Tuesday, November 30, 2010

QD: News Every Day--North Americans get enough vitamin D, calcium

The majority of North Americans get enough vitamin D and calcium for bone health, reports the Institute of Medicine after reviewing more than 1,000 published studies.

Weetabix cereal breakfast from blmurch via FlickrThe joke about any ubiquitous substance is that it will soon be sprinkled on breakfast cereal, which is literally true with these nutrients. The rising use of blood tests to detect vitamin D and calcium--each lab reading a test may use different values of what's appropriate--led the Institute of Medicine to review the subject.

Most Americans and Canadians up to age 70 need no more than 600 international units (IUs) of vitamin D per day to maintain health, while those 71 and older may need as much as 800 IUs because of potential physical and behavioral changes related to aging.

The amount of calcium needed ranges, based on age, from 700 to 1,300 mg per day, according to the report, which updates the nutritional reference values known as Dietary Reference Intakes (DRIs) for these interrelated nutrients. Now, 700 mg of calcium per day meets the bone health needs of almost all children ages 1 through 3, and 1,000 mg daily is appropriate for almost all children ages 4 through 8. Adolescents ages 9 through 18 require no more than 1,300 mg per day. For practically all adults ages 19 through 50 and for men until age 71, 1,000 mg covers daily calcium needs. Women starting at age 51 and both men and women age 71 and older need no more than 1,200 mg per day.

Upper intake levels represent the upper safe boundary and should not be misunderstood as amounts people need or should strive to consume. The upper intake levels for vitamin D are 2,500 IUs per day for children ages 1 through 3; 3,000 IUs daily for children 4 through 8 years old; and 4,000 IUs daily for all others. The upper intake levels for calcium are 2,500 mg per day from age 1 through 8; 3,000 mg daily from age 9 through 18; 2,500 mg daily from age 19 through 50; and 2,000 mg per day for all other age groups.

Some adolescent girls may not get quite enough calcium, cautioned the Institutes of Medicine report, and there is a greater chance that elderly individuals may fall short of the necessary amounts of calcium and vitamin D. These individuals should increase their intake of foods containing these nutrients and possibly take a supplement.

The increasing use of tests that measure levels in patients' blood have become widely used, and are a source of confusion. The cutpoints each lab uses vary and are not based on rigorous scientific studies. Furthermore, many labs use cutpoints that are higher than the evidence indicates are appropriate, leading to an overestimation of how many people are deficient. Based on available data, almost all individuals get sufficient vitamin D when their blood levels are at or above 20 nanograms per milliliter as it is measured in America, or 50 nanomoles per liter as measured in Canada.

Although sunlight triggers the natural production of vitamin D in skin and contributes to people's vitamin D levels, individuals' sun exposure varies greatly and many people are told to minimize it, so the committee assumed minimal sun exposure to establish the DRIs.

As for sprinkling it on breakfast cereal, greater amounts of food fortification and rising rates of supplement use have increased the chances that people consume high amounts of these nutrients. Getting too much calcium from dietary supplements has been associated with kidney stones, while excessive vitamin D can damage the kidneys and heart. Evidence about other possible risks associated with routine vitamin D supplementation is still tentative, and most studies have focused on very high doses taken short term rather than on routine, long-term consumption of large amounts. aHowever, some signals suggest there are greater risks of death and chronic disease associated with long-term high vitamin D intake, which informed the committee's conclusions about levels that consumers should not exceed.

The report's recommendations take into account nearly 1,000 published studies as well as testimony from scientists and stakeholders. A large amount of evidence, which formed the basis of the new intake values, confirms the roles of calcium and vitamin D in promoting skeletal growth and maintenance and the amounts needed to avoid poor bone health.

The committee that wrote the report also reviewed hundreds of studies and reports on other possible health effects of vitamin D, such as protection against cancer, heart disease, autoimmune diseases and diabetes. While these studies point to possibilities that warrant further investigation, they have yielded conflicting and mixed results and do not offer the evidence needed to confirm that vitamin D has these effects. Rigorous trials that yield consistent results are vital for reaching conclusions, as past experiences have shown. Vitamin E, for example, was believed to protect against heart disease before further studies disproved it.

"There is abundant science to confidently state how much vitamin D and calcium people need," said committee chair Catharine Ross, a professor in Pennsylvania State University's department of nutritional sciences. "We scrutinized the evidence, looking for indications of beneficial effects at all levels of intake. Amounts higher than those specified in this report are not necessary to maintain bone health."

She continued, "Past cases such as hormone replacement therapy and high doses of beta carotene remind us that some therapies that seemed to show promise for treating or preventing health problems ultimately did not work out and even caused harm. This is why it is appropriate to approach emerging evidence about an intervention cautiously, but with an open mind."
Monday, November 29, 2010

QD: News Every Day--One-month 'doc fix' passes Congress

Updating an earlier post, the U.S. House has passed a one-month extension of Medicare's current reimbursement rates--otherwise known as the "doc fix," by a voice vote. The Senate passed its version, which includes a 2.2% pay increase, before the Thanksgiving break.

In December, the legislature will have to figure out a long-term extension. It's estimated to cost $19 billion for a one-year measure, and potentially contentious legislators will have to come to an agreement how to offset the costs, according to California Healthline.

ACP members tell their stories about how Medicare reimbursement hasn't kept pace with the cost of doing medicine, and how any pay cut will force them to limit or drop their Medicare population. At issue is that, according to the Medicare Economic Index, the expenses of running a practice rose 18% from 2000 to 2008, while Medicare reimbursement rose 5%. One economist tells The Washington Post that if primary-care doctors relied exclusively on Medicare payment rates, their incomes would drop 9%. "It's just that doctors have gotten used to a certain income and lifestyle," the economist said.

In a retort to that, ACP members describe the effects of reimbursement threats in this video. In the words of one physician, "I want to take good care of [patients] and continue to live in my community." Note that that internist said live in the community, not maintain a lifestyle.

Why so much fuss about Anacetrapib?

I'm a bit puzzled by all the excitement about Merck's new drug, Anacetrapib (MK-0859) that's said to lower risk for cardiovascular disease by lowering bad cholesterol. Earlier this week at the annual meeting of the American Heart Association, researchers presented promising findings on the drug, including results from the phase III DEFINE (Determining the Efficacy and Tolerability of CETP Inhibition with Anacetrapib) trial. The list of disclosures for that abstract is long and fairly shocking. On Wednesday, the results were published online in the NEJM.

The new drug interests me, as an oncologist, because it's an enzyme inhibitor – in some ways like many new and in-the-pipeline cancer treatments. Anacetrapib raises high-density lipoprotein (HDL, a.k.a. "good cholesterol") and lowers low-density lipoprotein (LDL, a.k.a. "bad cholesterol") by interfering with a cholesterol enzyme transfer protein (CETP). The experimental medication is a pill that, based on earlier safety studies, is taken at 100 mg by mouth, once daily. So it's convenient enough.

In some respects, the results of this randomized, placebo-controlled large trial are knock-your-socks-off impressive: patients on the drug had, an average, a more-than doubling of their serum HDL levels, from 41 to 101 mg per deciliter (cho­les­terol units: mil­ligrams per deciliter). At the same time, the HDL shift was just 40 to 46 for patients assigned to the placebo (control). Conversely, LDL levels went down dramatically in patients taking Anacetrapib, from 81 to 45 mg per deciliter on average, and the corresponding drop seen among the control patients was only 82 to 77. These numbers are really terrific, and the results highly significant from a statistical perspective. The study lasted for 76 weeks, i.e. well over a year, and the drug was very-well tolerated according to all published reports.

What's wrong here? Well, it's that we don't know for sure how this new drug affects heart disease and other vascular conditions. In this study, the plasma cholesterol levels were monitored as surrogate markers for risk of atherosclerotic events, but these laboratory parameters are not the same thing as direct measures of disease. It is uncertain if this drug has any impact on mortality, or even on heart attacks, strokes or other clinical endpoints.

In my opinion, we need a lot more information about this new drug before we prescribe it to thousands or millions of people who have hyperlipidemia. Fortunately, as pointed out by Dr. Harlan Krumholz, writing for Forbes, Merck is "doing the right thing" by testing the drug in additional studies now, with clinical endpoints in mind. Still, his enthusiasm for what amount to very favorable blood testing seems extreme in light of the previous experience to which he refers with Pfizer's torcetrapib, a drug of the same class that turned out to have significant side effects, and Merck's previous marketing of Zetia.

According to the New York Times, John Boris, an analyst at Citigroup, wrote in a note to investors on Wednesday that the drug could potentially have sales of more than $1 billion a year. Dr. Steven Nissen, a sometimes cautious leader in the field, found the results encouraging, according to widely-cited comments such as those appearing in the Dow Jones Newswires.

In a few years, we'll see what Merck finds out with the ongoing trials, and if the drug really helps reduce heart attacks and deaths in people with hyperlipidemia.

Meanwhile, for those who are skeptical about cholesterol-lowering drugs and their side effects, as I am for people who have only modestly elevated lipid levels, you might consider the old-fashioned approach of dietary modification. The NIH offers tips for therapeutic lifestyle changes that can help reduce hyperlipidemia in many patients.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.
Wednesday, November 24, 2010

Whole body screening may harm people with illness and disability

I'll be staying close to home for Thanksgiving. But if I did have plans to travel by airplane for the holiday, I think I'd be apprehensive about the new screening procedures implemented by the Transportation Safety Authority (TSA).

My concern is not with the scanning machines. The level of potential radiation exposure, even by the back-scatter units, is almost immeasurably low relative to what's in our everyday environment. Rather, I'm worried about screening errors--false positive and false negative results--and about harms, physical and/or emotional, that patients and people with disability may experience during the screening process.

Even with these new machines in full-future swing, it's easy to imagine that an imperfectly-trained, inexperienced or just plain tired screener might miss an irregularity, especially in the context of a steady stream of passengers rushing to catch their flights. These operators might miss seeing the weapons despite the visual "information" available, right in front of their eyes.

The solution, to maximize the scanners' value and our unwanted exposures, would be through careful training and testing of the examiners. Ultimately, though, we can't get around the fact that they're human and sometimes nearing the end of a shift; we can reduce but not eliminate these kinds of screening errors.

My second concern is with the potential harm to patients and people with disabilities. Patients may be harmed physically, if screeners mishandle a pump or other device. A pat-down person might, for example, press too hard on a breast cancer patient's implant or expander and rupture that. Emotional trauma may be very real, and lasting. Most TSA screeners aren't accustomed, as are doctors and nurses, to seeing people's medical baggage--colostomies, stumps and other disfigurements that are usually concealed under a person's clothing.

There's been a lot of attention to one case, that of a 61-year-old man with a history of bladder cancer whose urostomy bag ruptured during an airport pat-down. The man described his urine spilling all over, and feeling humiliated. I think this a very understandable reaction. A person who's experienced significant illness with residual scars and deformities, may be unnerved by a stranger's brusque pat-down and look-over.

This is not a civil rights issue. After all, we don't have to travel on airplanes. In my opinion, no one has the right to board a public vehicle without full screening if that's what the TSA advises for public safety. Rather, I accept that one aspect of having a medical condition is that sometimes you have to put up with things other people don't experience. Nor is it a patient empowerment issue, in the sense that this is not about educating patients so they can better participate in their health decisions.

The matter is to what extent we can accommodate the needs of people with health issues and disabilities. Unfortunately, in a cost-cutting, fear-laden environment, patients' emotional needs may be shortchanged.

What would help, clearly, is better sensitivity and training of TSA staff, as was suggested in response to the urostomy incident. But given the huge volume of travelers and enormousness of our complicated transportation system, it seems unlikely we'll get a satisfactory solution among all staff at all airports, at least not in time for Thanksgiving.

This post originally appeared at Medical Lessons. Elaine Schattner, ACP Member, is a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.

Your kidneys might prefer that steak tartar

One last update from Renal Week. I attended a session about how to avoid the reduced renal function that is typically associated with aging. Much of the lecture focused on the effects of advanced glycosylation endproducts (AGEs) which come into your body through food. Cooking temperatures are a major determinant of the AGE content of food--the hotter you cook it, the more AGEs you get. For example, french fries have something like 90-fold more AGE than mashed potatoes, the speaker said.

It's mostly animal research that has shown the association between AGE and kidney function, but the findings are pretty interesting. You know all the research finding that calorie restriction makes you healthier? Well, researchers tried feeding some rodents a low-calorie diet, a normal diet, or a low-calorie diet with AGEs added in. The normal and low-cal plus AGE animals had the same outcomes; only the animals eating low-cal without AGE lived longer. The results show that the benefits of calorie-restriction may actually come from avoiding AGEs, the session speaker said.

He didn't address the possible corrolary that most interested me, though: could you get the benefits of calorie restriction (ie, live to be a 100) while still stuffing your face if you just avoid AGEs? In any case, he strongly advocated low-AGE diets as a potential means of preserving kidney function. "It's stupidly simple," he said.

Airport pat-downs disputed as unhealthy

Potential health effects of airport security are being questioned for their possible health consequences, from spreading germs to radiation exposure to the stress that being searched induces.

With cheaper flights available this year and the need for security in air travel, the Transportation Security Administration (TSA) is justifying its full body scans and its pat-downs that rise up travelers' legs--all the way up.

The scanners use microwaves, leading some to question whether people may be receiving too much radiation. It's also a concern to activists who may have already undergone a lot of radiation for existing condition, or who have other conditions for which TSA agents may not be trained. (Read one seasoned traveler's personal experience here.) The TSA reports the scanners expose users less energy than a cell phone.

Some protesters are refusing the body scans in favor of a pat-down, in an effort to tie up air travel on the day before Thanksgiving and force a review on the issue. But a manual exam spreads germs, say others.

Amid all the speculation of potential health consequences, federal officials are reminding travelers that the security measures are there for passenger safety. However, retorts Jason Mustian's Twitter feed, "Body scans and genital fondlings would save more lives if our government was paying to have them done in hospitals rather than airports."

QD: News Every Day--Prevent diabetes to bend the health care cost curve

By 2020, an estimated 15% of adults will have diabetes and 37% will have prediabetes, a total of 39 million people, compared with rates of 12% and 28% today, respectively.

Today, more than 90% of people with prediabetes, and about a quarter of people with diabetes, are unaware of it, according to a report from UnitedHealth Group, the provider of insurance and other health care services.

The health savings alone of preventing diabetes would bend the cost curve of health care spending in the country. Health spending associated with diabetes and prediabetes is about $194 billion this year, or 7% of U.S. health spending, the report said. That cost is projected to rise to $500 billion by 2020, or a total of almost $3.4 trillion on diabetes-related care.

Engaging the at-risk population could save up to $250 billion, or 7.5% of estimated spending on diabetes and prediabetes, in the next decade. Of that money, $144 billion, or about 58%, would come from savings in Medicare, Medicaid and health care exchange subsidies.

For UnitedHealth's population of insured lives, a sample of 10 million commercial health plan members, the average 2009 cost of a known diabetic was approximately $11,700, compared to $4,400 for the remainder of the population. Diabetes with complications costs an average of $20,700 annually, or three times as much as $7,800 for diabetics who do not have complications.

The report recommends. among other solutions, diabetes awareness and public education, more pay for and better models of primary care (such as the medical home), patient incentives (including money), and for the U.S. Preventive Services Task Force should to evidence for prediabetes screening.

[Editor's Note--QD: News Every Day will resume on Nov. 29.]
Tuesday, November 23, 2010

QD: News Every Day--Preauthorizations hurt patient care

Preauthorization hassles hurt patient care, according to a new survey by the American Medical Association (AMA)

The AMA survey, the first by the organization to measure the issue, assessed a national online survey of 2,400 physicians in May 2010. Responses indicate that health insurer requirements to preauthorize care had delayed or interrupted patient care, consumed significant amounts of time, and complicated medical decisions.

Physicians spend 20 hours per week on average dealing with preauthorizations. About two-thirds of physicians reported it is difficult to determine which drugs, test and procedures require preauthorization.

Other highlights include:
--57% of physicians experience a 20% rejection rate from insurers on first-time drug preauthorizations and 37% experience a 20% rejection rate for first-time preauthorizations for tests and procedures.
--58% of physicians experience difficulty obtaining approval from insurers on 25% or more of drug preauthorizations. 46% of physicians have difficulty obtaining approval from insurers on 25% or more of preauthorizations for tests and procedures.
--69% of physicians typically wait several days to receive preauthorization from an insurer for drugs, while 10% wait more than a week. 63% of physicians typically wait several days to receive preauthorization from an insurer for tests and procedures, while 13% wait more than a week.
--52% of physicians report appealing 80% or more of insurer rejections on first-time preauthorization requests for tests and procedures. 39% report appealing 80% or more of insurer rejections on first-time preauthorization requests for drugs.

Hassles continues, reported the AMA survey, as 43% report that first-time preauthorization requests are often reviewed by someone without medical training. Naturally, nearly all physicians ranked eliminating preauthorization hassles as important or very important, and 75% suggested using an automated preauthorization process.
Monday, November 22, 2010

The twinkie diet

"Hey ... where did those cupcakes go?"

Like a never-ending western North Carolina climb where each switchback reveals another uphill, and the finish is shielded by tall pines, the struggle to lose weight and to stay lean is incessant.

In wrestling weight gain, competitive cyclists share the same mat as "regular" Americans. Like jockeys, all competitive bike racers strive for maximal leanness. It's physics: Weigh less and the same number of watts push you farther and faster, especially when going uphill or accelerating from a slow speed. Remember those velocity problems in Physics 101?

But is it conceivable that losing weight, even if accompanied by lower cholesterol levels, could be detrimental to long-term wellness? Obviously, the question answers itself.

Unless your Internet connection has been interrupted in the last few days, you have probably heard of the "Twinkie diet." Kansas State University nutrition professor Mark Haub tested the hypothesis that if he reduced his daily calorie consumption from 2600 to 1800 he would lose weight.

Here's the cool part: To amplify his findings that calorie restriction is all that is required to lose weight, he primarily ate a convenience-store diet. Calories came from processed food, high in trans fat and high fructose corn syrup--the worst of the worst. Oreos, Hostess cakes, Little Debbie snacks, sugary cereals and Doritos were his staples. (He ate vegetables in the presence of his kids.)

The results were incredible. It worked. Not only did he lose 27 pounds, but he also markedly improved his cholesterol level and lowered his total body fat percent. Stunning. Despite the high-calorie inflammatory content of his food, faithfully adhering to a daily calorie restriction resulted in weight loss.

The message is that potato chips do not cause fatness, regularly eating the whole bag does. A few M&M's are okay, just not hundreds of them.

A master of the obvious is Professor Haub. He isn't saying he is any healthier, no one would argue that. He just makes it harder for the dietary perseverators, the nutritional elite, the peddlers of weight loss scams, to make a simple solution complex. Sorry.

It's a quandary isn't it: We want our obese patients to lose weight, but we cannot advocate junk food as the main entree. We want both fewer calories and more nutrients.

Reducing inflammation is the key to heart health. Keeping blood vessels healthy comes from good sleep, regular exercise and a good diet. Regularly eating inflammatory trans-fats and insulin-spiking high glycemic snack foods will surely negate the positive effects of weight loss.

But at least Dr. Haub has helped doctors shorten the coaching session part of an office visit with an obese patient. To the commonly heard phrase, "Doc, I really don't eat that much," we can respond--compassionately--that studies show that if you eat fewer calories you will lose weight.

In discussing "these studies" with our patients it will be best to omit the methodology section of Dr Haub's experiment. No worries, we are now a headline-only society anyways.

Seriously. Who ate those cupcakes?

This post by John Mandrola, MD, appeared at Get 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--Physicians fleeing from health reform's expected effects

Physicians are moving out of practice ownership and into employment models because of health care reform, reports a survey. But, health care reform is likely looking at some further changes of its own to make it more politically palatable.

The report was commissioned by The Physicians Foundation, a non-profit grant-making organization comprised of medical society and physician leaders, and was conducted by the physician recruiting firm Merritt Hawkins.

The survey was mailed to 40,000 physicians generated at random from the American Medical Association's Physician Master File database. Surveys were mailed to 10 medical specialties, including internal medicine and hospitalists, but weighted toward primary care physicians. An electronic version of the survey was e-mailed to 60,000 physicians in Merritt Hawkins' database, of which 56% are in primary care. The response rate was 2,379 completed surveys (2.4%). The overall margin of error for the entire survey is +/-1.93%, although the error rate fluctuates across questions.

Among the findings:
--26% of doctors thought they'd continue to practice as they do currently. The other 74% said they'd change how or whether they'd continue to practice.
--40% of physicians said they would drop out of patient care in the next one to three years, either by retiring, seeking a non-clinical job within health care, or leaving health care entirely.
--60% said health reform will compel them to close or significantly restrict their practices to certain categories of patients (93% restricting Medicaid patients, and 87% restricting Medicare patients).

Physicians were generally dour on health care reform's expected impact, according to the survey.
--Half expected health reform to increase patient volumes, but 69% said they no longer have the time or resources to handle more patients.
--59% said health reform will cause them to spend less time with patients.
--10% said reform will improve the quality of patient care they are able to provide, while 56% said reform will diminish it.

Finally, 89% believe the traditional model of independent private practice is either "on shaky ground" or "is a dinosaur soon to go extinct."

But independent of that report, there are hints of consensus building on Capitol Hill when it comes to health care reform.

The first bipartisan proposal to alter health care reform was proposed last week, according to The Hill. It's a waiver that would allow states to opt out of the individual mandate to buy health insurance. In exchange for waivers three years earlier than allowed under the current law, states would have to set up a health insurance system that meets federal levels for population covered, as well as affordability and comprehensiveness. One health policy professor described it as, "a clever way to force an adult conversation."

Also, an 18-member, bipartisan presidential panel is expected to vote on deficit-reduction measures, including higher taxes on health care and higher Medicare premiums. A majority vote from that panel would send their ideas to the full Congress for discussion, and the ideas reflect that, "Strange bedfellows are a 'testament to the moderate nature' of the ideas under discussion," reports The Washington Post.

History, health and Bloody Bloody Andrew Jackson

"If it's chafed, put some lotion on it."
--Some practical advice, offered by the character portraying Andrew Jackson, speaking toward the audience in the last scene of Bloody Bloody Andrew Jackson, a play written and directed by Alex Timbers

Recently I had occasion to see the outrageous politico-emo-rock musical, Bloody Bloody Andrew Jackson, which recently moved to Broadway's Bernard B. Jacobs Theatre. The production focuses on the life and times of the seventh President of the United States.

Now, Old Hickory comes on like a rock star. The story is narrated, in part, by an excitable, graying Jackson groupie who bumps around the stage in a motorized wheelchair. A wild and rattling cast sets the thing's tone in a startling first number, "Populism, Yea, Yea!" An early review of this musical, toward the end of its early 2008 Los Angeles run, cites these lyrics:
Sometimes you have to take the initiative.
Sometimes your whole family dies of cholera.
Sometimes you have to make your own story.
Sometimes you have to shoot the storyteller in the neck.
Sometimes you have to take back the country ... (These words antedate the Tea Party, to which the play vigorously alludes in its current form.)

You get the idea: It's lively, a bit disjointed and politically relevant. And fun. It messes with the facts, and is tangentially rife with medical topics.

In the play, Jackson's father, upon witnessing the whoosh and arrow-in-her-back slaying of Jackson's mother in a backwoods cabin somewhere in South Carolina or Tennessee, immediately and without hesitation attributes her death to cholera. A moment later, he and a cheery cobbler are felled by similar instruments. The future President Andrew Junior, who's playing with toy cowboys and Indians while both of his parents are shot dead in this life-motivating scene of pseudo-history, refers later to his parents' deaths from cholera.

Most historical sources and Jackson's Tennessee home's current website attribute the mother's death to cholera. According to a scholarly review of cholera epidemics in the 19th Century, the disease didn't appear in North America until after 1831 or so. A fascinating, original New York Times story details the ravaging effects of this illness in Tennessee in 1873, but that would be long after Jackson's death in 1837.

An unexpected medical writer's gem of a song, "Illness As Metaphor," cuts to the heart with a message about blood, symbolism, love and Susan Sontag's classic essays on the meaning of tuberculosis and cancer in literature and in life. The lyrics of the song from Bloody, Bloody Andrew Jackson are hard to find online, but you can get it through iTunes, by which I found these words:
A wise woman once wrote that illness is not metaphor.
So why do I feel sick when I look at you?
There is this illness in me and I need to get it out, so when I bleed
It's not blood, it's a metaphor for love.
These aren't veins just the beating of my heart.
This fever isn't real it represents how I feel ...

I'm not sure how Susan Sontag would feel about emo-rock in general and about this song in particular. A few other medical digs include mention of Jackson's hepatitis, acquired on "the battlefield," as he explains to his admirers, syphilis, a killer of Indians and, consistent with the play's hemi-modern approach, Valtrex, which some of the prostitute-turned government advisees run to get when it's given for free.

All in all, it's a terrific play about Americans, Manifest Destiny, populism, anti-elitism, economic frustration, anger toward foreigners, fears of terrorism and the founding of the Democratic Party, with a spoonful of medicine to go.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.
Friday, November 19, 2010

QD: News Every Day--House, Senate introduce 'doc fix' measures

Legislators in the House and Senate have introduced two 'doc fix' measures to again temporarily extend Medicare payments.

The Senate unanimously passed a bill this morning introduced by Max Baucus (D-Mont.) and Chuck Grassley (R-Iowa) that would pass a one-month fix in order to work out a year-long one. It would be paid for through $1 billion in savings from another program that bundles payments for outpatient therapy services performed in the same day.

In the House, John Dingell (D-Mich.), Frank Pallone (D-N.J.), Pete Stark (D-Calif.) and Henry Waxman (D-Calif.) seek to extend Medicare reimbursement rates for 13 months and provide a 1% update for both this year and next. Their measure will likely receive a vote after Thanksgiving but before the Dec. 1 deadline, when a 23% pay cut takes effect. The deal gives some interests breathing room as they try to keep their practices afloat. (The Hill, Modern Healthcare, Oroville [California] Mercury-Register)
Thursday, November 18, 2010

Beyond the numbers

I feel like I've seen so many reports of meta-analyses at this meeting that confidence intervals will appear on the backs of my eyelids when I try to sleep. And apparently some of the researchers agree with me about the surplus.

First one made a crack about how as soon as you have two RCTs on the same topic, it's time for a meta-analysis, of course. Then, in another session, a speaker said, "I think we've got a problem in nephrology when the number of meta-analyses exceeds the number of clinical trials."

I perked up, excited to hear someone speak a sentence without a p value, and thinking that more were coming. But no, then he went on to report the results of another meta-analysis.

Exhibit hall silliness

I'm a firm believer in minimizing the influence of industry on physicians, but my lunchtime trip to the Renal Week exhibit hall gave me a moment of nostalgia for the bad old days of pharma handouts.

I had hopes of snagging some entertaining renal-themed gear--maybe a keychain, a tshirt, or even a free kidney (yes, I know I already have a spare, but better safe than sorry). But there wasn't even a tiki bar mixing up creatinine coladas. One pharma company was doing their best to liven up the quiet with an "Are you smarter than a pharma exec?" quiz game, covering tricky medical topics like Justin Bieber's hair, with the prizes going charities of the winner's choice.

And that was all. I used to go home from conferences several pounds heavier with free food and plastic junk. But in almost 24 hours here, I have only this sad collection to disclose: one delicious cookie from the Hilton, one lukewarm coffee from the press room, one stale cupcake from the exhibit hall floor (no, not the actual floor--it was on a tray in an unguarded booth) and a CD of data from the US Renal Data System. I hope these doctors appreciate what I'm sacrificing for their ethics.

A nephrologic mystery

I'm at Renal Week (the annual meeting of the American Society of Nephrology) in beautiful 60 degree (!) Denver this week, so expect lots of reports on kidneys and their troubles.

A session this morning covered nephrogenic systemic fibrosis. Since even the FDA and I have already written about this, you're probably aware that this painful and damaging condition is caused by using gadolinium for contrast studies in patients with impaired renal function (so you should avoid the studies whenever possible in these patients and use the lowest risk agents). But did you know about the mystery of NSF's origins?

The first gadolinium agents (and the ones most associated with NSF) were approved in 1989 and 1993, yet the first cases of NSF didn't appear until 1997. Researchers have even gone back and searched tissue samples from the time period to see if the disease was around, but not diagnosed and reported. They found...(cue spooky music)...nothing. So if gadolinium causes NSF, why was there gadolinium but no NSF in the early and mid '90s? No one knows, but they suspect that there must be some as-yet-unidentified co-factor at work, session speaker and nephrologist Joel Topf, MD, said. Pretty mysterious, isn't it?

QD: News Every Day--Inner ear infections still don't need antibiotics

Kids get inner ear infections and then they get antibiotics, despite a long-standing knowledge that it's not always best. Any physician knows this, but who hasn't faced an irate or anxious parent in the exam room insisting on a prescription, whether the evidence warrants it or not?

Reuters reports that the tally for all those antibiotics is $2.8 billion dollars, or $350 per child annually. And there's only a slight benefit to them.

While hardly comforting to the parents, physicians can add more heft to their argument that antibiotics are only modestly more effective than nothing, and they can avoid the rashes and diarrhea that antibiotics incur.

Results in the Nov. 17 issue of the Journal of the American Medical Association reported that:
--Otoscopic findings of tympanic membrane bulging (positive likelihood ratio, 51 [95% confidence interval [CI], 36 to 73]) and redness (positive likelihood ratio, 8.4 [95% CI, 7 to 11]) were associated with accurate diagnosis;
--Heptavalent pneumococcal conjugate vaccine (PCV7) changed the microbiology of inner ear infections. Before and after PCV7, Streptococcus pneumonia decreased (33%-48% vs. 23%-31% of acute otitis media isolates), while Haemophilus influenza increased (41%-43% vs. 56%-57%); and
--Short-term clinical success was higher for immediate use of ampicillin or amoxicillin vs. placebo (73% vs. 60%; pooled rate difference, 12% [95% CI, 5% to 18%]; number needed to treat, 9 [95% CI, 6 to 20]), but increased rashes or diarrhea by 3% to 5%. Two studies showed greater clinical success for immediate vs. delayed antibiotics (95% vs. 80%; rate difference, 15% [95% CI, 6% to 24%] and 86% vs. 70%; rate difference, 16% [95% CI, 6% to 26%]).

The lead author told Reuters that an observation period without antibiotics may be the best option, and plain old amoxicillin works just as well as anything else.

The meta-analysis adds to the physician's understanding of antibiotics. Whether it adds to the parents' is another story.

Time well spent and well valued

Abraham Verghese is a professor of medicine at Stanford University, and one of the most articulate physician-writers today. He recently wrote an op-ed highlighting primary care's plight, and focuses on the scarcity of time: "The science of medicine has never been more potent--incredible advances and great benefits realized in the treatment of individual diseases--yet the public perception of us physicians is often one of a harried individual more interested in the virtual construct of the patient in the computer than in the living, breathing patient seated on the exam table. Time is the scarcest commodity of all. Patients, particularly when it comes to their routine, day-to-day care, want a physician who has time to understand them as people first, and then as patients."

It's been frequently discussed, with solutions ranging from paying physicians per hour to cash only practices.

There's no easy answer, and worse, money isn't even the root of the problem. Often left unaddressed is the burnout that primary care doctors face, practicing in unpalatable environments where the doctor-patient relationship is obstructed by bureaucracy and paperwork.

Dr. Verghese applauds expanding coverage, but acknowledges that significant payment reform needs to come next, writing, "[R]ewarding primary care physicians for time spent with the patient and taking away the fee-for-procedure incentives. Getting to know a patient and having the time to do so is a critical step; I am convinced it prevents unnecessary tests and saves money. It's just good practice. And it's what patients want."

Maggie Mahar recently had a guest piece saying that primary care doctors are being rewarded, to the tune of a 10% increase in Medicare office reimbursements.

Not only is that not nearly enough to sway the tide sinking primary care, it leaves the practice burden facing most primary care doctors completely unaddressed.

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 33,000 subscribers and 23,000 Twitter followers, KevinMD.com is the Web's definitive site for influential health commentary.
Wednesday, November 17, 2010

QD: News Every Day--End-of-life options might be better for cancer patients

The latest Dartmouth Atlas Project report examines care for Medicare patients over age 65 with cancers that have a poor prognosis and finds that care at the end of life. Major findings include:
--More than one third of patients with poor prognosis cancer spent their last days in hospitals and intensive care units. A significant proportion of patients received advanced life support interventions such as endotracheal intubation, feeding tubes and cardiopulmonary resuscitation.
--Chemotherapy in the last two weeks of life overall was about 6% of patients, but in some regions and academic medical centers the rate exceeded 10%.
--Hospice care varied markedly across regions and hospitals. In at least 50 academic medical centers, less than half of patients with poor prognosis cancer received hospice services.
--In some hospitals, referral to hospice care occurred so close to the day of death that it was unlikely to have provided much assistance and comfort to patients.

Manhattanites fighting cancer at the end of life spend more time in the hospital and receive more treatment and less palliative and hospice care than other regions. About 29% of cancer patients who died between from 2003 to 2007 did so in a hospital. Among cancer patients in the New York City area, 46.7% died in a hospital. That's six times higher than the rate in the Mason City, Iowa region, where only 7% of cancer patients died in the hospital.

On average, cancer patients spent 5.1 days in the hospital during the last month of life. Cancer patients spent a week or more of their last month of life in the hospital in New York City and surrounding regions. Patients in the greater New York City region were also more likely to receive life-sustaining medicines at the end of life than in other regions.

The report also takes a skeptical look at the value of endotracheal intubation, feeding tube placement and cardiopulmonary resuscitation at the end of life, saying these procedures diminish quality of life and won't always allow sought after outcomes, such as letting patients communicate with their families in the final days.

Hospitals need to embrace a family-centered care approach, and then examine whether their end-of-life practices meet those goals, the report states. Otherwise, patients' wishes can get lost amid the care teams' efforts to cure an incurable patient.

"It may help both patients and clinicians to recognize that achieving both the longest and the most functional life is not a simple choice between curative and palliative or hospice care," authors wrote in the report. "Palliative care early in the course of cancer illness can reduce discomfort from the disease and from curative treatments, and also legitimize the discussion of quality of life. For patients with poor prognosis disease, palliative and hospice care can actually prolong life, even as they improve its quality."

Lead author David C. Goodman, MD, explained at a briefing covered by The Washington Post that the variations are likely related to individual variations among doctors' and hospitals' practices, whether hospitals have more beds for intensive care or hospice care, and individual doctors acknowledging when cancer care can help any more.

But, health economist Stephen Zuckerman cautioned that paying doctors for end-of-life conversations led to politicized charges of death panels and health care rationing. He posed to the question to the Los Angeles Times, "If you provide financial incentives for people to move into less aggressive treatment, is that the reaction you're going to get?"

Rapid demise

Why Sparky Anderson's death occurred so soon after he went to hospice.

Hall of Fame baseball manager George "Sparky" Anderson's death (1934-2010) was announced less than 24 hours after a previous news item revealed that his family had moved him to hospice.

Sparky Anderson, Canadian Baseball Hall of Fame, St. Marys Ontario_2952 by Bobolink via FlickrBaseball fans across the U.S. are saddened by the loss of the first manager to win World Series championships in both leagues (Tony LaRussa is the other); many are likely puzzled as to why his death came so closely on the heels of his family's announcement about hospice.

Among patients, hospice in the U.S. has mixed connotations; some view it as the desirable way to make a final exit, others perceive the very word pejoratively as coded language for 'giving up all hope.'

The modern hospice movement can be traced back to Dame Cicely Saunders, who founded St. Christopher's Hospice in London in the mid-1960s. With her nursing background, Dame Saunders' experiences led her to formulate the principles of palliative care: alleviating pain and suffering to the maximal extent possible, with the ultimate promise of bringing dignity to the dying.

The difficult part for a patient like Anderson, his family, and his doctors is deciding when to initiate the referral to hospice. Making the decision is a gradual process, the key part of which is reaching acceptance of imminent death. Obviously, many patients and their families never reach this stage.

In order to qualify for hospice, a patient must have a terminal diagnosis, defined as six months or fewer of remaining life. This is fairly straightforward with cancer diagnoses, which are staged precisely and tend to move along predictable trajectories. Prognosis is much more challenging for patients in the end stages of chronic diseases like congestive heart failure, emphysema and dementia, which is the condition that Anderson was reported to have.

Dementia has multiple causes, the most common being Alzheimer's, which occurs when abnormal particles called neurofibrillary tangles and beta amyloid protein build up in the brain, impairing the neurochemical signalling between neurons and their synapses. Dementia is also caused by strokes ("cerebrovascular disease") and less commonly by Parkinson's and rarer conditions like Lewy Body disease and something called progressive supranuclear palsy (PSP). These latter two typically progress more quickly than Alzheimer's, but there is wide variation. Ultimately, what they share in common is the fact that they are progressive and irreversible, robbing victims of their memories, and their ability to think, speak, walk, and finally, eat.

Since those afflicted with dementia are often lost in their brain fog, they become what we doctors call "unreliable historians." Assessing their degree of pain or discomfort is extraordinarily challenging, which can lead to delays in recommending hospice. Caregivers have major struggles in providing care for loved ones with dementia, such that they often neglect their own health. Yet finally allowing a loved one to be placed in a nursing home or referred to hospice can feel like defeat after an investment of so much time and love.

News accounts of Anderson's hospice referral (and now his obituary) say only that he suffered from "complications of dementia," without mentioning the cause. On one hand this is not surprising, given that the only way to really know the cause of dementia is to perform a brain biopsy. For obvious reasons, this is not something that patients or their caregivers are eager to undertake, especially since there are no meaningful treatments that arrest or reverse dementia. Neuropsychiatric testing, which assesses multiple cognitive domains (e.g. memory, attention, concentration, organization), can reliably determine if an individual has dementia, and give clues to what areas of the brain are affected. Patients and families thus can have more of an idea of how quickly to expect the dementia to progress and therefore plan accordingly.

Anderson's case differs from that of another famous dementia-sufferer, former President Ronald Reagan. His dementia was declared in a publicly-released 1994 letter that said: "I have recently been told that I am one of millions of Americans who will be [sic] afflicted with Alzheimer's disease." Courageous for going public with his condition, his family's effort did much to increase and de-stigmatize dementia in America. Reagan lived another 10 years.

Sparky Anderson's slide seems so much more precipitous. Of course, it could be because he had a more rapidly progressive form of dementia than Alzheimer's. It might also be because his family only decided to enroll him in hospice when he was literally on his deathbed. Ask any hospice physician or nurse, and you will likely get an earful about why patients are referred so late in the course of their illnesses. It turns out that the median length of stay in hospice is a mere three weeks; 10% of hospice patients die within thefirst 24 hours they are there.

A whole subfield of medicine has arisen to encourage Americans to seek comfort over cure sooner. One recent study even showed that lung cancer patients randomly assigned to treatment and palliative care outlived those who had just treatment.

Poetically, Anderson himself said it best more than a year ago at a Detroit event celebrating the 25th anniversary of his World Series champion Tigers: "Think about this now, there will be four or five of these guys together again, maybe, but never all together again.

"I'm 75. I know I ain't gonna make it."

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.
Tuesday, November 16, 2010

Red yeast rice supplements for high cholesterol

People are always on the search for "natural" ways to stay healthy and reduce cholesterol. Chinese red yeast rice supplements have been touted as a natural, safer way to lower cholesterol compared to statin medications. The yeast that grows on a particular type of rice contains a family of substances called monocolins, which lower cholesterol by inhibiting cholesterol production in the liver in the same manner as prescription statin drugs. Some studies have shown as much as a 15% drop in cholesterol.

All of this sounds good until you dig a little deeper. Supplements are not regulated by the FDA and a new study in the Archives of Internal Medicine showed that different brands of red yeast rice supplements showed dramatic variation in levels of active ingredients. Furthermore, some contained toxic manufacturing byproducts.

The researchers analyzed capsules from a dozen different manufacturers. They found the consistency was far from standard, even though they all were labeled as containing 600 mg of red yeast rice extract.

The total monacolin levels per capsule varied from 0.31 mg to 11.15 mg. Four brands showed levels of citrinin, which is toxic to the kidneys, with ranges from 24 to 189 ppm. (parts per million). Citrinin is produced by Monascus, Penicillium and Aspergillus species.

Unfortunately, the authors of the Archives study did not share the names of the supplements with the readers so we are left to ponder!

Say what you will about pharmaceutical drugs, I think we all benefit from the FDA oversight and knowing that there is some standardization and safety in manufacture and distribution. Supplements can range from completely ineffective to potentially dangerous with contaminants or unknown side effects.

Red Yeast Rice Supplements should be used with caution.

This post originally appeared at Everything Health. Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

QD: News Every Day--Employers up the ante for workers' health

More than half of employers are likely to keep offering insurance rather than use state health insurance exchanges when they become available under health care reform in 2014, reported a survey by an insurance broker.

Willis Human Capital Practice released results of its Health Care Reform Survey 2010, which showed 55% of employers would keep their health plans in 2014 even if the new state exchanges offer competitive prices. The survey sampled 1,400 employers of varying sizes, industry sectors and geographies whose plans cover more than 9 million employees and dependents (including retirees).

Key findings from the survey include:
• 88% believe that group health plan costs will increase as a result of health care reform;
• 76% expect administrative compliance costs will increase;
• 72% plan to increase employee contributions in an attempt to offset higher administrative and premium costs. Employers might maintain plans by passing on more costs to employees, or by decreasing or cutting dental or vision benefits;
• 53% of employers expect the adult child coverage mandate to increase their health plans' costs;
• 52% anticipated an increase in the number of employees covered.

In another twist, employers are more likely to offer incentives for employees to adopt healthier habits, including by paying lower premiums or with good old-fashioned cash rewards. The Los Angeles Times reported that more companies are adopting incentive programs, and are upping the requirements of those program, such as maintaining healthy weight or weight loss, and undergoing more extensive tests. But, cautioned the experts, such incentive programs can backfire. People are notoriously difficult to program in that way, especially if they're being coaxed into something they wouldn’t normally do.

As long as employers expect health care plans to rise, and as long as they continue to plan to offer them anyway, businesses will try to figure out ways to keep the costs lower.
Monday, November 15, 2010

QD: News Every Day--Happy birthday, baby boomers

Today begins a lame duck session of Congress before it breaks for Thanksgiving. It's the final chance to work out a temporary patch to Medicare reimbursement before a 23% cut takes effect Dec. 1. Doctors are going to stop taking new Medicare patients if the cuts happen. And, as one breast cancer surgeon explains, if Medicare stops paying, so to private insurers and even military health programs. Congress will meet in December, but the damage will be done.

This all is happening two weeks before the baby become eligible for Medicare. That populous generation starts to turn 65 beginning on Jan. 1, which means they become eligible for Medicare on Dec. 1, which, as we mentioned, is the day the 23% Medicare pay cut kicks in. Boomers will continue to become eligible for Medicare, one person every eight seconds, until December 2029. (CNN, The Washington Post, USA Today)

Lessons from a lead poisoning outbreak in Nigeria

Over 400 Nigerian children have died from lead poisoning this year, the Times reported last month. The outbreak is centered in five villages in the northwestern state of Zamfara.

Small-scale gold mining in the region leads to lead toxicity, as follows: "In an attempt to extract gold from ore rich with lead, miners crush and dry the ore, often inside their own homes. The soil and in some cases the groundwater get contaminated," according to an Oct. 5 field report from Doctors Without Borders/Medecins Sans Frontieres (MSF).

I learned long ago that lead poisoning is sometimes called plumbism, stemming from plumbum, the Latin term for lead (Pb, atomic number 82), a metal used by plumbers. A rarer term is Saturnism, based on the metal's association with the planet and ancient Roman god.

Now, in the U.S., lead poisoning most commonly comes from environmental toxins like lead-based paint. It affects children, who may eat flakes of peeling, lead-based paint or accidentally ingest lead by licking or eating toys or jewelry that contain this toxic metal. The problem occurs in adults, too, typically from unknown sources.

The EPA provides some helpful information on its website. Lead poisoning can be subtle; common symptoms are fatigue and poor concentration. Doctors may detect anemia, and upon inspection of a patient's red blood cells might find characteristic basophilic stippling. The National Institute of Environmental Health Sciences (NIEHS) reports that lead toxicity declined dramatically from 1980 to 2000 in the U.S.
Lead_poisoning - Wikimedia Commons / lead poisoning; arrows point to characteristic basophilic stippling (attr: Herbert L. Fred, MD and Hendrik A. van Dijk, Wikimedia CommonsIn northwest Nigeria, MSF workers are treating some of the affected children and nursing mothers with chelating agents; these metal-binding compounds clear lead from the bloodstream and, to some extent, remove it from body organs where it's already deposited. The World Health Organization (WHO) issued a bulletin on lead poisoning from gold-mining in Nigeria in June, 2010.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.
Friday, November 12, 2010

QD: News Every Day--Analysts see health care use returning

Health care consumption for basic care and chronic conditions is recovering from the recession, although use of expensive diagnostic tests continues to sputter, analysts said. People lost their jobs (and their health insurance) can only defer procedures for so long, analysts noted, and will opt for care as the recession ends. Medical suppliers are seeing their earnings increase, as facilities can only defer upkeep and replacement of outdated equipment. They made their predictions at a conference hosted by Reuters.

In case you missed it ...
People in Connecticut rank highest in well-being, as defined by health, education and income, and West Virginia is the least so, according to results published by the American Human Development Project. The difference is enough from first place to last that there's a five-year difference in life expectancy between the two states.
Thursday, November 11, 2010

The big picture

Her eyes were bloodshot. She responded to my casual greeting of "How are you?" with a sigh. "How am I? I'm alive; I can tell you that much for sure."

She went on to describe a situation with her adult son who is in a bad marriage and has struggled with addiction. She sighed again, "I feel weak. I don't know if I can deal with this one. I've had so many hard things in my life already. When will it stop?"

Many hard things. Yes, I agree with that assessment. She's been my patient for more than a decade, and I've had a front row seat to her life. Her husband died a few years ago (while in his 40s) of a longstanding chronic disease. Her daughter also has this disease, and has been slowly declining over time. I've watched her bear that burden, and have actually shared some in that load, being the doctor for the whole family.

I've also taken care of her parents, who had their own psychological problems. They were difficult patients for me to manage, and they had died long enough ago that I had forgotten that difficult chapter of her life.

I've helped her with her emotional struggle from all of this. It was hard, but she hung on as best as she could. I know. I was there when it was happening.

To me, this is the biggest benefit of primary care. Yes, it's nice to have a doctor who knows what's going on with all of your other doctors. It's good to have a doctor you are comfortable talking with about anything. It's good to have someone without a financial stake in doing surgery, performing procedures, or ordering tests. But the unique benefit a long-term relationship with a primary care physician is the amazing big-picture view they have.

I had a man come into my office with his daughter, who was struggling with emotional problems. We discussed the situation for a while, and the subject of extended family came up. When he reminded me who the girl's grandparents were, I laughed out loud. They saw my moment of insight as to how the grandparents might be influencing this problem, and they both started laughing with me. Nobody had to explain anything. Nobody even said anything about the grandparents. He just reminded me who they were, and I already knew more than enough.

I have now been practicing for more than 15 years, and have a longstanding relationship with a lot of people. When they come in to see me, it isn't just for my expertise, knowledge, or to listen to my jokes; they come for my perspective. They come because they know that I know them like no one else. I have spent years gathering information for this visit. I saw them when they were depressed. I took care of their dying child. I broke the news of their spouse's cancer. My care for them is not just an office visit, it is a legacy.

When she stopped explaining her present situation to me, she let out another sigh, deeper than the rest. "Can you help me?" she asked.

"Sure, I can help you," I responded. "But let me reassure you that you are not weak. I've seen you weather the storms in your life and have been impressed by your strength. Sometimes when you are being crushed by a weight, it isn't that you are weak, it's that the weight is too heavy. I've seen you carry heavier weights than most people could carry. I'll do what I can to help you, but don't get discouraged with yourself. You aren't weak."

She paused in thought--thinking about all I have seen of her life and my qualification to make this pronouncement. She sighed, then nodded.

She knew that I knew.

As always, I have changed details about both of these situations to protect the identity of these patients.

This post appeared at Musings of a Distractible Mind. Rob Lamberts, ACP Member, writes the blog 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--Widespread health care cuts proposed to balance the budget

A bi-partisan Presidential commission suggested paying physicians less and ending the sustainable growth rate (SGR) reimbursement calculation as ways of balancing the federal budget.

The National Commission on Fiscal Responsibility and Reform, created by President Obama to draft policies to improve fiscal sustainability, proposed recommendations to balance the budget by 2015.

Health care is one of the five areas the commission reviewed, alongside others involving military spending and Social Security. For health care, the commission recommended (starting on page 31):
--pay doctors, other health providers and drug companies less and improve efficiency and quality;
--replace cuts required by SGR through 2015 with modest reductions while directing Medicare to create a new system;
--require rebates for brand-name drugs as a condition of participating in Medicare Part D;
--increase cost-sharing in Medicare; and
--enact comprehensive medical malpractice liability reform to cap non-economic and punitive damages and make other changes in tort law;

Other proposals would expand accountable care organizations and payment bundling, increase nominal Medicaid co-payments, and cut federal spending on graduate and indirect medical education, reported Modern Healthcare.

In the long term, the commission also recommended setting global targets for total federal health expenditures after 2020 (Medicare, Medicaid, CHIP, exchange subsidies, employer health exclusion), and reviewing costs every two years to keep growth at the Gross Domestic Product plus 1%. They would also overhaul the fee-for-service system.

At least 14 of the commissions's 18 members must approve the recommendations before the package can be sent to Congress for action. That vote is supposed to occur by Dec. 1.
Wednesday, November 10, 2010

QD: News Every Day--Lame duck Congress likely to trip over SGR cuts

Congress is facing pressure to take up another temporary patch to expected Medicare reimbursement cuts. First, Health and Human Services Secretary Kathleen Sebelius told the Association of American Medical Colleges that the best way to support Medicare would be to prevent the cuts. Then, the American Medical Association is running a publicity campaign that will urge Congress to pass a 13-month fix. Just six months ago, the AMA vowed only a permanent fix was appropriate. Congress is unlikely to make any headway when it reconvenes next week for one week. (Health and Human Services, AMerican Medical Association, The Hill, Modern Healthcare)

Meanwhile, one-fifth of smaller employers (10-499 employees) are looking to jettison health care plans once state exchanges come online, reporting the consulting firm Mercer. This is compared to 6% of companies with more than 500 employees and 3% of companies with more than 10,000 employees. Meanwhile, the government continues to grant waivers to encourage companies to keep their plans. This still doesn't look like the end of private insurance, survey authors noted. Four years after Massachusetts created universal coverage, enrollment in employer plans grew. Uninsured rates for non-elderly adults fell to 4.8%, a record low. (Mercer, New York Times, Health Affairs)
Tuesday, November 9, 2010

QD: News Every Day--Doctors are cutting ties with industry relationships

Physicians and particularly primary care doctors are reporting fewer industry ties than five years ago, according to a survey.

While 94% of doctors reported some type of perk from a drug or device maker in 2004, 83.8% did in 2009, researchers reported in the Nov. 8 Archives of Internal Medicine.

Christmas present by the Italian voice via FlickrResearchers surveyed a stratified random sample of 2,938 primary care physicians (internal medicine, family practice, and pediatrics) and specialists (cardiology, general surgery, psychiatry and anesthesiology) with a 64.4% response rate.

Of the 83.8% who reported some type of industry relationship:
--70.8% received gifts, primarily food and beverages in their offices (down from 83%),
--63.8% received drug samples (down from 78%),
--18.3% received reimbursements for meetings or free or subsidized admission to CME meetings (down from 35%),
--14.1% received payments for professional services to pharmaceutical companies (down from 28%), and
--the median number of meetings between physicians and industry representatives decreased from three per month to two.

Also, 23.2% of those with at least one industry interaction compared with 35.5% of physicians who didn't had never prescribed a brand-name drug when an equivalent generic was available. And, more frequent industry interactions are significantly and inversely associated with less Medicare spending.

The decline might have been caused by concentrated efforts by schools and hospitals, medical society policies, and the Physician Payment Sunshine Act. But, they added, it's also possible that time constraints on primary care doctors and financial pressure on companies' marketing budgets also contributed to fewer interactions.


It was a straightforward phone message (names changed): "Hey Dr. S., this is Bobbie Jones, April Dixon's granddaughter. I was calling to inform you that April Dixon passed away today at City Hospital. They said she was bleeding in her stomach or something; I'm not quite what sure what happened but she got real sick. But she's gone, so, thanks so much. You've been a real neat doctor, and it's been good working with you through the years taking care of my grandmother. Take care. Bye."

Bobbie Jones is a saint. Pure and simple. She took care of her 88-year-old grandmother with tender, loving care. I am certain if left to the vagaries of the "health care system" that her grandmother would have died at least three years ago; maybe longer.

Ms. Jones will get no recognition. No income. No honors, save this blog post which she'll never see. She will get a letter from me, expressing my condolences and appreciation for the love and care that she provided her grandma.

She singlehandedly advocated for an octogenarian with advanced dementia and probable cancer (we were never able to get a definitive diagnosis of it) and gave her a quality of life that I would want were I in her grandma's shoes.

I've read lots of stuff about caregiver burden. As you know, our population is aging because people are living longer on average than in eras past. The implications are many, but there are couple of things I see every day that I'd like to emphasize: Patients with caregivers do much better (i.e. feel better more often and live longer), and the caregivers usually neglect their own health. [Sometimes dangerously so. I have a couple of patients with dementia who have outlived their children, sadly.]

When you search the literature, you'll find a lot about caregiver burden. It emphasizes baby boomers who are caring for their aging parents. If you add the term "grandchild" to caregiver, you'll find articles mostly about grandparents raising their grandkids. But you won't find much about grandchildren taking care of their elders.

Where we live, in the shadow of GlassHospital, this is a fairly common arrangement.

Bobbie Jones is one such grandchild. I worry about her, since she's lost not only her dear Grandma, but the focus of her life. Her grief will no doubt be prolonged, and her "re-entry" to the job market, if it can be called that, will be difficult. What "marketable" skills does she have, save caregiving, in a society that vastly undervalues it?

With her expertise, some lucky elder will find a true blessing when Ms. Jones becomes their homemaker, home health aid or advocate.

My thoughts and prayers are with her.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.
Monday, November 8, 2010

First do no harm

One of the ancient principles of medicine is Primum non nocere, the Latin phrase that means "First, do no harm". It means that sometimes doing nothing is a better decision than doing something that might cause more harm than good. It is an ethical precept for physicians, but it becomes harder and harder to adhere to as more and more exotic tests and treatments are at our disposal.

But just because we can do tests or surgery, doesn't mean we should. Looking at the whole patient; their lifestyle, beliefs, support system and activity level, should be part of the analysis and decision.

There are so many ways and times in treating patients, that doing nothing can be the best decision. A prime example is Mr. Leon Sanit, who is 97 years old. Mr. Sanit lives in Los Angeles and plays tennis every single day at 11 a.m. He was diagnosed with bladder cancer and doctors recommended surgery that had a 50% chance of extending his life. Here is a guy with an active life, playing tennis at age 97, who has wisely decided to forgo surgery and just enjoy himself.

The risks of surgery in a 97-year-old person are considerable. The convalescence and recovery itself are risky and would certainly impact the good time he has left in his life. The odds of him ever being back on the tennis court are considerably lower than the chance he would live longer.

I know of another elderly man (a friend's father) who had prostate surgery for prostate cancer, even though he was over 80 years old and had a lower Gleason score, which means it is a slower growing form of cancer. I was upset to learn his physicians had recommended surgery. He had a bad post-op course and never really returned to his pre-op activity level. He died within a year of the surgery. Doing something was worse than doing nothing.

One way patients can help a doctor stop and consider the recommendation for surgery or treatment is to ask, "If this were your mother/father/wife, would this be the treatment you would recommend?" At the very least it slows the process down and makes it a more thoughtful one.

This post originally appeared at Everything Health. Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

QD: News Every Day--Shut down the government and blame the opposition for it

The assault on health care reform has begun in earnest. What will begin as "trench warfare" over a piece-by-piece rollback of the legislation--for example, defunding the Internal Revenue Service so it couldn't enforce tax penalties on business and individuals who don't comply with health insurance requirements--could escalate into a government shut-down (and Republicans are already blaming the President for any eventual gridlock.) (AP, The Fiscal Times, The New York Times, MSNBC)

But think-tankers warn that success in chipping away at health care reform would weaken any eventual effort to fully repeal it. And, they acknowledge, repealing some parts would raise the deficit. President Obama acknowledged that the political toll has been costlier than expected, and that health care reform has been a long-avoided issue for exactly that reason. (Kaiser Health News, AFP)

Considering cholera and the recent outbreak in Haiti

Cholera was a far-away kind of affliction, almost an abstraction, when I first studied microbiology in 1984. The legendary, infectious scourge still affected people in places like Bangladesh or Indonesia, but was a treatable condition that, surely, would be eradicated within a decade or so through progress, if you could call it that, like basic plumbing and sanitation.

The tiny, comma-shaped bacteria, Vibrio cholerae, tend to thrive in brackish water, the kind that's just a bit salty from a mix of ocean and fresh sources. These sometimes stagnant watery places crop up in river deltas, like the Ganges, and coastal estuaries such as those along the U.S. Gulf Coast. We learned that you might, very rarely, pick up a case of cholera by eating contaminated shellfish like crabs or oysters.

The most common symptom of cholera is diarrhea, so rapid and voluminous that a person can die, quickly if without remedy, by straightforward dehydration. The diagnosis of cholera can be tricky, as many people are afflicted with severe gastrointestinal diseases worldwide, but most don't have this particular potent, toxic germ. Cholera spreads by contamination of infected human feces in the water supply. The disease can afflict people who drink tainted water, who touch it and then put unclean fingers into their mouths, as children do, and who eat food prepared by those with affected hands.

Dr. John Snow, an anesthesiologist and founder of public health, recognized the means of cholera's spread more than 150 years ago in London, where he became famous for mandating the closure of the Broad Street Pump. Snow died at the age of 45, of what was said to be apoplexy, old jargon for a stroke.

In 2009, there were 221,226 cholera cases reported and 4,946 cholera deaths in 45 countries, according to the CDC. Based on information put together by the World Health Organization, the case-fatality rate is 2.24%. A trend in recent years is that the overwhelming majority of cases, roughly 99%, are reported in Africa.

According to the 17th edition of Harrison's Principles of Internal Medicine, there have been seven global cholera pandemics since 1817. The current rage, attributed primarily to the El Tor biotype, started in Indonesia around 1961. That strain spread, eventually, as far as coastal Peru in the early 1990s. There have been no cholera epidemics in North America since the middle of the 19th Century.

What's happening in Haiti now is the real deal, says the CDC. Thousands are infected, mainly in towns along the Artibonite River, which squiggles on the map and in real terrain through the western section of Hispaniola, north of Haiti's capital, Port-Au-Prince. Among other concerns are the vast numbers of people living without toilets in tent cities and slums outside of the capital, especially since an earthquake devastated the region last January.

The CDC offers some very practical tips for people who live or travel in areas where cholera is endemic. Most people who are exposed to cholera and survive become immune, although infectious strains vary and immunity may not be long-lasting. In the U.S. there is no available vaccine for cholera, according to the CDC. Treatment consists primarily of giving electrolyte solutions, for rehydration, and antibiotics in some cases.

Now, the mortality rate from cholera in Haiti is running just under 10%, according to today's news. Hopefully, doctors from Medecins Sans Frontieres and other agencies working in the region will get this epidemic under control. But already it's clear that hundreds of lives have been lost to an illness that it seems should have been eradicated long ago.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.