyone else). The White House posted the ceremony at YouTube so you can count for yourself, starting at 25 minutes into the 27 minute ceremony, when Mr. Obama quips, "This is going to take a little while."

The pens hits the page 22 times. But there's only 11 letters in "Barack Obama" (add seven more for his middle name) so he's clearly having to sign partial letters.

There's a long history to this practice, which creates historical artifacts and gifts. President Kennedy used his middle name and flourishes to stretch things out. President Lyndon Johnson used 75 pens to sign the Civil Rights Act, with one of the first going to Martin Luther King, Jr., and then key legislators. Here's a list of who'll get the 22 pens. (New York Times, Los Angeles Times, TIME, Washington Post)
Tuesday, March 23, 2010

QD: News Every Day--Who will cover 32 million more patients?

Debate continues today in the Senate on the fixes to health care legislation that passed in the House Sunday night and was signed just before noon today by President Barack Obama.

Concerned over getting stuck with supporting federal legislation, states attorneys general are gearing up to litigate a halt to the new law while opposition continues to drag out the fix-it bill's progress through the Senate. (New York Times, Reuters, Los Angeles Times)

Drug makers won, device makers lost, hospitals win, but nursing homes lost, primary care doctors get a pay raise for delivering some types of care but overall, other doctors didn't win or lose. (Chicago Tribune, Kaiser Health News)

Reform covers 32 million more Americans, but where will they seek care? Physicians could (not should) increase their caseloads to 40 patients a day. But also accepting this surge of patients will be hospitals, free clinics and physicians' medical assistants. So, internists in the second half of this report explain their thoughts on training more primary care doctors. (KABC TV, Daily Record, TCPalm, WIS TV, WCVB TV)
Monday, March 22, 2010

Six Reactions to the Health Care Reform Plan

This post by Evan Falchuk, JD, appeared at Better Health.

Since the 2000 Presidential election, and most especially since the world-changing events of October 17, 2004, I've known this: Don't assume anything is over until it's over. I'm going to give you my six quick reactions to the health care reform plan:

1. It's Historic. It is, but mostly because people keep saying that it is. I mean the President of the United States has gambled most of what he's got on this, so it's one for the history books in that sense. Still, a health care program that was truly historic would be something like taking all of the uninsured and just enrolling them immediately in Medicare. This plan doesn't come anywhere close to doing that. Much of what is meant to deal with the serious problem of the uninsured doesn't start for years, and is going to be handled through a complicated mechanism that may not even work. I suspect the history-making part of this will have to do more with the political fortunes of the Democrats and President than American health care.

2. Talk to Benefits People Who Have Messed Up. You know who the President really ought to talk to now? It's private-sector executives who have presided over botched implementations of new employee benefit plans. Because their experience at how to repair damaged relationships with people are what he needs.

Why? Because what happens is that management decides to put in some new benefits plan that will save the company money and which they just know employees will like once they understand it. So they don't spend a lot of time worrying about how the changes are going to play with employees. The trouble is, people take their health benefits very seriously. Anything they think will affect them creates a lot of anxiety, and failing to communicate well makes it much worse. Sound familiar? It's very much what's happened here.

3. It's Not Over. That's right, it's not. Congress is going to be taking up the so-called "doc fix," which is another multi-hundred billion dollar federal health care expenditure. The same issues we've been talking about for a year are going to get dredged up again. And again. And again. Plus we've got an election coming up. Barring some major international catastrophe, we'll be stewing in the juices of health care reform for many more months to come. And you know, if the Republicans somehow manage to take Congress, this could go on right until 2012. I wonder if President Obama really wanted things to go this way.

4. It's Not a Left-Right Thing. It's not. Sure, the existing infrastructure of the culture war has grabbed hold of reform and is riding it. But Republicans opposing the plan should learn from Massachusetts. Don't confuse the fact that you are saying things people like for a shift in support for your culture war causes. There is a glimpse of this in the last minute wrangling over abortion. While that's an important issue for a lot of people, it's not what public anxiety over reform is about. So if, for example, Republicans decide to make abortion a big part of their strategy going forward, they shouldn't be surprised when they find there aren't as many people behind them as they expect.

5. Health insurance regulation is now federal territory. Little-noticed (well, except by me) is the fact that Congress has repealed the anti-trust exemption for health insurance and that the reform plan sets up the basics of a federal infrastructure for insurance regulation. The federal government doesn't just drop by and visit, they move in. Memo to state insurance regulators: the feds are outside, and they have a HUGE moving van.

One day we'll all be able to tell our kids we lived in a quaint time when we used to regulate health insurance in the states. Our kids will laugh. Actually, strike that. They'll wonder why we thought it was interesting to tell them that.

Some state attorneys general say (on Facebook, no less) they're going to mount some kind of (sure to fail) challenge to the bill. Too little, too late.

6. Elections matter. I don't think the reform plan is a good idea, but we live in a democracy and the other side won. Good for them. Now, once the President signs it, the reform plan is law--not Democratic or Republican law, but American law. For those who don't vote or those who do, for those who don't get involved in politics or those who do, the success of the reform plan is a tremendous lesson: Elections matter.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

House passes health reform, now Senate will mull fixes

Health care reform passed the U.S. House of Representatives Sunday night.

The legislation will:
--limit physician ownership of hospitals,
--mandate that individuals obtain health insurance,
--cover 32 million more Americans,
--establish a health insurance “exchange,”
--close Medicare's doughnut hole and expand Medicaid,
--prohibit lifetime caps on insurance policies, and
-- prohibit denying care and coverage for pre-existing conditions.

While the bill itself goes to the White House for signature by the president, negotiations will renew Tuesday when the Senate takes up discussion on a companion bill with fixes.

ACP President Joseph W. Stubbs, FACP, applauded the measure, while ACP Members Kevin Pho (aka KevinMD), and Manoj Jain, MD, of Memphis, Tenn., offered their reactions to the legislation.
Friday, March 19, 2010

Does Pay for Performance Improve Health Care Quality?

This post by Evan Falchuk, JD, appeared at Better Health.

The Jobbing Doctor, a primary care doctor in the U.K., writes about the British version of what Americans call "Pay for Performance," or "P4P."

He says something I've said many times before (like here, here and here), which is this: Incentives fail because they try to treat medicine as an assembly line process when it's not.

But what's most interesting about his post is that it could have been written by a doctor from anyplace on the planet Earth.

The Jobbing Doctor talks about a U.K. program that started in 2004 called the Quality and Outcomes Framework, or "QoF." Now, the American "P4P" is a much more catchy name, so score one for American marketing. But it doesn't matter what you call it, that which we call a rose would, by any other name smell as sweet.

Or, as in this case, as sour.

According to the Jobbing Doctor, QoF has actually increased costs (or at least doctors' income; he says it went up 33%) because the government seemed to have underestimated the extent to which doctors were already delivering high quality primary care. He also notes that because the guidelines are so crude and so focused on certain illnesses, there are incentives to meet targets rather than understanding a patient's medical condition. It's pretty much the opposite of what doctors are taught to do in their training. And his complaints about QoF sound very similar to complaints from doctors in other countries about the impact of such well-meaning efforts by government and private industry.

Which is the larger point.

As Jobbing Doctor put it so eloquently, measures like these distort the practice of medicine and take it away from what is really important:

The other downside is that ideas like the QoF diminish a profession's values and judgments, meaning that high quality care is not driven by an internal motivation for doing a good and valuable job well, rather we have to be driven by targets. Targets are the antithesis of professionalism.

So, yes, the quality of medical care needs to improve. But how you define quality is the first question that must be answered. If I'm sick, I want my doctor motivated and paid to do "a good and valuable job well."

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Sunday House vote may set up Senate next week

In advance of the anticipated House vote to pass health care reform on Sunday, Democratic legislators are "jittery" about the measure. Republicans are playing that up and pressuring their colleagues across the aisle. President Barack Obama is applying counter-pressure.

It's far from the end-game that it's been called. Once the House votes, the package heads back to the Senate, which will take up the measure in that legislative body's "deliberative" way. Republicans are threatening endless procedural delays; Democrats counter they can address any procedural points.
Thursday, March 18, 2010

QD: News Every Day--Spend more to save more

Health care reform will cost more than previously predicted, $940 billion, but also trim more from the federal deficit in the long run, $130 billion in the first 10 years and $1.2 trillion in the second 10 years, the Congressional Budget Office is reporting. The release of those figures sets up a 72-hour window for legislators to consider the bill, and vote possibly by Sunday. (Politico, Washington Post)

H1N1 influenza
New cases continue for H1N1 influenza; 2 million illnesses hospitalized 18,000 and killed 310, according to CDC figures for mid-January to mid-February. Apathy is spreading faster than the disease and the flu season can continue until May, so health officials seek novel venues to encourage vaccination. (WebMD, Chicago Tribune)
Wednesday, March 17, 2010

Insurance Companies Should Pay Primary Care Physicians More

This post by Kevin Pho, ACP Member appeared at Better Health.

I've often given doctors too little credit when it comes to business decisions.

But, in an op-ed published at Reuters, physician Ford Vox argues otherwise.

He notes that doctors, indeed, have tremendous business sense: "How can anybody say that doctors don't have business sense, when not only do most American physicians forge their way in small private practices, but new doctors lay their cards on the table every year? The competitiveness of residencies, where doctors train to become a pediatrician or a cardiologist, correlates strongly with the field's earnings potential."

Insurance companies usually intercede when it comes to financial transactions between doctor and patient.

Instead, why not let doctors have more control over health care dollars, instead of wonks and administrators who have little clinical experience?

Health insurers use nearly one-third of premiums before spending on health care delivery. Dr. Ford contends that, "It's time to boost the rank and responsibility of primary care physicians by handing them the source of insurance company power--the money."

Government officials and health insurers pay constant lip service to the importance of primary care. The only way to truly back up their words is to ensure primary care has the adequate financial resources and independence to do its job properly.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Health care reform amid rising consumer costs

As clashes continue over using a "deemed passed" procedure to avoid a formal vote on health care reform legislation, business groups are pressuring Democrats who are fence-sitting as party leaders shore up support. (New York Times, AP, Wall Street Journal)

Meanwhile, to offset declining Medicare reimbursement, one California cardiology practice instituted annual fees for unreimbursed items such as notification of test results. The practice instituted three tiers of service, ranging from $500 annually for in-office pro-time and warfarin adjustments and pacemaker follow-ups, $1,800 for priority appointments and e-mail communication, to a concierge option for $7,500. Patients who do not choose one of the three tiers will receive medically needed services, but have to schedule an office visit to discuss non-urgent test results, for example. Consumers face these and similar increasing extra health care costs more often. For example, Medicare's prescription doughnut hole affects seniors at a time when prescription prices are outpacing inflation. (Kaiser Health News)
Tuesday, March 16, 2010

QD: News Every Day--When did voting become passe?

A tally shows the House is struggling to muster enough votes to pass health care reform by a simple majority. The president and House leaders are trying to muster enough votes to pass it, but House representatives either oppose it, or are feeling the pressure from all sides and across the country. (CNN, AP, The Hill, Albany Times Union,

With the decision being so polarizing, House leadership is looking to relieve the pressure. Votes? Who needs votes? Representatives don't even need to vote on legislation any more to pass it. (Washington Post)
Monday, March 15, 2010

QD: News Every Day--Health reform vote by the weekend

A vote on health care reform could come this weekend, with the House members considering whether to pass the Senate's version and then a bill of budget changes. House members are leery of the upper chamber's following through. The Majority Whip is trying to ensure there will be enough votes for passage. Abortion, immigration and costs remain key sticking points. Both sides are applying pressure to those on the fence, and Republicans are trying to make sure Democrats pay a price for victory. (Wall Street Journal, Washington Post, Fox News, Los Angeles Times)

The impact from this weekend's vote will play out over the next decade. Primary care doctors will see a 10% payment boost from Medicare for their office, nursing home and other outpatient visits. Medicare also plans to pilot accountable care organizations that reward primary care doctors for managing multiple chronic illnesses. Doctors and hospitals would band together for payments, similar to a "Mayo Clinic model." (AP) [Editor's note: This post originally stated the legislation applies to rural and inner city physicians. It applies to all physicians for the three conditions stated above.]

Medical News of the Obvious

At first, the results of this study seemed totally unobvious. Researchers found that people didn't lie any more often when online dating than they did in person, reported HealthDay. Really? This finding immediately led me to wonder how many daters are wearing platform shoes and compression garments on their in-person dates.

But then it turns out the methodology was to ask people whether they lied. Mightn't the liars be likely to lie to the surveyors, too?

Regardless of whether you believe them, most of the findings were pretty entertainingly obvious: older people lied more about their age, more "extroverted" people (ahem) lied more about their past romantic experiences. And interestingly, men lied more about "how nice and polite they are," according to a study author. Can you picture that? "I told her I open doors for women, and really I never do. Heh heh."

So what's the big conclusion we can draw from all this research? Hold on to your hats. "Online daters, speed-daters, and the like seem to be just like the rest of us in most ways," said the study's author. Does that mean that the people you see on the computer are also people in real life? This is going to require further investigation.
Friday, March 12, 2010

QD: News Every Day--Considering health care reform, and the uncertainties of medicine

Democratic legislators want at least a week to consider elements of health care reform, as they parse out language over abortion, federal subsidies and regulating insurers. (Los Angeles Times, AP)

The Byzantine rules of passing legislation have left House representatives in the position of having to trust their colleagues in the Senate to follow through on their promise to fully reconcile health care reform goals, not just use reconciliation to pass it. Yet, they don't fully do so. (The Hill)

Literature in medicine
Book clubs in the workplace are common, and now, they're extending into the hospital. Literature in medicine programs are growing, and medical staff say a background in the humanities helps them deal with the messiness and uncertainty of practicing medicine in real life. (AP)
Thursday, March 11, 2010

QD: News Every Day--Federal action leads to states' reaction

Congressional leaders and the White House will introduce health care legislation's latest incarnation to the entire Congress today. Immigration reform and abortion remain sticking points for some Democrats. (AP, The Hill, New York Magazine)

Meanwhile, Virginia's legislature passed a bill that would exempt that state from federal health care reform. It's the first state to reach this point, and legislators recognize their action as symbolic. But 34 other states are lining up to fight state recognition of federal law, setting up a Constitutional debate, albeit a short-lived one. (New York Times, WTVR of Richmond, Va., University of Missouri-Kansas City School of Law, New England Journal of Medicine)
Wednesday, March 10, 2010

QD: News Every Day--The end is in sight (until later)

The Senate voted today to delay until September 30 Medicare's 21% reimbursement cut. The legislation also extends federal financial assistance for state Medicaid programs for six months and COBRA and unemployment insurance benefits through all of 2010. (Modern Physician)

For the broader issue of health care reform, Democrats are trying to build a majority for the final push, while Republicans hope to capitalize on the divisions as well as create procedural roadblocks to the reconciliation process that might be used to pass it. (Christian Science Monitor, Washington Post, New York Times)
Tuesday, March 9, 2010

Coffee and the Heart - Researchers are Getting Paid Way Too Much to Rehash Old Data

This post by Westby Fisher, MD, originally appeared at Better Health.

This week, coffee seems to be good for the heart: "People who are moderate coffee drinkers can be reassured that they are not doing harm because of their coffee drinking," said Arthur Klatsky, the study's lead investigator and a cardiologist at Kaiser's Division of Research.

These "surprising" data were presented at the American Heart Association meeting on March 5th.

Valentine’s Day Coffee by Damian Cugley via FlickrBut a quick Google search on Dr. Klatsky's earlier studies using the same questionnaire database shows the problems with using questionnaire data to make such sweeping conclusions. Take, for instance, these findings from 1973: Coffee drinking is not an established risk factor for myocardial infarction.

And yet a bit later, in 1990, there's a flip flop: Because of conflicting evidence about the relation of coffee use to coronary artery disease, the authors conducted a new cohort study of hospitalizations among 101,774 white persons and black persons admitted to Kaiser Permanente hospitals in northern California in 1978-1986. In analyses controlled for eight covariates, use of coffee was associated with higher risk of myocardial infarction (P=0.0002). (By the way, British researchers failed to find a similar correlation in instant coffee drinkers.)

So what, really, do these data from the Kaiser questionnaire data regarding heavy coffee consumption and the heart say?

What they say is:
1) Questionnaire data crunched to suggest correlations are insufficient to mean causation, irrespective of how the media parses it.
2) Questionnaire data are subject to significant sampling and reporting biases.
3) Rehashing the same old questionnaires using the same samples with newer data can dramatically alter prior findings.
4) Researchers are getting paid way too much to keep rehashing the same data for large health systems.
5) On the lighter side, college undergrads and medical students should note that they could use these types of questionnaire data to justify significant caffeine consumption along with alcohol to protect themselves from developing cirrhosis.


This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

What if Other Parts of Life Were Like Healthcare?

Health care is bizarre. Anyone who spends significant time in its ranks will attest to the many quirky and downright ludicrous things that go on all the time. But I am not sure people realize just how strange our system is. Perhaps it would be interesting to see what it would be like if other parts of our lives were like health care.

1. Get up in the morning

The first thing that happens in your day is that your alarm fails to go off. Although you have major things happening, nobody ever has explained to you exactly what you are supposed to do and when. You watch the morning TV show and it seems that some experts say you should go to school while others say you should avoid school at all cost. You call a friend who says that she knows someone who went to school and it destroyed their liver. Another friend goes to school every day and is just fine.

Tea leaves by by allaboutgeorge via FlickrConfused, you turn to the Internet and go to a Web site that explains that you should base your schedule on the pattern of tea leaves in a cup. This site claims that your normal schedule is actually fraught with secret appointments that will, unbeknown to you, make you have cancer. It states that those people in power are making you go through this dangerous schedule so they can make money off of you. They don't care for you like the people who made this web page (and for $400 you can have six months of magic tea leaves).

Finally, you decide that you are going to go with the majority opinion and go to school.

2. School

You go to your bus stop and wait. You keep waiting. You know that the bus was supposed to come at 8 a.m., but after an hour you begin to wonder if you missed it. Calling the bus service, you find out that the bus got caught up doing some extra routes. There is a shortage of buses, and so the ones that remain have to do twice as many routes as is feasible. After a two-hour wait, the bus finally arrives to take you to school.

The first teacher comes into the classroom and looks very distracted. She teaches general studies and is staring at a curriculum that contains a huge amount of subjects. As she is doing her lessons, she furiously takes notes on her own teaching so that she can submit documentation to the school board and prove that she taught you. This is the only way she gets paid.

In total, she teaches for about 15 minutes and documents her teaching for 45 minutes. You want to ask questions, but the bell rings and you have to move on to your next class before any can be answered.

The next teacher only teaches a small specialized subject. This teacher is paid four times more than the first teacher. Instead of teaching and answering questions, however, he is constantly making you take tests. Apparently, the school system pays a huge amount for making you take tests, but very little for teaching lessons that would make you do well on those tests in the first place.

School is finally over, but you don't feel like you got much out of it (except for taking a lot of tests and getting more confused). You decide that a trip to the store would perhaps make you feel better.

3. The grocery

Upon entering the grocery store, you notice something odd. There are very few different brands of items stocked on the shelves. Your choice is limited to only the brands that have struck the best deal with the grocery chain. These brands have to send the grocery store a large "rebate" check because they are carried exclusively in this store.

When you go to the meat counter and ask for some steak, the butcher asks you if you have first tried the ground beef. You may not purchase steak unless you have first tried and disliked the ground beef. The ground beef, of course, is actually ground turkey, but the butcher says that these two are basically interchangeable and so the substitution is permitted.

The grocer can't post prices because all customers have different negotiated prices. Posting prices, in fact, would be considered collusion since other grocers could find out exactly what this grocer is charging. Some congressman in California decided that grocers are all crooks and should not be allowed to share what they charge for things.

You go to the cash register to pay. The total is $380, but the cashier informs you that your negotiated price is only $150. A poor person behind you has not had the chance to negotiate a price and so must pay full price for everything.

There are a few people in the store who don't have to pay anything. They have had the price negotiated for them by the government, and so will come to the store very often. They sometimes come for real food, but are often coming for candy and cigarettes--all paid for by the government.

This experience leaves you more tired and confused, and so you decide to go home.

4. Home

Coming home, you notice that your house is under construction. There is a new wing being built that contains all sorts of the newest and fanciest gadgets, such as flat-screen TVs, the fastest computers, and wonderful new kitchen appliances. Going into the house, you notice that there is no running water or heat. Apparently, there are all sorts of grants and low-interest loans to pay for the fancy gadgets, and so contractors find it much more profitable to do that instead of fixing water or heating.

Your mother is in the kitchen trying to make dinner, but instead of cooking she is staring into a cookbook and at the ingredients you brought from the grocery store. You assume she can make do with what you brought, but she just sighs helplessly. Despite the fact that your mother is incredible at improvising meals, she is required to follow a cookbook that doesn't fit the ingredients that are available. This makes dinner taste pretty bad. Your mother, obviously angry about this, gives you a weak smile and tells you to finish what is on your plate.

After dinner, you settle down to watch some television. As you are finally starting to relax, a knock on the front door breaks your peace. At the front door stands a police officer. "You are only authorized to be in the house for two hours today, so I am going to have to ask you to leave."

You try to explain that two hours is not enough to get the rest you need, but the officer threatens a stiff fine and forces you to leave. Before you can get your necessary things, you are forced to leave without an explanation of how you are supposed to survive on the streets.

If it doesn't make sense in real life, how can it make sense in medical practice?

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

QD: News Every Day--Reform rhetoric heats up

All eyes are on the bully pulpit as President Barack Obama begins stumping for health care reform. His talking points include rising insurance rates, legislators who fear election repercussions, and those who would politicize the process. (New York Times, Los Angeles Times, USA Today)

But the Republicans plan to capitalize on the later two points. If it passes, they'll use it during their own stump speeches during the fall Congressional campaigns. They'll focus on the short-term pain--have people's health care costs fallen by election time--and not the long-term gain. (MSNBC, Politico)
Monday, March 8, 2010

Is Chronic Fatigue Syndrome Caused By Retroviruses?

This post by Harriet Hall, MD, originally appeared at Better Health.

When I first heard that a retrovirus had been identified as a possible cause of chronic fatigue syndrome, I withheld judgment and awaited further developments. When I heard that two subsequent studies had failed to replicate the findings of the first, I assumed that the first had been a false alarm and would be disregarded. Not so.

It's a classic case of wishful thinking outweighing good judgment. One unconfirmed report of an association between the XMRV virus and chronic fatigue syndrome (CFS) resulted in a rush to test for the virus, speculation about possible implications, and even suggestions for treatment. And the subsequent negative studies did little or nothing to reverse the trend.

XMRV is Xenotropic murine leukemia virus-related virus. In the past, there were reports that this retrovirus was associated with prostate cancer, but then other reports found no link. In 2009 a study was published in Science, Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome by Lombardi et al., reporting an association with CFS:

We identified DNA from a human gammaretrovirus, xenotropic murine leukemia virus-related virus (XMRV), in 68 of 101 patients (67%) as compared to 8 of 218 (3.7%) healthy controls.

Later, the researchers reported that up to 95% of CFS patients test positive with antibody testing. The study did not prove a causal relationship. The authors suggest that the retrovirus may reactivate other viruses, such as herpes viruses (the opposite is also possible). There could be many different viruses behind CFS/ME. And it could be that XMRV is an incidental finding secondary to the immune dysfunction in CFS/ME. Two subsequent studies in the UK, here and here, also looked for the virus in CFS patients but both failed to find it.

CFS is still a controversial diagnosis. Some observers have implicated psychological factors and somatization. Sufferers are on the defensive, wanting to validate CFS as a real physical entity. The finding of a virus was just what they were hoping for. They want to believe in it, and their emotions have clouded their judgment.

A battle has erupted between retrovirus believers and non-believers, each side attacking the other's research and accusing them of bias. Some of the criticisms are based on virological laboratory procedural details that I am not competent to judge. Some of the other criticisms are about things I can understand.

The Science study came out of the The Whittemore-Peterson Institute. This institute was founded by a couple (the Whittemores) whose daughter had CFS and who was treated by Dr. Peterson with an experimental antiviral drug. They are clearly biased towards finding a viral etiology. The researchers in the UK were similarly accused of bias towards finding a psychological etiology. Accusations of bias may be credible but don't necessarily mean that the bias contaminated the results. Another criticism is less credible: the UK studies used a different set of criteria for diagnosing CFS. Even if you think that some of the UK subjects didn't qualify as having CFS, if even a few of them had CFS and the virus was really associated with it, the virus should have shown up in at least a few subjects. Critics have tried to rationalize away the negative findings in the UK by suggesting that the virus occurs regionally and is absent in the UK; but then if the virus were the cause of CFS, there wouldn't be any CFS in the UK.

So far we have one study for and two against the association of XMRV with CFS. More studies are underway that should settle the debate. If the virus is there, it will be found by other labs and a consensus will eventually develop as to whether there is an association. If an association is confirmed, there will still need to be further research to determine what the association means and whether there is a causal relationship. The logical response is to stay tuned, not to leap prematurely into testing and treatment.

Tests are already commercially available. One is offered by VIP Diagnostics, a company owned by the Whittemore family. It costs $450 and uses the same methods as were reported in the Science article. The website discloses that the tests have not been approved by FDA for diagnostic purposes and that medical expertise is required for test interpretation. The lab pays a royalty to the Whittemore-Peterson Institute for each test it performs.

In his Nov. 3, 2009 Lyndonville Times newsletter, Dr. David Bell offered this cogent advice: "I am reluctant to suggest to anyone that they spend big bucks for a commercial test now. We do not know if a particular test is accurate, and even if it is accurate we do not know what it means, and even if we did know what it meant we would not know what to do with it."

That pretty much says it all. Nevertheless, patients are flocking to be tested. If they test positive, they can feel vindicated. If they test negative, they can rationalize that they may actually be positive but have a viral load too small to be picked up on the test at the moment; they might even rationalize that they are better off than if the test had shown a larger viral load. Win/win.

Antiretroviral treatments are already being proposed by some doctors. Most proposals are based on the drugs used for HIV/AIDS, on the assumption that antiretroviral AIDS drugs would be equally effective for the XMRV retrovirus. But that might well be a false assumption, and these are powerful drugs with worrisome side effects, not the sort of thing that you would want to try "just in case."

Other concerns have been raised by the CFS community. Is XMRV sexually transmitted like HIV/AIDS? If you have chronic fatigue syndrome or another XMRV-related condition, should you take special precautions with your sexual partners, even if you're in a committed relationship? Should you opt for not breastfeeding your children? Should you not even have children?

I can understand the desperation of these patients. I can understand their need to believe anything that would validate their suffering. I can understand their motivation to try anything that might bring them relief. But I don't want to see people wasting money on useless tests, I don't want to see mothers unnecessarily worrying about whether it is safe to breastfeed their children, and I don't want to see people suffering side effects from drugs they don't need. A cautious wait-and-see approach is dictated by common sense and by an understanding of how often initial scientific research findings turn out not to be true. Like remarriage after divorce, the overblown enthusiasm for the XMRV/CFS connection is a triumph of hope over experience.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Health care reform's "endgame" All the talk is of the endgame to health care reform. You'll find the word used repeatedly as the fourth column discusses the timeframe, strategy and roadmap how to finish the legislation. ACP Internist points out that even if passed, future legislators can continue the game year after year. It's the sport of kings.

Medicare pay cut
Primary care doctor William Schreiber, MD, broke down his practice expenses and figures the pending 21% Medicare pay cut would leave him with the equivalent pay of a minimum-wage job. The pay cut has been pushed back until the end of the month. (CNN)

Medical News of the Obvious

You might already be aware of this week's finding if you've watched baseball in the past decade or so and noticed that Mark McGwire's arms are about the circumference of the average ballplayer's waist in the 70s. But just to be sure, researchers recently compared the BMIs of professional baseball players from 1876 to 2007 to find that, like serving sizes and master bathrooms, they've gotten bigger.

Clear, right? But in taking the next step, drawing conclusions from this study, this article from HealthDay gets about as confused as a science article can be. The study authors are concerned because they correlated the ballplayers' "increased BMIs with an increased risk of death." (We're assuming that's a risk of premature death, since it seems pretty certain that the 1876 team would be dead regardless of their % body fat.)

But a critic of the study argued first that ballplayers' increasing size is not a health risk, and then that the players might be dying early because they're using steroids. Um, we're not scientists, but mightn't there be a relationship (even a causal one, perhaps?) between steroid use and increased BMI?
Friday, March 5, 2010

QD: News Every Day--Ratcheting up the pressure to pass reform

The push is on to pass health care reform. The president is using his bully pulpit as opponents push back, targeting members of Congress who could for it or against. (Los Angeles Times, Washington Post, NPR, Politico)

Primary care shortage
Government support of medical school education is falling, and medical colleges are shrinking their enrollments and raising medical school tuition to make up for the huge shortfalls. (USA Today)
Thursday, March 4, 2010

QD: News Every Day--President resigned to reconciliation

ACP Internist continues its daily wrap-up of current events affecting internal medicine.

Health care reform
Citing the Children's Health Insurance Program and COBRA unemployment health coverage as examples, President Barack Obama called on Congress to pass health care reform using reconciliation. Those two health programs used the legislative tactic to secure passage. Senate Minority Leader Mitch McConnell said health care reform was bigger legislation, and "Big legislation always requires big majorities." (Washington Post, Wall Street Journal)

Haitian earthquake relief
The overwhelming wave of trauma victims has dwindled to a trickle aboard the USNS Comfort, the military hospital ship anchored in the harbor of Port-au-Prince, Haiti. Civilian doctors want the ship to stay to handle what they describe as a second wave of treatment--resetting poorly healed fractures and remaining public health issues. The Navy has not decided what the Comfort's future mission might be, if any. Read reports of the challenges internists faced while aboard the ship. (Baltimore Sun, U.S. Navy, Annals of Internal Medicine)

U.S. Navy photo by Staff Sgt. Loobens Alphonse/ReleasedLt. Yonnette Thomas, Officer in Charge of the Center for Information Dominance Learning Site in Norfolk, translates between Haitian patients and a delegation of visiting physicians from Colombia aboard the USNS Comfort.
Wednesday, March 3, 2010

Chasms and comparisons covered by Carolyn Clancy

As one would expect from such a diverse group, comparisons were a common topic at the co-located National Medical Home Summit, National Retail Clinic Summit, and Population Health and Disease Management Colloquium this week.

During an opening session, Carolyn Clancy, head of the AHRQ, updated us on some of the comparison work her agency has been doing. Last year's stimulus bill dedicated a lot of funds ($300 mill directly, more through the Secretary of HHS) to the agency's work on comparative effectiveness.

But there's still a long way to go, according to Dr. Clancy. "We're a little bit slow to translate scientific advances into clinical practice," she understated. The good news is that in recent years there have been steady declines in the "quality chasm" between guidelines and care actually provided. If the current pace continues, Dr. Clancy said, "my top statistician tells me it will take 20 years to close the gap between the highest quality care and that which gets delivered."

Her agency's trying to spend that effort along by providing info for patients about evidence-based care, supporting research to gather needed evidence, and scanning the horizon to see what questions are likely to come up next. There's a particular need and effort to figure out the best practices for narrower patient groups (such as the 9% of diabetics with no comorbidities, for example), she said. And for those who worry that comparative effectiveness could lead to rationing, she reassured the audience that the agency's findings are meant to be "descriptive not prescriptive."

QD: News Every Day--Medicare cuts delayed by 30 days

Medicare reimbursement cuts have been delayed for 30 days. (Nowhere else in our country's economy would someone's paycheck be bandied about like this.) The same legislation, actually a jobs bills, also extended the time that the federal government will pick up some of the tab for COBRA health insurance. (Health Leaders Media, Los Angeles Times)

As mentioned in yesterday's edition, the president plans to siphon off some Republicans by incorporating a few of their ideas. He might need them to counter Democrats who opposed health care reform legislation, but Republican leadership scoffed at the idea of breakaways. (ACP Internist, Washington Post, Politico)

H1N1 influenza
H1N1 influenza took an unexpected course in its timing and severity. Novel pandemics are different than seasonal flu outbreaks, explains those who tracked its course. And seasonal flu was mild this year, too. (Wall Street Journal, Pittsburgh Tribune-Review)

In case you missed it ...
W.G. Watson, MD, is a 100-year-old practicing obstetrician. One baby he delivered grew up to become his practice's partner, as a matter of fact. (CNN)

Tuesday, March 2, 2010

QD: News every day--"Final act" for health care reform?

In a letter today to congressional leaders, President Obama said he is exploring four ideas proposed by Republicans at last Thursday's health summit, including using undercover clinicians to track down Medicare/Medicaid waste, allocating $50 million in federal funds to help states retool methods of dealing with medical malpractice lawsuits, increasing state Medicaid reimbursement to doctors, and expanding access to health savings accounts and high-deductible plans. The White House press secretary said today that the health care reform debate is in its "final act." President Obama is expected to release his revised health care plan tomorrow. (New York Times, Washington Post, LA Times)

Meanwhile, a jobs bill introduced in the Senate would put off Medicare cuts to physician reimbursement until August. (MedPage Today)

One expert's view on the prospects for reform

This week I'm attending the co-located National Medical Home Summit, National Retail Clinic Summit, and Population Health and Disease Management Colloquium here in Philly. (If only they had invited the transitions of care folks, they could have covered every hot-button issue in medical practice.)

The opening lecture, by Health Affairs editor Susan Dentzer, was meant to be an overview of health system change, but not surprisingly, the focus was on one obvious potential source of change--pending health care reform legislation. She saw the major accomplishment of last week's summit as convincing the "three or four people who might have believed in a bipartisan solution" that it wasn't going to happen.

She rated the chances of Obama's new reform plan passing at about 50-60%. One of the major stumbling blocks will be abortion coverage, she predicted. Obama's proposal adopts the Senate's provision, which would allow abortion coverage in the new health exchange plans, as long as it was paid for out of a separate premium, not government funding. (In other words, women who want to be covered if they have an abortion would have to write two checks every month, Dentzer explained.) House members who inserted a provision banning coverage of abortions might balk at that.

Dentzer put her bad news for the other side of the political spectrum poetically. "It looks like the public option is dead even if the body is still twitching and may continue for the next few weeks."

As for the mass of the populace in the middle, they continue to be confused about what they want, Dentzer said. She reported on a Kaiser survey completed in Massachusetts the day after Scott Brown's election. 68% of the respondents said they supported Masschusetts' universal coverage system, but 48% opposed national health reform, which would basically expand the Massachusetts model to the rest of the country. Hunh?

Whatever happens with the current legislation, the pressure will still be on those in the industry to reform health care to deal with the major problems of cost, quality and access, Dentzer told the audience of health care business leaders.
Monday, March 1, 2010

Once Upon A Time

AUTHOR'S NOTE: I am very frustrated with a system that increases cost dramatically and yet reduces what I get paid. The rest of the money is going somewhere, and since it is not improving the overall quality of care, it is mostly waste. We are enamored with MRI scans, stents, and expensive cancer treatments, with little to show for them except increased expenses and a lot of third parties getting rich off of this waste: drug and device manufacturers, medical imaging companies and other para-healthcare industries. This story, which originally appeared at Musings of Distractible Mind, is prompted by my frustration with waste and how it spurs unneeded health care delivery.

Once upon a time there was a land on the ocean. The people lived off of the food from the ocean and were very happy. But as they grew bigger, they had a problem: They made a lot of waste! Yuk! Nobody likes waste. What could they do about all of this that stuff that nobody needed?

Santa Cruz West Cliff Today by veeliam via FlickrSome said that they should find a way to make less waste. They said that the people of the land were not smart and should be making less waste. But most of the people in the land didn't like to change what they were doing. It's hard to change. So they built a large pipe that pumped the waste into the ocean.

The land was clean again and the people were happy!

As time went on, they had to build more and more pipes to handle their waste. Nobody ever tried to make less waste because they could just make more pipes and pump it into the ocean. This even built a very successful industry of pipe-workers. This helped the economy.

But then one day something terrible happened. The pipes pumping waste killed off several species of sea life. This made the environmentalists in the land cry out in protest. But as it stood, the number of species in the ocean were so vast that the killing off of a few of them was felt to be no harm. So the pipes kept pumping. The people still could be happy with a few less species.

And then came a day when something magical happened. New species of sea creatures formed around the pipes. These creatures fed off of the waste and thrived around these pipes. These new creatures became very big and very fancy, and this made the people of the land very happy. What were the environmentalists all worried about? So what if a few species had died off; there were new exciting species being formed! The people were so excited that they made even more waste and more pipes so they could make more new species of sea creatures.

What fun!

Now, these fancy new creatures were hungry. They ate all of the waste and wanted more. They ate most of the other sea animals and wanted still more. They couldn't get enough food. So they sent lobbyists to the government of the land to get them to build more pipes and send more waste. The creature lobby was very rich, and so poured lots of money at the government of the land. This made the politicians very happy. So the happy politicians told the companies of the land to make more pipes and send more waste out to the sea. And the sea creatures were happy.

And so it went for many years: more pipes sending more waste making more fancy sea creatures eating more waste sending more lobbyists to make politicians get more companies in the land to build more pipes. Everyone seemed to benefit from this nice arrangement! Maybe they'd be happy forever!

But one day, some of the people of the land got tired of putting all of their money into building pipes to send waste. They thought their land should stop making so much waste and start putting those resources into schools, food and fighting crime. The government was raising taxes more and more so that they could afford to make more pipes. This made these people mad because some people couldn't afford any more taxes. Paying for all of this waste was too much.

But the lobbyists from the sea creatures put commercials on television saying how good the waste was. In fact, having so much waste made the land one of the best lands anywhere. They pointed out how many new sea creatures came to be because of this waste and how other lands couldn't do this. The pipe manufacturers also made commercials telling about all of the jobs these pipes were creating. They all made so much sense!

They also sent more money to the politicians so they would ignore the people who couldn't afford paying for the waste.

But then some of the people of the land ran out of money and stopped paying taxes. This made the government mad, and so it left these bad people to live in their own waste. Many of these people became sick in their waste, and some of them died. Finally, the cry of the people was loud enough that the politicians in the land took notice. They decided that all of this waste was a real problem. No other land had so many pipes sending so much waste. True, there were lots of fancy new sea creatures, but the people in the land were getting angry, and some were dying.

But the politicians started fighting. One group of the politicians decided that the pipe-making companies were the problem. They thought that the government should take over the pipe-making job and guarantee waste pipes for every home. Others thought that the government could never do as good of a job as the companies did. They said that those people who couldn't afford pipes were dead-beats and probably deserved to die.

They held town hall meetings to talk about who should be making pipes, and people got very angry.

Finally, someone who wrote a waste-pipe blog suggested that perhaps the problem wasn't the pipes, but instead it was the waste. He said that the people should find a way to cut back on the waste, and so need fewer pipes. The blogger was criticized sternly, because his suggestion would have very bad consequences. The new fancy sea creatures that made everyone so proud would die off if they cut back on waste, and the pipe-workers would lose their jobs and be very sad. Plus, people didn't want the government telling them how much waste they could make. It's a free country, and people should be able to make waste without the government rationing it.

But as the people of the land thought about what this blogger said, they saw the sense in it. Yes, the sea creatures and the pipe manufacturing companies put very moving commercials on TV about dying sea creatures and unemployed pipe workers. They were very sad commercials and they made a lot of people weep. But the people of the land realized that this land was for people to live in, not for pipe companies or fancy sea creatures. Yes, it would be sad to not have those fancy creatures, and they'd have to get new jobs for the pipe company workers, but it was the only way.

Oh, it was hard to cut back on waste and kill off the fancy sea creatures. People got very mad and lobbyist groups tried to change laws or pay off politicians. But this was a good and smart kingdom, and they didn't listen to the creatures any more. And finally the day came when the sea was clean again.

And everyone was happy.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

QD: News Every Day--Medicare holds claims to prevent pay cuts

Today's the deadline for a 21% cut in Medicare reimbursement. Congress didn't get a temporary fix pushed through in time, so Medicare is going to hold claims for 10 days to allow lawmakers enough time to act. Still, solo doctors and small practices worry that they will immediately feel the pinch. One internal medicine practice wrote its patients partly to warn them, but also to put pressure on lawmakers to act. Another warns that practices serving a large proportion of retirees are in even more trouble. ACP President Joseph Stubbs, FACP, remarked to Medscape that this has happened before, forcing some practices to take out short-term loans to meet payroll. (Health Leaders Media, The Daily Sentinel,

It's going to be a busy week. Lawmakers can take up the issue of Medicare cuts later this week, but the White House is also going to signal its intentions on health care reform in the next few days. Both sides are taking sides, and talk about bipartisanship is being left behind. Democrats may have the votes to pass it without Republican support, but it's not a sure thing. Democrats counter that with 100 Republican amendments, the bill is bipartisan even if the final voting isn't. (New York Times, The Christian Science Monitor, Wall Street Journal, CNN)

In case you missed it ...
President Barack Obama received his annual check-up, and the results are online if you want to peek at the president's lab results.

Medical News of the Obvious

You might not have guessed it from how we're beating up on them at the Olympics, but Americans are fatter and lazier than Canadians. At least according to a new study, published by Arthritis Care & Research but conducted at the Toronto Western Research Institute (hmm, do you get the feeling they might be less than totally impartial in this US/Canuck comparison?).

Anyway, the researchers concluded that it's Americans' slothful habits that cause us to develop more arthritis than our northern peers. As you've probably already guessed, the solution to this problem is obvious, too. "Public health initiatives that promote healthy weight and physical activity," recommended a study author, according to HealthDay.