Houston's Clear Thinkers

January 7, 2010

What killed F.D.R.?

This interesting Lawrence Altman/NY Times article examines the theory that that an undiagnosed melanoma contributed to the death of President Franklin Delano Roosevent in 1945.

Of course, regular readers of this blog know that another killer disease -- the dire implications of which were not well-known in 1945 -- was probably the main cause of FDR's death.

But despite the historical curiosity, the most important point to glean from FDR's demise is the importance of continued investment in clinical and scientific research.

We sometimes forget that it was the generation of doctors and researchers who came of age after World War II who embraced the optimistic view of therapeutic intervention in the practice of medicine, which was a fundamental change from the sense of therapeutic powerlessness that was taught to these men by their pre-WWII professors. In short, it has not been that long since medical science has understood that it could cure disease and prolong life.

For example, if FDR's doctors had known in 1945 what specialists in hypertension discovered in the two following decades, then those doctors would never have allowed FDR to be subjected to the stress of the Yalta Conference that doomed Eastern Europe to almost 50 years of totalitarianism and economic deprivation.

Stated simply, earlier discovery of the research into the implications of hypertension could well have changed the course of human history.

In fact, we all tend to under-appreciate the advancements in medicine since World War II. For male babies born in the U.S. in 1960, the life expectancy was about 66.5 years and for female babies a tad over 73 years. By 2005, the live expectancies had increased to over 75 and 80 years respectively. Although medical advances don't account for all of those gains, newly-discovered drugs and medical devices -- as well as enhanced understanding of disease -- have had an enormous impact on improving the quality of life of most Americans.

Thus, as Congress considers reforming the U.S. health care finance system, it is important for citizens to understand that American medical care and research remains the hope of the world. The current health care finance system has generated enormous investment in that medical innovation, which has been a crucial and treasured export of America to the rest of the world.

Let's think hard before radically changing a system that generated the investment that produced those benefits for us and the rest of the world.

Posted by Tom at 12:01 AM | Comments (1) | TrackBack (0)

December 16, 2009

Criminalizing the neighborhood pharmacist

This blog has long addressed the enormous cost to American society of overcriminalization generally and particularly with regard to business and risk-taking.

But lest we think that the problem is limited to such things as business and victimless crimes, think again says Bob Wachter:

Along comes another case involving jail time for a medical mistake, this one featuring an Ohio pharmacist named Eric Cropp.

Eric was the lead pharmacist at Cleveland’s Rainbow Babies and Children’s Hospital on February 26, 2006. The pharmacy, understaffed that day, received a rush order for chemotherapy for a 2-year-old girl, Emily Jerry, who was undergoing treatment for a spinal malignancy.

An unlicensed and distracted (by press accounts, she was planning her wedding on the day of the event) pharmacy technician mistakenly mixed the chemo with 23% saline rather than the intended 0.9%. Eric, working in cramped quarters and rushed for time, gave final approval to the mixture, partly because, after seeing a spent bag of 0.9% saline next to the mixed solution, he assumed that it had gone into the solution.

In other words, the case was a classic illustration of James Reason’s Swiss cheese model, in which numerous safety checks failed due to a confluence of systems and human errors. Tragically, little Emily died from the hypertonic saline infusion.

On hearing of the error, a Cuyahoga County DA decided that the case merited criminal prosecution, even though Eric had no history of errors in his pharmacy career and root cause analysis of the case confirmed that its cause was simple human error compounded by systems problems. At trial, fearing even harsher penalties, Eric pleaded guilty to involuntary manslaughter, and was sentenced to 6 months in the state prison, 6 months of home confinement, 3 years of probation, 400 hours of community service, and a $5,000 fine. Moreover, the Ohio pharmacy board permanently stripped him of his license, depriving him of his livelihood – forever.  .  .  .

During last week’s webcast, Mike Cohen described visiting Eric in prison. “Like a scene out of a movie,” he recalled, with Eric in his orange jumpsuit, speaking to visitors through a glass wall, other felons – including violent offenders – milling about. As he related the visit, Mike choked up with emotion, clearly seeing this tale as both powerfully tragic and cautionary.

How has it come to the point where the criminal justice system exacerbates the tragedy of a young girl's accidental death by ruining a career and inflicting enormous damage on an innocent family? At least the young girl's family recovered substantial financial damages resulting from the pharmacist's negligence. Where does the young pharmacist's family turn for help?

A truly civil society would find a better way.

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

October 7, 2009

Fat chance

A couple of interesting health care-related items caught my eye today.

First, I went by my internist's office for my annual physical and noticed that another group of doctors had leased a much larger office across the hall from my doctor's office.

I peaked inside the new doctors' office window and noticed that the reception area was nicely furnished with plush leather sofas and chairs, flat screen TV's, handsome hardwood flooring and tasteful Persian rugs.

The opulence of the office prompted me to find out what kind of doctors were apparently doing so well, so I grabbed one of the doctor's cards from the reception area. It read (not the real name):

"John Smith, M.D., Laparoscopic Obesity Surgery"

Meanwhile, this NY Times article reveals the utterly unsurprising fact that New York City regulations requiring fast food restaurants to post the caloric content of their food did not induce obese consumers from eating less:

A study of New York City’s pioneering law on posting calories in restaurant chains suggests that when it comes to deciding what to order, people’s stomachs are more powerful than their brains.

The study, by several professors at New York University and Yale, tracked customers at four fast-food chains — McDonald’s, Wendy’s, Burger King and Kentucky Fried Chicken — in poor neighborhoods of New York City where there are high rates of obesity.

It found that about half the customers noticed the calorie counts, which were prominently posted on menu boards. About 28 percent of those who noticed them said the information had influenced their ordering, and 9 out of 10 of those said they had made healthier choices as a result.

But when the researchers checked receipts afterward, they found that people had, in fact, ordered slightly more calories than the typical customer had before the labeling law went into effect, in July 2008.

The findings, to be published Tuesday in the online version of the journal Health Affairs come amid the spreading popularity of calorie-counting proposals as a way to improve public health across the country.

“I think it does show us that labels are not enough,” Brian Elbel, an assistant professor at the New York University School of Medicine and the lead author of the study, said in an interview.

"Labels are not enough?" Makes one wonder what regulation Professor Elbel will suggest next -- maybe governmental rationing of fast food?

The argument in favor of these types of absurd governmental intrusions into our lives is that government subsidizes medical insurance, so government should attempt through regulation to decrease obesity, which unfairly heaps a portion of health-care costs relating to obesity on tax-paying citizens who are not obese.

But putting aside for a moment the debatable notion of whether obesity really increases health-care costs all that much, the far more effective regulation to decrease obesity would be to provide a financial incentive for citizens to lose weight. Namely, reduce the governmental subsidy of medical insurance for those who choose to remain obese.

Fat chance of that happening.

Posted by Tom at 12:01 AM | Comments (2) | TrackBack (0)

August 31, 2009

Rationing health care in a disaster

If you read one article health care-related this week, make it this extraordinary Sheri Fink/NY Times Magazine article on the impossible choices that the heroic doctors -- including Dr. Anna Pou -- faced at the former Memorial Medical Center in New Orleans in rationing limited medical and evacuation services for their patients during the chaotic aftermath of Hurricane Katrina.

Ms. Fink summarizes the issues raised by the issues that Dr. Pou and her colleagues well:

The story of Memorial Medical Center raises other questions:

Which patients should get a share of limited resources, and who decides?

What does it mean to do the greatest good for the greatest number, and does that end justify all means?

Where is the line between appropriate comfort care and mercy killing?

How, if at all, should doctors and nurses be held accountable for their actions in the most desperate of circumstances, especially when their government fails them?

Interestingly, after the federal, state and local governments largely failed the doctors, other workers and patients at Memorial in the aftermath of Katrina, get a load of how the government forces acted once the decision was made to arrest Dr. Pou:

AT ABOUT 9 P.M. on July 17, 2006 — nearly a year after floodwaters from Katrina swamped Memorial hospital — Pou opened the door of her home to find state and federal agents, clad in body armor and carrying weapons. They told her they had a warrant for her arrest on four counts of principal to second-degree murder.

Pou was wearing rumpled surgical scrubs from several hours of surgery she performed earlier in the day. She knew she was a target of the investigation, but her lawyer thought he had assurance that she could surrender voluntarily. “What about my patients?” she asked reflexively. An agent suggested that Pou call a colleague to take over their care. She was allowed to freshen up and then was read her rights, handcuffed and ultimately driven to the Orleans Parish jail.  .   .   .

Read the entire article. Whose judgment do you trust more? Dr. Pou and her colleagues? Or that of those governmental officials who decided to arrest her?

Posted by Tom at 12:01 AM | Comments (3) | TrackBack (0)

August 24, 2009

The evolution of primary care

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

July 6, 2009

The Homeopathic ER

An instant classic from That Mitchell and Webb Look (H/T Kevin, M.D.). Enjoy.

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

July 1, 2009

The tough choices of health care finance reform

Following on a point made in this recent post, this Avery Johnson/WSJ article addresses one of the tough issues that must be addressed if there is going to be any meaningful reform of the U.S. health care finance system:

The widespread use of expensive cancer drugs to prolong patients’ lives by just weeks or months was called into question by an article published Monday in the Journal of the National Cancer Institute.

Crunching data from published studies, the authors found that treating a lung-cancer patient with Erbitux, a drug that costs $80,000 for an 18-week regimen, prolongs survival by only 1.2 months.

Based on that estimate, extending the lives of the 550,000 Americans who die of cancer annually by one year would then cost $440 billion, they extrapolated.

How to control escalating spending on end-of-life care is one of the thorniest questions facing lawmakers working on the overhaul of the U.S. health-care system. [.  .  .]

“Many Americans would not regard a 1.2-month survival advantage as ‘significant’ progress,” the authors wrote. “But would an individual patient disagree? Although we lack the answer to that question, we would suggest that the death of a mother of four at age 37 years would be no less painful were it to occur at age 37 years and 1 month, nor would the passing of a 67-year-old who planned to travel after retiring be any less difficult for the spouse were it to have occurred one month later.”

While some policy experts consider the rationing of health-care resources inevitable in the quest to control medical spending, many Americans have long resisted putting the collective fiscal good over their individual health.  .   .   .

Read the entire article. I have many reservations about the direction of the Obama Administration's proposed reforms of the U.S. health care finance system. But that the proposed reforms are triggering discussion of key issues such as the one set forth above is not one of them.

Posted by Tom at 12:01 AM | Comments (2) | TrackBack (0)

June 15, 2009

Will Obama address this key health care finance issue?

Marginal Revolution's Tyler Cowen penned this insightful NY times op-ed over the weekend that addresses the problem of the elephant in the parlor in regard to Obama's proposed reform of America's dysfunctional health care finance system:

MEDICARE expenditures threaten to crush the federal budget, yet the Obama administration is proposing that we start by spending more now so we can spend less later.

This runs the risk of becoming the new voodoo economics. If we can’t realize significant savings in health care costs now, don’t expect savings in the future, either.

It’s not the profits of the drug companies or the overhead of the insurance companies that make American health care so expensive, but the financial incentives for doctors and medical institutions to recommend more procedures, whether or not they are effective. So far, the American people have been unwilling to say no.

Drawing upon the ideas of the Harvard economist David Cutler, the Obama administration talks of empowering an independent board of experts to judge the comparative effectiveness of health care expenditures; the goal is to limit or withdraw Medicare support for ineffective ones. This idea is long overdue, and the critics who contend that it amounts to “rationing” or “the government telling you which medical treatments you can have” are missing the point. The motivating idea is the old conservative chestnut that not every private-sector expenditure deserves a government subsidy.

Nonetheless, this principle is radical in its implications and has met with resistance. In particular, Congress has not been willing to give up its power over what is perhaps the government’s single most important program, nor should we expect such a surrender of power in the future. There is already a Medicare Advisory Payment Commission, but it isn’t allowed to actually cut costs. [. . .]

Those cuts alone will not solve the fiscal problem, but if we aren’t willing to take even limited steps to conserve resources, we shouldn’t be spending any more money elsewhere. [.  .  .]

The demand for universal coverage sounds like a moral imperative to “take care of everybody,” but in reality it would make only a marginal difference when it comes to the overall health of the American population. The sober reality is that universal coverage is another way to spend money, which may or may not be a good idea.

The most likely possibility is that the government will spend more on health care today, promise to realize savings tomorrow and never succeed in lowering costs. It is rare that governments successfully cut costs by first spending more money.

Mr. Obama has pledged to be a fiscally responsible president. This is the biggest chance so far to see whether he means it.

Read the entire op-ed. Any reform of the U.S. health care finance system will not be successful in controlling costs unless or until a consensus is reached on a fundamental issue that most Americans do not even want to discuss -- that is, what is the basic level of health care that every individual in the U.S. is entitled to receive regardless of cost? For example, what level of care is an insolvent, uninsured, illegal immigrant entitled to receive? How much care should we be willing to subsidize to extend the life of a seriously-ill 90 year-old?  A terminally-ill 50 year-old? These are thorny issues, but they must be addressed if we are ever going to achieve a coherently-financed health care system.

As Arnold Kling has been saying for years, many of us live under the delusion that we cannot possibly afford health care if we pay for it individually, but of course we can afford it if we pay for it collectively. For those of you who think that the government can magically make health care more affordable, just remember what happened after the government directed Fannie Mae and Freddie Mac to make home ownership more affordable.

Update:Charles Kenny makes a good point that better health care is not necessarily expensive.

Update II: Steve Chapman chimes in with a timely observation:

There are only three ways to pay for this expansion of health insurance coverage: increased taxes, reduced benefits, or shiny gold ingots falling out of the sky. Voters emphatically prefer the latter option, so that is the one most likely to be embraced by Congress and the administration.

Update III: Arnold Kling notes the problems with Obama's "dessert now, spinach later" approach.

Posted by Tom at 12:01 AM | Comments (3) | TrackBack (0)

June 3, 2009

Nice job, Doc

Check out this Lisa Sanders/NY Times article if you think that a trail of specialists is the surest way to figure out a knotty medical problem:

How come not one of the dozens of doctors — including an endocrinologist — that he saw over the nearly 15 years of interrupted sleep and other symptoms figured out that he had acromegaly? Perhaps because the various symptoms of his tumor were, for the most part, common problems: insomnia, high blood pressure, allergies and acne. They developed separately, years apart, and each was addressed by a specialist. It would take an act of imagination to link these symptoms. The patient never made that leap, and neither did any of his doctors. [.  .   .]

Not long after meeting [the doctor who finally made the correct diagnosis], the patient visited his primary-care doctor — the doctor who had known him for years — and told her that acromegaly was being considered. No way, she first told him. But sitting there, looking at his face and thinking about the changes caused by this disease, she began to reconsider. He did have the characteristically broad chin and nose. He was wearing braces because of changes in his jaw and teeth. His hands were huge. Suddenly, she could see the possibilities. Maybe he did have acromegaly.

The diagnosis was staring her in the face for years, but she did not see it. Psychologists call this inattention blindness — instances when we don’t see something because it’s not what we are expecting to see; it’s not what we are looking for. Sherlock Holmes had a somewhat different description. “I have trained myself to notice what I see,” Holmes says.Arthur Conan Doyle, himself a physician, imbued his character with the kind of keen observational skills so essential to a good physician. This ability consists of casting a wide net to see the whole picture — even when the complaint that brings the patient to medical attention is commonplace, like insomnia.

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

May 6, 2009

A big risk of health care finance reform

In addressing issues relating to health care and health care finance reform over the years, I've tried to be careful to differentiate America's Byzantine and inefficient health care finance system from the quality of America's health care, which remains very good overall.

But strains in the quality of care are definitely beginning to show as America's existing health care finance system crumbles under the weight of, among other things, excess government regulation on medical insurance markets, unrealistic expectations regarding the supply and allocation of medical resources, over-reliance on third-party payors and the failure of American society to confront the issues pertaining to the limits of care.

The following is an email from a friend of mine, who is a first-rate internist who has been working as a hospitalist for the past several years. He is preparing to leave a hospital for which he has worked for the past couple of years because of the failure of the hospital's administration to address worsening working conditions for the hospital's primary care physicians:

I'm down to ten days left there, and those days can't go by fast enough for me.

The average number of admissions in a weekday day shift (7 a.m. to 7 p.m.) is 12.

We had 23 yesterday.

When you take the standard estimate of an average of 75 minutes necessary to complete a new patient admission to the hospital -- with the attendant patient interview and data collection, physical exam, review of lab and x-ray results, formulation of treatment plan, preparation of admission orders, and dictation of the official patient history & physical for the medical record -- the amount of work requested from our hospitalist group yesterday was 13+ hours over average. This is more than another full-time equivalent doctor, yet we can't persuade the national hospitalist company managing the hospital to provide any more help for us.

As a consequence of the barrage of admissions, I did not complete my "morning" rounds on existing hospital patients until 6 p.m.  There were a couple of patients who could have been discharged from the hospital yesterday, but by the time we got to them, it was too late in the day to discharge them (area nursing homes won't take transfers after 2 p.m.).

As you can imagine, this type of delay causes longer length-of-stay and more expense for the system.  And this does not even begin to address the mistakes in care that may have been (or more likely WERE) made due to all of us rushing around as if we were in a 12-hour long fire drill.

It's a bad way to practice medicine.

Contrast this to my new situation, which is a hospital-administered program. They believe in and adhere to the notion that the risk is high that patient care is likely to suffer once a doctor is required to see more than 15 hospitalized patients per day. Inasmuch as they don't have the heavy administrative overhead that national hospitalist companies are required to service, my new hospital can allow their docs to work at a more controlled pace and still make ends meet.

Ten more shifts and I'm gone.

Thanks for letting me vent.

Believe me, my friend is the type of doctor that you want to have taking care of you if you find yourself in the hospital. That a hospital administration is willing to let him get away is a sure warning sign that the problems in the health care finance sector are adversely affecting the quality of care.

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

April 15, 2009

Defining Health Insurance

All sorts of interesting debates regarding reform of the American health care finance are breaking out across the blogosphere, which is a good thing.

Those discussions prompted one of the best thinkers on health care finance reform -- Clear Thinkers favorite Arnold Kling -- to provide a particularly lucid explanation of the illusory nature of American health insurance and, in so doing, highlight one of the key issues to implementing reform of the current system:

Let me offer two choices:

(a) Health insurance is the collective provision of all health care.

(b) Health insurance is the sharing of extreme risk in health care spending.

In my view, (a) represents what most people think of as good health insurance. For example, I have a friend who says her health insurance is great because she can get new eyeglasses every year for everyone in her family for a co-payment of only $10.

We have never observed (b). (b) would mean something where you only make a claim when your expenses are going to run into the tens of thousands of dollars. Claims would be rare and large, as in fire insurance. Premiums would be low, as in fire insurance.

Since we never have observed (b), we do not know whether it is something that could be provided by the market or would have to be provided by government. I am willing to concede that it may be the latter. However, what most people mean by universal health coverage is (a), which has some pretty obvious incentive problems. [.  .  .]

The bottom line is that what we think of as health insurance is not going to survive if we are going to get control of health care costs. Either health insurance is going to become very intrusive about our choices of medical services (the top-down, government option, under the guise of "health care quality"), or we are going to see much higher deductibles and co-payments (the bottom-up option).

Posted by Tom at 12:01 AM | Comments (1) | TrackBack (0)

April 8, 2009

Rationing health care

One of the common complaints heard regarding government-controlled, single payor health care finance systems is that they ration care in a manner that often results in long delays for even routine procedures.

However, as this MedPage blog post points out, private providers in America's Byzantine health care finance system also ration care, and the results aren't all that satisfying, either.

Meanwhile, this NY Times article reports on how many private physicians are rationing care by choosing not to accept patients who use Medicare for payment because the net reimbursement for services rendered is simply not worth it. The article also notes the growing trend of physicians opting for a concierge practice, a development that is the subject of earlier posts here and here.

Finally, Arnold Kling, who has done some of the best thinking on health care finance in the blogosphere over the past five years, sums up a big problem with the way in which the American system currently rations care:

In America, about 90 percent of health care spending is paid for by third parties--most individuals do not fend for themselves.  .  .  . My view of the American health care system is that it hardly rations health care at all. That is why we spend so much more than other countries. I wish we put more responsibility on individuals. Instead, we have this delusion that we cannot possibly afford health care if we pay for it individually, but of course we can afford it if we pay for it collectively.

Posted by Tom at 12:01 AM | Comments (1) | TrackBack (0)

April 1, 2009

The Postrel Health Care Finance Articles

Clear Thinkers favorite Virginia Postrel (previous posts here) is well-known in health care finance circles for her authorship of a reasoned critique of one-payor, centralized health care plans back in the 1990's. She now writes for The Atlantic.

Over the past year or so, Virginia has been experiencing serious health care issues, so she has recently penned two extraordinary articles in The Atlantic (here and here) chronicling her personal experience with America's Byzantine health care finance system. Both articles are must-reads for anyone interested in these important issues, but here are a couple of snippets from the second article that are representative of the wisdom that Virginia provides:

Mr. Daily [a critic] shares a common belief, expressed less dramatically in other letters, that there is somewhere a pot of money dedicated to “health care” which “society” divides between winners and losers. In the United States, at least, there is no health care pot, any more than there is a pot for housing or education or magazine subscriptions. There is simply an economy, which includes health care among other goods, and the amount we spend on health care grows out of the largely decentralized decisions made by individuals and organizations. As productivity increases and prices drop in some areas—food, clothes, entertainment—we can afford to spend more on health care (even without overall economic growth or increased health-care efficiency). [.  .  .]

.  .  . We do not currently treat health care as a right. That we don’t is, in fact, what most letter writers are objecting to. Neither do we regard it exactly as a privilege, to be allocated to the worthy few or even to be limited to those who can afford to pay for it, directly or indirectly. Rather, it is a good, produced and purchased in a complex marketplace through a combination of individual, organizational, and political decisions.

Even this formulation is misleading, however. Health care isn’t a single good, nor, like food, is it easily defined in terms of a minimum to sustain life. Studying other countries’ supposedly universal systems only demonstrates how fraught the concept of “health care” is: one bundle of services in British Columbia and a less-generous one in Nova Scotia, one in England and another in Scotland, one in New Zealand before the election and another afterwards. Arguably the U.S. already has universal care, in the sense that everyone can get some care—if only from an emergency room—for some things, and that citizens (a critical word in this context) without money are covered by Medicaid.

The real issue is how you define “health care.” What gets included is a matter not only of medicine and economics but of culture and politics.

What limitations on health care are Americans willing to accept in return for universal coverage? That is one of the core issues that those who are currently crafting health care finance reform are assiduously avoiding. But true reform will never occur without addressing that issue.

Posted by Tom at 12:01 AM | Comments (1) | TrackBack (0)

February 14, 2009

An unintended consequence of drug prohibition

While this post from earlier in the week highlighted the historical backdrop to the United States' failed drug prohibition policy, this Telegraph.co.uk article passes along an unintended consequence of that policy that should put to rest any concerns about reconsidering it:

The Home Office has admitted that the street price of both cocaine and heroin has fallen by nearly half in the last ten years, making the most dangerous illegal drugs cheaper than they have ever been.

That means a line of cocaine can cost as little as £1, with an average price per line of between £2 and £4.

The average price of a pint of lager is around £2.75, although some pub chains have reacted to the credit crunch by cutting the price of a pint as low as 99p. A glass of wine typically costs £3.50.  .  .  .

Posted by Tom at 12:01 AM | Comments (3) | TrackBack (0)

January 31, 2009

Vitals

Vitals is an ambitious project -- providing free information and patient ratings on doctors throughout the U.S.

I've checked on a number of my doctor friends and every one of them is included in the database, so it appears to be quite thorough. Inasmuch as the project is quite new, there are not many patient reviews yet. But the information provided is cleanly presented and quite helpful.

My sense is that this is a very good idea.

Posted by Tom at 12:01 AM | Comments (4) | TrackBack (0)

January 23, 2009

Thinking about Ted Kennedy's health care

As the Obama Adminstration begins exploring how to reform America's broken health care finance system, Kevin Pho makes an insightful observation regarding the current medical treatment of one of the leading reformers:

As we know, Massachusetts Senator Ted Kennedy has an advanced stage brain tumor, and was recently hospitalized for a seizure.

Seizures are a common side effect of malignant brain tumors, and often controlled with a variety of anti-seizure medications. There will be times where seizures can break through medication control, leading to the frightening episode that occurred on Inauguration Day.

Family physician Doug Farrago asks some pointed questions about the stellar care that the Senator receives, observing that "he travels around with a team of physicians," and, "most patients in [Senator Kennedy's condition] usually are in hospice care."

Senator Kennedy should be commended for his efforts to bring about health care reform. But is the care he is receiving, including instant opinions and access from revered institutions like Massachusetts General Hospital and Duke University Medical Center, representative of the kind of care he's advocating for the American public?

Posted by Tom at 12:01 AM | Comments (3) | TrackBack (0)

January 16, 2009

Marathon madness

The annual running of the Houston Marathon is this weekend, so the Houston Chronicle is running its typical series of supposedly inspiring stories about various participants.

A couple of days ago, the story was about a couple of folks who had lost huge amounts of weight while training for marathons. Richard Justice wrote this column about some fellow who is so obsessive about running that he has run in "82 marathons across 26 years, four continents and 29 states."

Yesterday's Chronicle article, however, takes the cake. Check out the headline:

Sunday’s race will be extra special for Stacie Rubin, who will be competing five months after suffering a heart attack

The story goes on to describe a Kingwood mother of four children who has run long distances daily for years. She had a heart attack while training one day and didn't even go to the doctor's office for several days because she was so convinced that someone as "healthy" as her could not have anything seriously wrong with her. Even after the heart attack, she was so obsessed about her long-distance training that she was back running again within a couple of weeks of the heart attack and is now planning on running in the marathon this weekend.

The Chronicle article presents all of this as heroic and the epitome of physical fitness.

Frankly, I think these stories are grossly misleading and the people telling them are badly misguided.

In my younger days, I used to run long-distances, too. I even ran a 37 minute flat 10K -- 6.2 miles -- once. As with most folks in my generation, I bought into the myth that long-distance running was excellent aerobic exercise that allowed me to maintain good health while eating most anything I wanted.

However, about 15 years ago, after falling out of shape during a busy time in my practice, I decided to do some extensive research into exercise protocols and nutrition to put myself back on track. After about six months of research, I concluded that most of my pre-conceived notions about exercise and nutrition were flat-out wrong.

For example, I discovered that long-distance running is neither a particularly healthy form of exercise nor an effective method of weight control.

Note, for example, this abstract from the a study published in the Annals of the New York Academy of Sciences:

Ann N Y Acad Sci. 1977;301:593-619. Related Articles, Links

Coronary heart disease in marathon runners.

Noakes T, Opie L, Beck W, McKechnie J, Benchimol A, Desser K.

Six highly trained marathon runners developed myocardial infarction. One of the two cases of clinically diagnosed myocardial infarction was fatal, and there were four cases of angiographically-proven infarction. Two athletes had significant arterial disease of two major coronary arteries, a third had stenosis of the anterior descending and the fourth of the right coronary artery. All these athletes had warning symptoms. Three of them completed marathon races despite symptoms, one athlete running more than 20 miles after the onset of exertional discomfort to complete the 56 mile Comrades Marathon. In spite of developing chest pain, another athlete who died had continued training for three weeks, including a 40 mile run. Two other athletes also continued to train with chest pain. We conclude that the marathon runners studied were not immune to coronary heart disease, nor to coronary atherosclerosis and that high levels of physical fitness did not guarantee the absence of significant cardiovascular disease. In addition, the relationship of exercise and myocardial infarction was complex because two athletes developed myocardial infarction during marathon running in the absence of complete coronary artery occlusion. We stress that marathon runners, like other sportsmen, should be warned of the serious significance of the development of exertional symptoms. Our conclusions do not reflect on the possible value of exercise in the prevention of coronary heart disease. Rather we refute exaggerated claims that marathon running provides complete immunity from coronary heart disease.

This recent University of Maryland Medical Center study examines another health risk of long-distance running.

Art DeVany -- who has been studying physiology and exercise protocols for years -- has written a series of blog posts over the years regarding the unhealthy nature and outright dangers of long-distance running. DeVany points out that many endurance runners in fact are not particularly healthy people, often suffering from lack of muscle mass, overuse injuries, dangerous inflammation and dubious nutrition.

Similarly, in this timely article, Mark Sisson lucidly explains why endurance training is hazardous to one's health. Here is a snippet:

The problem with many, if not most, age group endurance athletes is that the low-level training gets out of hand. They overtrain in their exuberance to excel at racing, and they over consume carbohydrates in an effort to stay fueled. The result is that over the years, their muscle mass, immune function, and testosterone decrease, while their cortisol, insulin and oxidative output increase (unless you work so hard that you actually exhaust the adrenals, introducing an even more disconcerting scenario). Any anti-aging doc will tell you that if you do this long enough, you will hasten, rather than retard, the aging process. Studies have shown an increase in mortality when weekly caloric expenditure exceeds 4,000. [. . .]

Now, what does all this mean for the generation of us who bought into Ken Cooper’s "more aerobics is better" philosophy? Is it too late to get on the anti-aging train? Hey, we're still probably a lot better off than our college classmates who gained 60 pounds and can't walk up a flight of stairs. Sure, we may look a little older and move a little slower than we'd like, but there's still time to readjust the training to fit our DNA blueprint. Maybe just move a little slower, lift some weights, do some yoga and eat right and there's a good chance you'll maximize the quality of your remaining years… and look good doing whatever you do.

In this recent post, Sisson describes a weekly method of aerobic exercise that provides most of the health benefit derived from long-distance running at a fraction of the time expenditure and at far less risk of injury. Add in a couple of short (about 20-25 minutes sessions) weight-training sessions per week to maintain your lead body mass, lead an active recreational lifestyle and observe balanced nutrition, and you are likely to be far healthier than the folks who are spending untold hours beating themselves up running long-distances.

If you are interested in developing such a plan, check out both DeVany and Sisson's blogs. They provide a wealth of information on how to tailor an efficient exercise and nutrition plan.

Posted by Tom at 12:01 AM | Comments (1) | TrackBack (0)

October 28, 2008

Placebo Nation

In light of this NY Times article reporting that half of American doctors responding to a nationwide survey regularly prescribe placebos to their patients, I pass along the following business opportunity, courtesy of the ever-clever Dr. Boli:

Posted by Tom at 12:01 AM | Comments (1) | TrackBack (0)

October 3, 2008

Following up on my concierge health care experience

This post from about a year ago explored the reasons why my friend and personal physician -- internist Bill Lent, MD -- decided to convert his internal medicine practice to a concierge practice in which he limited his practice to 600 patients who pay $1,500 per year to retain his services. Inasmuch as I am blessed with good health, the only time I see Bill in most years is for my annual physical, which was this past week. As always, it was good to catch up with him and hear his thoughts about the first year of a concierge practice.

In short, Bill's experience has been overwhelmingly positive. The funds generated through his patients' retainer payments have relieved Bill of the financial pressure that had been mounting over the past decade to increase patient visits as Medicare and private medical insurers systematically reduced the amount paid to doctors for such visits. Released from that pressure, Bill is now able to spend more time with each patient, which Bill believes provides the patient with better quality service. The response from Bill's patients has been uniformly positive.

Although Bill's workload has been reduced from the standpoint that he no longer feels compelled to see more and more patients to maintain revenue levels in the face of reduced insurance payments, Bill has had to spend quite a bit of time over the past year in the process of computerizing his patients records. Part of the deal for patients in signing up for the concierge service is that their records are digitized so that the patient, Bill or any other doctor who the patient retains can review the records from anywhere via the Web. That perk has required a considerable expenditure of effort over the past year in digitizing those records, but now that the process is largely complete, Bill will spend far less time in future years as he simply amends a patient's computerized record with each visit.

There have been a number of pleasant surprises in Bill's first year of the concierge practice. For example, Bill was initially concerned that a number of his less affluent patients would opt not to participate because of the retainer payment. Surprisingly, however, his patient base has remained quite diverse from a socioeconomic standpoint -- even a large number of his elderly patients on Medicare elected to participate despite the fact that Medicare doesn't cover any of the retainer payment.

One of those is a long-time patient who is a retired bus driver with a host of medical problems that Bill has helped control for years. Rather than taking the risk of moving on to another physician, the retired bus driver's five children decided to split payment of the retainer between themselves so that their father could remain one of Bill's patients.

But the most pleasant aspect of the concierge practice is that Bill is back to doing what he loves to do -- taking the requisite amount of time to visit with patients about their symptoms and then diagnosing the nature of the problem. He no longer feels rushed to complete a patient visit so that he can move on to the next patient in an effort to fill his quota for the day.

Bill did have one foreboding experience in the transition to a concierge practice. Being the kind of fellow that he is, Bill offered at no cost to his former patients who opted out of the concierge practice to help them find another internist to replace him as their personal physician. Many of Bill's former patients took him up on his offer and he accommodated each of them. However, in so doing, Bill discovered that a growing number of internists and family practitioners in the Houston area are no longer accepting patients on Medicare because of the economic constraints of taking on such patients. As the number of primary care physicians continues to decline across the country, where are patients on Medicare going to find a primary care physician if this trend continues?

So, one of Houston's best internists was successful in saving his practice from the perverse impact of America's Byzantine health care finance system. As I noted in the previous post, if such entrepreneurial spirit can succeed in reviving a doctor's practice in the current highly-regulated health care finance system, then imagine what might happen if we unleashed the power of the marketplace to reform the health care finance system and the delivery of health care, as well?

Posted by Tom at 12:01 AM | Comments (3) | TrackBack (0)

August 19, 2008

Say what, Doc?

Inasmuch as my family and social groups include a large number of medical doctors, I've noticed that the slang that the docs use when they are talking shop can be incomprehensible at times. That's why this comprehensive list of Doctor's Slang, Medical Slang and Medical Acronyms will come in handy. A few good ones:

"Blade" -- Surgeon: dashing, bold, arrogant and often wrong, but never in doubt (very much appreciated by the primary care doctors);

"Captain Kangaroo" -- chairman of the pediatrics department;

"DTMA" -- Stands for "Don't Transfer to Me Again";

"Fonzie" -- Unflappable medic;

"Improving His Claim" -- Victim of minor accident, needs no treatment but wants something to support his insurance/legal claim;

"Masochist" -- Trauma surgeon;

"Sadomasochist" - Neurosurgeon

"NOCTOR"-- A nurse who has done a 6 week training course and acts like she or he is a Doctor;

"Two beers" -- the number of beers every patient involved in an alcohol-related automobile accident claims to have drunk before the accident.

Check out the entire list. Those docs are a tough bunch.

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

August 16, 2008

Dr. Ralph Feigen, R.I.P.

In this recent post on the death of Michael DeBakey, I noted that a substantial part of Dr. DeBakey's legacy was his involvement in the massive importation of talented medical professionals to Houston over the past 60 years. That talent transformed the Texas Medical Center from a sleepy regional medical center into one of the largest and most dynamic medical centers in the world.

Dr. Ralph Feigen, who died at the age of 70 on Thursday,epitomizes the doctors who have been at the center of that transformation.

Drawn to Texas Children's Hospital and Baylor College of Medicine at the age of 40 in 1977, Dr. Feigen spent the rest of his life in Houston cultivating a culture of excellence in research and patient care that turned Texas Children's into one of the largest and best pediatric hospitals in the world. Dr. Feigen was an excellent teacher, superb clinician and a highly-regarded researcher, but his personal warmth for his patients is what thousands of parents and their children will remember most about this fine man. A large part of Dr. Feigen's legacy is that Texas Children's -- despite its enormous growth over the past 30 years -- still reflects the comfortable warmth of its long-time leader.

Todd Ackerman, the Chronicle's fine medical reporter, summarizes Dr. Feigen's enormous impact well (the NY Times obituary is here):

Feigin, considered by many the most important pediatrician of the past 25 years, died Thursday. [.  .  .]

Feigin transformed Baylor pediatrics from a small, poorly funded department into the nation's biggest, made Texas Children's Hospital one of the nation's elite children's hospitals and trained an amazing roster of doctors, including almost half of Harris County's current population of pediatricians and many academic leaders nationally.

He also was known for research that contributed to the better understanding and treatment of pediatric disease, as the author of textbooks that changed the care of children worldwide and as a tireless advocate who never missed a chance to take up the cause of children's health.

Colleagues described him as unfailingly cheerful and energetic, even after the lung cancer struck. Diagnosed with the disease in late 2007, he continued as Baylor's chairman of pediatrics and Texas Children's physician-in-chief while in treatment. In May, he announced he would step down but attributed the decision to a plan he had made at 65 to stop his administrative duties at 70. [.  .  .]

In all, Feigin trained more than 2,000 pediatricians and pediatric specialists. Of those, two went on to become medical school deans, 22 became associate medical school deans, 10 became pediatric department chairmen and 180 became section heads of pediatrics.

Feigin came to Houston in 1977, a time when neither Baylor pediatrics nor Texas Children's were players of any significance. In 30 years, Baylor's pediatric faculty grew from less than 40 to more than 500, and pediatric's federal research funding became the most in the country, nearly $100 million. Texas Children's created and developed several of the nation's most respected clinical centers, and its patient load skyrocketed.

In addition to his pediatric administrative and clinical duties, Feigin served as president of Baylor from 1996 to 2003 and as interim CEO of Texas Children's from 1987 to 1989.

Despite the administrative roles, Feigin remained focused on children's health. He pushed for the state to extend the Children's Health Insurance Program to the maximum number of children and Medicaid to the maximum number of indigent mothers. He and his colleagues were at the forefront whenever there was an infectious disease outbreak, giving shots to kids and urging people to exercise caution.

He was considered such a great diagnostician that twice a week residents would gather to seek his help on their most baffling cases at "stump Feigin" sessions.

Without books or computers, Feigin would reel off myriad possible causes, then describe what he'd do to arrive at a diagnosis as quickly as possible. The performance left the residents awed.

We often get sidetracked as to what bells and whistles will supposedly make Houston better, but it's people such as Ralph Feigen who truly make Houston such a special place to live.

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

July 13, 2008

Dr. Michael DeBakey, R.I.P.

Dr. Michael DeBakey (previous posts here) died late Friday at the age of 99. One of the most influential men in Houston's history, Dr. DeBakey was the world-famous cardiovascular surgeon who researched, developed and initially implemented not only a variety of devices that help heart patients, but also such now-common surgical procedures as heart-bypass surgery. Two of the Chronicle's finest reporters -- Science reporter Eric Berger and Texas Medical Center reporter Todd Ackerman -- provide this outstanding article on Dr. DeBakey's remarkable life, and Eric provides an audio file of his 2005 interview of Dr. DeBakey here. The New York Times' article on Dr. DeBakey's death is here.

As with my late father, Dr. DeBakey was one of the leaders of a talented generation of post-World War II doctors who embraced the optimistic view of therapeutic intervention in the practice of medicine, which was a fundamental change from the sense of therapeutic powerlessness that was widely taught to doctors by their pre-WWII professors. As noted earlier here and here, that seismic shift in medicine has changed the course of human history.

But the tremendous impact that Dr. DeBakey had on medicine is exceeded by the massive effect that he had on Houston. When Dr. DeBakey accepted the president's position at Baylor College of Medicine a few years after the end of World War II, the Texas Medical Center was a sleepy regional medical center. Over the next two decades, Dr. DeBakey was one of the key leaders who transformed the Medical Center into one of the largest and best medical centers in the world. Dr. DeBakey was the catalyst who established the culture within the Texas Medical Center of cutting-edge research, productive competition but also widespread collaboration, quality care for patients and good, old-fashioned hard work that attracted the best and brightest physicians, teachers and students from around the world to the Medical Center.

This massive importation of intellectual capital over the last 60 years of Dr. DeBakey's life generated enormous wealth and benefits for Houston. Today, the medical facilities of the Texas Medical Center are the largest aggregate provider of jobs in the Houston area, even greater than the local jobs provided by the energy industry.

That's quite a legacy in my book.

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

May 1, 2008

Neuroscience and the Law

I am always on the lookout for creative and interesting Continuing Legal Education seminars. This one clearly fits the bill:

Baylor College of Medicine’s Initiative on Neuroscience and Law is proud to announce its 2008 Conference. This conference showcases talks from experts in several aspects of neurolaw. Topics include responsibility, punishment, prediction, rehabilitation, brain death, genetics, competence, intention, and ethics – all with an eye toward understanding how cutting edge neuroscience will touch the current practice of law.

The conference, which is worth 3.5 hours of CLE credit, will take place on Friday, May 23, 2008, from 1-5 p.m. at Baylor College of Medicine (Room M321) in the Texas Medical Center. One of the speakers for the conference is Daniel Goldberg, a local attorney and former Texas Supreme Court clerk who is currently working on his PhD at the University of Texas Medical Branch while serving as a Research Professor at Baylor's Initiative on Neuroscience and Law and as a Health Policy Fellow at Baylor's Chronic Disease Prevention & Control Research Center (Daniel is also a frequent commenter on health care and health care finance issues on this blog). The preliminary agenda for the conference is here. Check it out.

Posted by Tom at 12:01 AM | Comments (2) | TrackBack (0)

April 23, 2008

Getting to 120/80

Jane Brody, the NY Times' excellent reporter on health and fitness issues, provides this good overview of the current treatment options for high blood pressure, including this summary of the current drugs that are most commonly prescribed. My late father was one of the pioneers in the development of the first drugs and treatment protocols for hypertension.

As this earlier post noted, if FDR's physicians had known in 1945 what doctors know today about the damaging effects of high blood pressure, those physicians would not have recommended that the seriously ailing FDR be allowed to go toe-to-toe with an avaricious Stalin at Yalta. Even a relatively short delay in the insight gained from scientific research can have a major impact on the course of mankind.

Posted by Tom at 12:01 AM | Comments (1) | TrackBack (0)

April 17, 2008

What is Tiger thinking and has The Masters become a bore?

So, Tiger Woods is being forced to take a month off from the PGA Tour as he rehabs from knee surgery. I know that Woods' workout routine is considered cutting edge, particularly for a professional golfer, but what on earth is he running seven miles per workout with a bad knee? Don't his trainers know that long-distance running is not a particularly healthy form of exercise?

Long-distance running is a fine form of recreation for folks who enjoy it. But as a method of exercise, I am hard-pressed to think of one that is more physically damaging. Woods would be smart to re-think his workout to delete long-distance running and concentrate on short sprints for the aerobic part of his workout.

The knee operation will prevent Woods from defending his title at the Wachovia Championship in two weeks or competing in The Players Championship at TPC Sawgrass a week after that.

By the way, Geoff Shackelford (see this Daniel Wexler post, too) is leading a discussion over at his blog on whether the design changes at Augusta National -- which have clearly prompted players to play more defensively and less aggressively during the Masters Tournament -- have undermined the excitement of the tournament for spectators. Geoff passes along the following interesting stat from Brett Avery's Golf World stat package:

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

April 7, 2008

Acupuncture or fake acupuncture?

This Respectful Insolence blog post reports on yet another in an increasingly long line of medical studies that demonstrate that acupuncture is nothing more than an elaborate and fancy placebo. In this particular study involving patients in "true" acupuncture and "fake" acupuncture protocols, patients in the sham acupuncture group improved more than patients in the "true" acupuncture group.

My conclusion? On one hand, if you stick pins in people who are complaining about something, then some of them will eventually quit complaining. On the other hand, if you take pins out of some people who were previously complaining, then some of them will also stop complaining.

Posted by Tom at 12:01 AM | Comments (6) | TrackBack (0)

February 25, 2008

Thinking about schizophrenia

Two recent NY Times article regarding the vexing nature of schizophrenia, one sad, one hopeful. Let's all hope for more of the latter.

Posted by Tom at 12:01 AM | Comments (0) | TrackBack (0)

February 19, 2008

An emerging risk of youth sports

As youth sports become increasingly specialized, a family from The Woodlands is the subject of this Gina Kolata/NY Times article on one of the big risks to children of that trend -- increased torn anterior cruciate ligaments ("ACL"), the main ligament that stabilizes the knee joint:

The standard and effective treatment for such an injury in adults is surgery. But the operation poses a greater risk for children and adolescents who have not finished growing because it involves drilling into a growth plate, an area of still-developing tissue at the end of the leg bone.

Although there are no complete or official numbers, orthopedists at leading medical centers estimate that several thousand children and young adolescents are getting A.C.L. tears each year, with the number being diagnosed soaring recently. Some centers that used to see only a few such cases a year are now seeing several each week.

A friend of mine and I were discussing last week how unfortunate it is that most children these days depend on their parents to organize athletic activities for them rather than simply playing sports informally with neighborhood friends. Increased specialization is the natural evolution of organized sports, which means more games, more practice and more pressure on growing muscles, joints and bones. Not a particularly healthy risk in my book.

Posted by Tom at 12:02 AM | Comments (0) | TrackBack (0)

February 3, 2008

WinkingSkull.com

Check out WinkingSkull.com, a worthy counterpart to the Visual Medical Dictionary (noted earlier here) in better understanding anatomy and medical conditions.

Along those lines, did you know that "the bacteria count in the plaque on human teeth approaches the bacteria count in human feces?" (H/T Kevin, MD)

Still biting those fingernails? ;^)

Posted by Tom at 12:00 AM | Comments (0) | TrackBack (0)

January 30, 2008

Arnold Kling's Medicare experience

As I've noted many times, EconLog's Arnold Kling is doing some of the best writing and thinking about health care and health care finance issues in the U.S. right now. In his latest TCS op-ed, Kling describes the care received recently by his elderly father (who sounds as if he should have been a patient of my late father) and observes:

Medicare is wonderful for relieving the elderly from the burden of worrying about health care expenses. By the same token, it is wonderful for relieving doctors of the burden of worrying about the elderly as customers. You get paid for understanding the billing system, not for understanding your patients.

Read the entire op-ed. An update post is here.

Posted by Tom at 12:10 AM | Comments (0) | TrackBack (0)

January 25, 2008

The vanishing primary care physicians

This earlier post on my internist's decision to adopt a concierge health care model for his practice noted that the economic crisis faced by most primary care physicians was one of the primary reasons for the change in his practice. In this recent post, Kevin Pho passes along the story of yet another internist hanging up the stethoscope as a result of not being able to make ends meet within the frazzled U.S. health care finance system:

"I am an Internist for over 20 years, and I recently closed my primary care practice as I cannot make a living at it. I made $23K in the last 11 months. And, my departure from practice is only the beginning of a tsunami of closures of primary care practices . . .

Primary care is unraveling around us. Indeed, all of the articles about the inordinate strain & crowding of emergency departments across the U.S., overlook the obvious - the impending failure of primary care is going to completely overwhelm emergency rooms. There is no way to prepare for this other than to save primary care.

The whole house of cards has begun to collapse, and all the articles and discussions fail to put it in terms with sufficient emphasis. All of the 'universal' systems that actually work are built on very strong and well-funded foundations of primary care. Everything else in health care is built upon that foundation, and that is precisely what is failing across the country. Why are emergency rooms overcrowded? Why are the wait times increasing even for the seriously ill? Because primary care is failing!

Just remember, I told you so."

And here is another primary care physician's analysis of why he turned to the concierge model.

Posted by Tom at 12:05 AM | Comments (1) | TrackBack (0)

January 21, 2008

Visual Medical Dictionary

This is quite interesting.

Posted by Tom at 12:00 AM | Comments (0) | TrackBack (0)

January 17, 2008

The fascinating "Flea"

Eric Turkewitz interviews Dr. Robert Lindeman, the Boston-based pediatrician who caused quite a stir last year when the Boston Globe broke the story that he was the anonymous blogger nicknamed "Flea" who was blogging a medical malpractice trial while participating as a defendant. One of Dr. Lindeman's answers even has a Houston twist:

A hypothetical question: You've been called for jury duty and the case involves a question of medical malpractice. What will you tell the attorneys during the jury selection process about your ability to sit impartially?

Answer: "I will tell them that Roger Clemens will admit to using performance-enhancing drugs before I will able to sit impartially on a malpractice jury."

Posted by Tom at 12:03 AM | Comments (0) | TrackBack (0)

January 11, 2008

America's worst 20 fast food items

Most folks can get by quite well with eating less than 2,000 calories per day. Each of these food items pretty well gets you there.

Caramel Banana Pecan Cream Stacked and Stuffed hotcakes?

By the way, just to show that you can find almost anything on the Web, The Healthy Dining Finder can help you pick healthier choices from standard restaurant menus by eliminating high-calorie add-ons.

Posted by Tom at 12:00 AM | Comments (0) | TrackBack (0)

January 9, 2008

No sympathy

This NY Times article from the other day reports on the increasing numbers of lawyers and doctors who are plagued by self-doubt (who'd have ever thought that?). Mr. Juggles over at Long & Short Capital has no sympathy:

To the lawyers:

In case the Neiman Marcus purchases succeeded in lifting your morale and left you with the impression that what you did counted for something, please let me add some critical information: It doesn’t. This is why you are paid, on an hourly-adjusted basis, like a recent (2nd tier) college graduate.

To the doctors:

The fact that I was able to diagnose my own illness after 15 min on WebMD speaks to the value of your knowledge. Perhaps our relationship would be more productive if you would stop making me wait 3 days for an appointment (and 90 minutes once I get to the office) to diagnose a sinus infection that I already know I have. Give me the antibiotics without the self-importance. I will come see you again when I have something you can actually be helpful with. For instance, after I break my arm trying to carry my bonus home, I will come see you and you can set the cast. Until then, please stop whining.

Posted by Tom at 12:05 AM | Comments (3) | TrackBack (0)

January 8, 2008

Dr. Pou's fog of Katrina

This Dr. Susan Okie/New England Journal of Medicine article (H/T Kolahun) provides the most extensive analysis to date of the circumstances surrounding the tragic deaths of the nine New Orleans area hospital patients during the aftermath of Hurricane Katrina that led to the egregious prosecutorial decision to bring criminal charges against one of the treating physicians, former University of Texas Medical School physician, Dr. Anna Pou (previous posts here). Dr. Okie addresses the key question of why these nine patients died ". . . in light of the eventual evacuation of about 200 patients from [the hospital], including patients from the intensive care unit, premature infants, critically ill patients who required dialysis, patients with DNR orders, and two 400-lb men who could not walk." It's an important question to address, but not in the context of a criminal case.

The fog of war analogy is certainly appropriate. Even with as good information as we have about the horrific conditions at the hospital in the aftermath of Katrina, it's still hard to imagine how difficult it was making even basic decisions in the face of the breakdown of civil society and infrastructure. What we do know is that Dr. Pou, who was not experienced in providing emergency medical services in what amounted to a heavy combat war zone, was no ethicist on mission to make a political statement. Rather, she was simply a physician doing the best she could to make the right decisions under the worst circumstances imaginable. It should not surprise us if, with the benefit of hindsight bias, some of those decisions would not have been the ones that a reasonable physician would have made under better conditions.

Posted by Tom at 12:10 AM | Comments (0) | TrackBack (0)

December 21, 2007

Self-deception about calories

This Gina Kolata/NY Times article (previous posts here) explains how many people continue to misconstrue exercise as a primary means of weight-control by overestimating the number of calories they expend during exercise. A well-structured exercise program can assist in controlling a person's weight over the long term, but it really doesn't have much effect on weight over the short term.

On the other hand, my anecdotal experience is that many of the same folks who overestimate the amount of calories that they expend during exercise dramatically underestimate the amount of calories that they are consuming, particularly in regard to restaurant food.

I'm convinced that the combination of these misunderstandings -- along with not having a clear understanding of the difference between exercise and recreation -- has much to do with the obesity syndrome that many Americans battle throughout their lives.

Posted by Tom at 12:05 AM | Comments (5) | TrackBack (0)

December 19, 2007

The remarkable story of Kevin Everett

Three months ago, Kevin Everett, a tight end for the Buffalo Bills who was born and raised in Port Arthur just east of Houston, suffered a serious spinal cord injury during an NFL game. At the time of the injury, there was grave doubt whether Everett would ever walk again.

As this Sports Illustrated article recounts, Everett's recovery from his serious injury has been nothing short of amazing. One of the interesting aspects of Everett's recovery is that it may have been fueled by the gutsy call of a 45 year-old orthopedic surgeon on the scene in Buffalo, but it was certainly facilitated by the remarkable rehabilitation services of the Texas Medical Center's Institute for Rehabilitation and Research (known as "TIRR") and the inspiring resolve of the 25 year old patient. TIRR is regularly ranked as one of the finest rehabilitation institutions in the U.S. and is one of the many reasons that Houston is among the world's finest medical centers.

Posted by Tom at 12:30 AM | Comments (0) | TrackBack (0)

December 17, 2007

Satel on desperately seeking kidneys

Sally Satel, the receipient of Virginia Postrel's kidney (see also here), authored this amazing NY Times Magazine article in which she describes the overwhelming emotions that donors and would-be recipients go through under the current system of donating organs:

A week after my 49th birthday in January 2005, half a year after being given a diagnosis of renal failure, a friend and I were drinking coffee at a Starbucks when I wondered aloud if I would find a donor before I reached 50. I wasn’t hinting. I knew she would never offer because she was so squeamish about blood and pain. My friend, whom I met a decade before when we were both new to Washington and worked together on an advocacy project, was a little older than I; she was charming, stylish, smart — and a hypochondriac.

Nor, to be honest, did I want her kidney. Anyone as anxious about health as she was would surely view donation as a white-knuckle ordeal. And the bigger the sacrifice for her, the heavier the burden of reciprocity on me. The bigger the burden on me, the more I would resent her. Then I would feel guilty over resenting her and, in turn, resent the guilt. Who could survive inside this echo chamber of reverberating emotions? Thank goodness my friend would be holding on to her kidney.

But then to my amazement, within a minute or so of my speculating when or if a donor would ever appear, she offered to do it. Later that night we talked on the phone and she rhapsodized about what a “mitzvah” it would be. Yes, her sentiments were lovely, but I felt secretly annoyed because I knew it was her habit to embark upon grandiose plans; when they fizzled, she would just shrug. I told her that giving me a kidney was out of the question — “It would be too weird,” was what I kept saying — but she persisted. I couldn’t quite believe it when she told her family of her decision (they were graciously in favor) and then had blood tests and consulted with my transplant team.

Gradually, I began to believe that she meant it, and I decided to embrace her just as you might accept an in-law, as someone who could drive you a little mad but whom you loved because they were the source of something very precious to you — in my case, not a spouse but a kidney. But then after a few months she stopped talking about it. When I finally broke the silence, she said her doctor had advised against it. More likely, I thought, she was scared. I felt sorry to have put her in this position, but I was also bitter: just when would she have gotten around to telling me?

Such near-transplant experiences are not uncommon. All of the transplant candidates I spoke to, as part of my own small nonscientific sample, mentioned at least one person who promised to donate, had some tests done and then developed cold feet. Transplant teams explicitly, and properly, offer face-saving “medical alibis” to potential donors who don’t really want to go through with it, which suggests that bailing out isn’t all that rare. They might tell the person needing the transplant and the rest of the family, for example, that additional tests on the prospective donor revealed a compatibility problem or some evidence that the donor might be putting her own health at risk.

Inasmuch as the supply-demand imbalance for kidneys and other organs is well known, it seems obvious that the simple solution is to allow markets to fix the problem. However, absent political leadership to change the existing obsolescent system, many patients who need a transplant will remain relegated to long waiting lists. Many of those patients will die before their name is called. As Satel notes at the end of her article:

"But unless we stop thinking of transplantable kidneys as gifts, we will never have enough of them."

Posted by Tom at 12:05 AM | Comments (1) | TrackBack (0)

December 14, 2007

More on the myth of beneficial long-distance running

The increasing evidence that long-distance running is not healthy has been a frequent topic on this blog, and this Lou Schuler/Men's Health article surveying the most recent research and expert opinions comes to the same conclusion:

[No expert] today believes that endurance training confers immunity to anything, whether it's sudden death from heart disease or the heartbreak of psoriasis. Every time you lace up your running shoes, there's a chance your final kick will involve a bucket, and every expert knows this. [. . .]

The highest death rate is among the men who exercise long and hard, and is much higher than that of the men who exercise short and hard.

Schuler concludes that frequent, short exercise sessions that balance strength-training with moderate aerobic exercise is probably the healthiest approach. Read the entire article.

Posted by Tom at 12:05 AM | Comments (0) | TrackBack (0)

November 6, 2007

30 year anniversary of the first angioplasty

Angioplasty has been a common topic on this blog, so it seems fitting to pass along this article and related video about Dolf Bachmann, the first patient to undergo balloon angioplasty. Bachmann was 38 years old when he underwent the procedure on September 16, 1977 and now is a healthy and happy 68 year-old who enjoys an "excellent life" that includes hobbies such as "hiking, Nordic walking, skiing, working in my garden and playing cards."

Posted by Tom at 12:10 AM | Comments (0) | TrackBack (0)

November 5, 2007

Risky business

The tragic death Saturday morning of 28-year-old veteran marathoner, Ryan Shay, during the United States Olympic trials marathon in Central Park in New York City reminds us of a very important health tip -- long-distance running is not particularly healthy.

Update: Another participant in the marathon died afterward.

Posted by Tom at 12:00 AM | Comments (1) | TrackBack (0)

October 26, 2007

My concierge health care experience

Bill Lent is one of Houston's finest internists. How do I know this? Well, because I know who trained him (my late father) and he has been my personal physician for the past 15 years or so. Having been blessed with good health, the only medical service that I buy from Dr. Lent in most years is my annual physical, which I generally schedule for about this time each year. I always enjoy catching up with Dr. Lent, who provides me with "on the front line" information regarding the horrific cost of health care regulations, which are literally strangling the market for primary care physicians in the U.S.

It's been particularly interesting watching the evolution over the years of Dr. Lent's internal medicine practice, from one in which Dr. Lent provided an unusually high level of personal care to his patients (something my father emphasized in his teaching) to a high volume, impersonal practice that virtually all primary care practices have been required to adopt to remain even marginally profitable under the present U.S. health care finance system. Over the past ten years or so, Dr. Lent has continually confided to me during our annual visits that he was uncomfortable with the direction of his practice.

So, I was pleased to learn when I scheduled my physical a couple of weeks ago that Dr. Lent is doing something about it. Starting next month, Dr. Lent is commencing a concierge health care practice, administered by MDVIP out of Boca Raton, in which he is limiting his practice to about 600 patients who will pay Dr. Lent $1,500 annually for the benefit of receiving his personalized style of service. Coincidentally, this Wall Street Journal ($) article earlier this week described the proliferation of pre-paid health care plans, which is sort of a lower-priced form of what Dr. Lent is doing. The WSJ article essentially describes how many primary care physicians are simply dropping out of insurance plans -- both public and private -- in favor of prepaid plans that offer unlimited access to basic health care for set monthly fees.

Inasmuch as the employer-based health insurance system typically offers low-copays and deductibles for the vast majority of health care services, a substantial amount of the American health care finance system is basically prepaid health care already. In order to maintain profitability in a highly-regulated market, insurance companies compensate for these low usage fees by charging higher monthly premiums, lowballing doctors' fees, and challenging claims continually. The result has been the evolution of a primary care system that is incredibly bureaucratic (have you ever tried to figure out how your insurance pays claims?) and literally breaking down.

The MDVIP model treats primary care service similar to a health club membership. The model focuses on the delivery of relatively inexpensive, protocol-driven care than can be offered at a relatively low cost while still providing patients more overall access. MDVIP's model is relatively expensive, so low-income patients will have a difficult time affording the fee. However, providing a tax deduction for individual health insurance would make such pre-paid plans more affordable for low-income patients, while providing Medicaid patients with vouchers for prepaid health care would have a similar impact.

Who will be threatened from the proliferation of these plans under the current health care finance system? Well, it's a bit early to speculate, but my sense is that insurance companies with big stakes in employer-based health insurance will not enjoy the competition from MDVIP-type practices. Similarly, speciality providers who depend on state regulatory mandates in comprehensive insurance plans to subsidize their practices will also feel the competitive pressure if these types of plans catch on in a big way.

So, I'm going to enjoy learning about how Dr. Lent's practice changes over the next year under the MDVIP structure. If it is successful, as I suspect it will be, it makes you wonder -- if such entrepreneurial spirit can be generated even in the current highly-regulated health care finance system, then imagine what could happen if we unleashed the power of the marketplace to reform the delivery of health care and the health care finance system?

Posted by Tom at 12:10 AM | Comments (5) | TrackBack (0)

October 19, 2007

The risk of witch doctors

It never fails to amaze me that seemingly rational people continue to seek out witch doctor treatments for anything more complicated than a massage:

On the same shift I saw two very sick patients, both of whom were under the care of chiropractors before they decided to pay us a visit in the Emergency Department. The first was an old woman with a one week history of dyspnea, chest pain, and a cough. Her chiropractor had diagnosed her with a “displaced rib,” and had been dilligently popping it back into place every day for the previous week. After a simple set of vital signs revealing low blood pressure, a slow heart rate, and a slightly low temperature, not to mention a chest x-ray which showed a huge unilateral pleural effusion, it was not hard to come up with the diagnosis of pneumonia with sepsis.

“He [the chiropractor] said she didn’t have a fever and she wasn’t coughing anything up,” said the sister. [. . .]

The second patient was a 70-year-old man who finally came in after a week of ineffectual adjustments for “muscle aches” and general malaise which had evolved, by the time we saw him, into a vague intermittant chest pain related to exertion but which the chiropractor insisted, apparently, was some kind of subluxation. The EKG told the true story, an evolving myocardial infarction. My patient would have probably died if his son hadn’t raised the alarm and insisted his father see some real doctors.

Meanwhile, this article reports that researchers have determined that acupuncture works. But the same research study concluded that fake acupuncture, where the needles are inserted shallowly and in the wrong places, also works:

The results suggest that both acupuncture and sham acupuncture act as powerful versions of the placebo effect, providing relief from symptoms as a result of the convictions that they engender in patients.

My conclusion: On one hand, if you stick pins in people who are complaining about something, then some of them will eventually quit complaining. On the other hand, if you take pins out of some people who were previously complaining, then some of them will also stop complaining.

Posted by Tom at 12:00 AM | Comments (0) | TrackBack (0)

October 18, 2007

The end of socialized medicine

Peter Huber is a Manhattan Institute senior fellow, an MIT-trained engineer and a lawyer who has authored several books, including Hard Green: Saving the Environment from the Environmentalists and Galileo’s Revenge: Junk Science in the Courtroom. In this provocative City Journal article, Huber observes that the complexity of modern diseases virtually assures that a "one-size-fits-all" socialized medical system will fail:

That is the real crisis in health care—not medicine that’s too expensive for the poor but medicine that’s too expensive for the rich, too expensive ever to get to market at all. Human-ity is still waiting for countless more Lipitors to treat incurable cancers, Alzheimer’s, arthritis, cystic fibrosis, multiple sclerosis, Parkinson’s, and a heartbreakingly long list of other dreadful but less common afflictions. Each new billion-dollar Lipitor will be delivered—if at all—by the lure of a multibillion-dollar patent. The only way to get three-cent pills to the poor is first to sell three-dollar pills to the rich.

With almost $30 trillion under management, Wall Street could easily double the couple of trillion it currently has invested in molecular medicine. The fastest way for Washington to deliver more health, more cheaply, to more people would be to unleash that capital by reaffirming patents and stepping out of the way.

On the other side of the pill, molecular medicine can only be propelled by the informed, disciplined consumer. Any scheme to weaken his role will end up doing more harm than good. Foggy promises of one-size, universal care maintain the illusion that the authorities will take good care of everyone. They reaffirm the obsolete and false view that health care begins somewhere out there, not somewhere in here.

Neither Pfizer nor Washington can ever stuff health itself into a one-price uniform, One America box—not when health is as personal as ice cream, genes, and pregnancy, not when every mother controls her personal consumption of carbs, cholesterol, Flintstones, and Lipitor. But the thought that government authority can get more bodies in better chemical balance than free markets and free people is more preposterous than anything found in Das Kapital. Freedom is now pursuing a pharmacopoeia as varied, ingenious, complex, flexible, fecund, and personal as life itself, and the pursuit will continue for as long as lifestyles change and marriages mix and match. Given time, efficient markets will deliver a glut of cheap Lipitor for every glut of cheap cholesterol. And given time, free people will find their way to a better mix.

Read the entire article here.

Posted by Tom at 12:10 AM | Comments (2) | TrackBack (0)

October 17, 2007

Immune to reason

Paul Howard is a senior fellow at the Manhattan Institute Center for Medical Progress and the editor of the blog Medical Progress Today. In this Washington Post op-ed, Howard addresses the potential danger to public health of indulging in the current wave of trendy skepticism toward vaccinations:

Sadly, too many parents have lost faith in vaccines. Partly, this is because of a "generation gap." In 1940, U.S. infant mortality rates stood at 40 deaths per 1,000 live births. Tens of thousands more children would go on to be killed or maimed by measles, polio and chicken pox. Today, infant mortality averages about 7 deaths per 1,000 live births, and those other diseases have been largely vanquished by vaccines. A childhood free of serious illness is now taken for granted.

When mysterious disorders like autism strike seemingly healthy children -- at about the same age when childhood vaccines are typically administered -- frustrated parents lash out at doctors and pharmaceutical companies. And today's vaccine inventors must contend with a powerful force that had yet to arise when Jonas Salk created his revolutionary polio vaccine -- mass litigation.

The birth of "liability without fault" in pharmaceutical litigation in 1958 -- captured in Dr. Paul Offit's riveting book The Cutter Incident -- set the dangerous precedent that vaccine companies would be held liable for side effects even when their products were made using the best available science and according to government regulations. [. . .]

The debate over vaccine litigation has thus shifted from a presumption of innocence to a presumption of guilt. While the number of major studies that have failed to find any substantive link between vaccines and developmental disorders or autism is now in the double-digits (including a September 27th CDC study in the New England Journal), critics are effectively demanding that scientists prove that thimerosal does not cause illness -- an impossible standard.

The very success of vaccines has become their downfall. As Dr. Offit writes in Vaccinated, "When [vaccines] work, absolutely nothing happens. Parents go on with their lives, not once thinking that their child was saved."

The entire op-ed is here. This earlier post addresses the devastating impact that the Cutter Incident had on the production of vaccines and public health.

Posted by Tom at 12:04 AM | Comments (4) | TrackBack (0)

October 9, 2007

Kolata on Good Calories, Bad Calories

NY Times nutrition columnist Gina Kolata (previous posts here) reviews Gary Taubes' new book, Good Calories, Bad Calories: Challenging the Conventional Wisdom on Diet, Weight Control and Disease (Knopf September, 2007), which was previewed earlier here. Kolata observes:

His thesis, first introduced in a much-debated article in The New York Times Magazine in 2002 challenging the low-fat diet orthodoxy, is that nutrition and public health research and policy have been driven by poor science and a sort of pigheaded insistence on failed hypotheses. As a result, people are confused and misinformed about the relationship between what they eat and their risk of growing fat. He expands that thesis in the new book, arguing that the same confused reasoning and poor science has led to misconceptions about the relation between diet and heart disease, high blood pressure, cancer, dementia, diabetes and, again, obesity. When it comes to determining the ideal diet, he says, we have to “confront the strong possibility that much of what we’ve come to believe is wrong.” [. . .]

Taubes convincingly shows that much of what is believed about nutrition and health is based on the flimsiest science. To cite one minor example, there’s the notion that a tiny bit of extra food, 50 or 100 calories a day — a few bites of a hamburger, say — can gradually make you fat, and that eating a tiny bit less each day, or doing something as simple as walking a mile, can make the weight slowly disappear. This idea is based on a hypothesis put forth in a single scientific paper, published in 2003. And even then it was qualified, Taubes reports, by the statement that it was “theoretical and involves several assumptions” and that it “remains to be empirically tested.” Nonetheless, it has now become the basis for an official federal recommendation for obesity prevention.

But the problem with a book like this one, which goes on and on in great detail about experiments new and old in areas ranging from heart disease to cancer to diabetes, is that it can be hard to know what has been left out. [. . .[

. . . I kept wondering how he would deal with an obvious question. If low-carbohydrate diets are so wonderful, why is anyone fat? Most people who struggle with their weight have tried these diets and nearly all have regained everything they lost, as they do with other diets. What is the problem?

On Page 446, he finally tells us. Carbohydrates, he says, are addictive, and we’ve all gotten hooked. Those who try to break the habit start to crave them, just as an alcoholic craves a drink or a smoker craves a cigarette. But, he adds, if they are addictive, that “implies that the addiction can be overcome with sufficient time, effort and motivation.”

I’m sorry, but I’m not convinced.

John Tierney comments, too.

Posted by Tom at 12:05 AM | Comments (4) | TrackBack (0)

September 21, 2007

Coopertown?

Dr. Kenneth Cooper of Dallas may have oversold the benefits of aerobic exercise, but will the same be true for his new real estate venture?:

Dr. Cooper is developing a $2 billion residential wellness community here called Cooper Life at Craig Ranch that is going up on the first 51 of an eventual 151 acres on the Texas plains, north of Dallas.

Taking the concept of spa real estate into the medical realm, Dr. Cooper’s community promises home buyers a life that sounds equal parts Norman Rockwell and Olympic village: a small town where doctors will make house calls and where every resident has a bevy of experts close at hand for keeping in tiptop shape.

It appears to be the first of its kind. . . .

Included in the monthly residential fee ($1,041 for an individual to $2,181 for a family of six) will be an annual physical and a six-month follow-up, which Dr. Cooper calls key to his utopian vision of a place where everyone can live in peak health. The fee also includes home doctor visits, a fitness center membership, concierge services and exterior home maintenance, lectures and social activities.

While a diverse mix of ages and fitness levels are welcome, Dr. Cooper admits that many prospective residents may well be baby boomers with cushy bank accounts. “They’ve got the money,” Dr. Cooper said, “now they want to live long enough to enjoy it.”

I get exhausted just thinking about the thought of living there. ;^)

Posted by Tom at 12:05 AM | Comments (0) | TrackBack (0)

Something ailing you?

If so, and even if not, check out these 100 Web Resources for Medical Professionals.

Posted by Tom at 12:02 AM | Comments (0) | TrackBack (0)

September 18, 2007

What makes us healthy?

Gary Taubes, a writer for Science magazine, is the author of the soon-to-be-released book Good Calories, Bad Calories: Challenging the Conventional Wisdom on Diet, Weight Control and Disease (Knopf September 25, 2007). He provides a don't miss preview of his book in this past Sunday's New York Times:

Many explanations have been offered to make sense of the here-today-gone-tomorrow nature of medical wisdom — what we are advised with confidence one year is reversed the next — but the simplest one is that it is the natural rhythm of science. An observation leads to a hypothesis. The hypothesis (last year’s advice) is tested, and it fails this year’s test, which is always the most likely outcome in any scientific endeavor. There are, after all, an infinite number of wrong hypotheses for every right one, and so the odds are always against any particular hypothesis being true, no matter how obvious or vitally important it might seem. [. . .]

The dangerous game being played here, as David Sackett, a retired Oxford University epidemiologist, has observed, is in the presumption of preventive medicine. The goal of the endeavor is to tell those of us who are otherwise in fine health how to remain healthy longer. But this advice comes with the expectation that any prescription given — whether diet or drug or a change in lifestyle — will indeed prevent disease rather than be the agent of our disability or untimely death. With that presumption, how unambiguous does the evidence have to be before any advice is offered? [. . .]

Richard Peto, professor of medical statistics and epidemiology at Oxford University, phrases the nature of the conflict this way: “Epidemiology is so beautiful and provides such an important perspective on human life and death, but an incredible amount of rubbish is published,” by which he means the results of observational studies that appear daily in the news media and often become the basis of public-health recommendations about what we should or should not do to promote our continued good health. [. . .]

All of this suggests that the best advice is to keep in mind the law of unintended consequences. The reason clinicians test drugs with randomized trials is to establish whether the hoped-for benefits are real and, if so, whether there are unforeseen side effects that may outweigh the benefits. If the implication of an epidemiologist’s study is that some drug or diet will bring us improved prosperity and health, then wonder about the unforeseen consequences. In these cases, it’s never a bad idea to remain skeptical until somebody spends the time and the money to do a randomized trial and, contrary to much of the history of the endeavor to date, fails to refute it.

Read the entire article.

Posted by Tom at 12:05 AM | Comments (0) | TrackBack (0)

August 31, 2007

Property rights, economics and AIDS

Peter F. Schaefer explains how economics and property rights in African nations combine to facilitate the proliferation of the AIDs virus:

However no one in the US government and few in the anti-AIDS community are dealing with a major issue in the transmission of AIDS called "property stripping." Since the cure for property stripping is cheap, technically quite easy and would have an enormous secondary impact on economic growth (poverty is a hidden vector of AIDS) it would seem like a sure thing for attention. But it is virtually ignored.

On World AIDS Day two years earlier Dr. Jim Yong Kim - [head of World Health Organization's HIV Division, Kevin] De Cock's predecessor - said,

"In sub-Saharan Africa almost 60 percent of AIDS sufferers are women [and] in some settings ... we are finding ... that the number one risk factor for women in becoming infected with HIV is marriage. [And] married women have the highest rates of HIV infection. We have to take on some of the most fundamental and difficult cultural and social issues that are definitely affecting the way this epidemic is spreading. And ... if we can take on things like for example, property rights [so] women can inherit the property of their husband if [he] dies, that really reduces the likelihood of them getting into sex work for example. If we can ... change laws, change fundamental beliefs and culture by [getting] people the right kinds of prevention messages we will have done a lot not just for HIV AIDS but for issues like gender equity that have been with us forever."

In the scholarly literature, the traditional practice of the husband's family inheriting all his property after he dies is called "property stripping." In normal times, this had some logic; the husband's family had responsibility for the widow and her children, a brother often taking her as a second wife and so assuming responsibility for his nieces and nephews.

But things have changed. In the time of AIDS, the widow is likely also infected with the HIV virus, though not yet sick since her husband often gets it first and the disease is less advanced in her when her husband dies. So even if her brother-in-law hasn't died from AIDS himself, he is not willing to marry someone infected with HIV. And often the brother-in-law himself is sick or dead. Nevertheless, the family often still follows custom and seizes her house and farm and so she has no recourse but to turn to menial jobs, begging or prostitution. And since she was infected later, she may have years to spread her illness to her sex partners which are commonly many a day.

[A] Washington Post editorial by Richard Holbrooke . . . noted that increased testing and detection efforts was the "only effective prevention strategies can stop the spread of AIDS." He goes on to point out that "...monogamous women [are] thrown out of their homes for a disease they got from their husbands."

Read the entire article, which is another reminder that there are few simple solutions to this terrible disease.

Posted by Tom at 12:05 AM | Comments (1) | TrackBack (0)

August 28, 2007

What's ailing you?

Have you had a symptom of an illness or an injury that has bothering you for awhile? Medgle allows you to click on the body part that's bothering you and select the specific symptom from a list of possible options. Then, Medgle asks how long the symptom has been apparent, as well as th inquirer's sex and age. Medgle then returns a listing of possible matches for the symptoms.

Moreover, you can then take the result that Medgle generates and, on the following page, provides you with a brief summary of the condition and a Google search relating to treatment, prevention, drugs, tests, research, diet, alternative medicine, and fitness. You can even refine the search by changing the age or gender.

This is never going to replace a visit to your doctor, but it sure provides a handy way to increase the patient's knowledge and understanding regarding diagnosis and treatment. Check it out.

Posted by Tom at 12:05 AM | Comments (0) | TrackBack (0)

August 27, 2007

In Dr. Pou's words

Dr. Anna Pou (previous posts here), the former faculty member of the University of Texas Medical Branch in Galveston, performed heroically in the horrific aftermath of Hurricane Katrina. For her heroism, she became the main subject of one of the most egregious examples of prosecutorial misconduct in recent memory. In this extensive Newsweek article, Dr. Pou finally tells her side of the story and it magnifies the enormity of the injustice that a few irresponsible Louisiana state officials have put her through. The following are a few tidbits:

What was it like after the levees broke?

Monday after the storm passed, we figured, ‘OK, minimal damage; we began organizing how we were going to evacuate the hospital.’ We didn’t have full power so we needed to move patients. Tuesday morning we were planning our day and one of the nurses called me to the window and said you’ve got to come see this. Water was gushing from the street. So we all kind of looked in disbelief. What is this? We could tell the city was flooding, you could see water down Claiborne Street. It was rising about a foot an hour. Then the whole mood at the hospital changed and what we were doing changed. We were in hurricane mode and we had to go into survival mode because we knew we had to be there for some time.

How did things change on Wednesday?

Tuesday night, we lost generator power, and that changed things a lot. ‘Til then we were on generator power so we did have some lights, and we did have some water. Water wasn’t clean, but it was running. But then we didn’t have water, we didn’t have any electricity, commodes were backing up everywhere. Conditions in the hospital started to deteriorate Tuesday night and early Wednesday. When that happens it makes care a lot more difficult. I was called to help suction a patient who had a tracheotomy but we had no suction running. We were going down to very, very basic care. You try every old-time method you can … [P]eople in charge were trying to get helicopters to come, [but] at that time we were told we were low priority. There were people on rooftops [who were going to get rescued first]. They said … there’s not going to be a lot of help coming, [so] what we decided [was] if helicopters were going to show up sporadically, we have to have patients ready and waiting to go. [. . .]

The conditions were unbearable. Inside the hospital it was pitch black, with odors, smell, human waste everywhere. It was very rancid. You would take a breath in and it would burn the back of your throat. The patients were very sick. That’s when we had to go from triage to reverse triage because we came to realize if patients aren’t being evacuated, [we had to deal with what we had]. Basically it was a general consensus that we’re not going to be able to save everybody. We hope that we can, but we realize everybody may not make it out. [. . .]

By the time Wednesday evening came around, if you can imagine in our mind, there is a central area that is a sea of people. A lot of very sick patients in that central triage area. It’s grossly backed up. Few patients had been evacuated. So there was just enough space to walk between the stretchers. It is extremely dark. We’re having to care for patients by flashlight. There were patients that were moaning, patients that are crying. We’re trying to cool them off. We had some dirty water we could use, some ice. We were sponging them down, giving them sips of bottled water, those who could drink. The heat was—there is no way to describe that heat. I was in it and I can’t believe how hot it was. There are people fanning patients with cardboard, nurses everywhere, a few doctors and wall-to-wall patients. Patients are so frightened and we’re saying prayers with them. We kind of looked around at each other and said, “You know there’s not a whole lot we can really do for those people.” We’re waiting [for help]. The people in that area could have [been evacuated] by boat but no boats were coming. I would do what I could with the nurses: changing diapers, cooling patients down with fanning. It wasn’t like, “I’m a doctor, you’re a nurse.” We were all human beings trying to help another human being, whatever it took.

What happened Thursday?

On Thursday morning we were told nobody was coming and we had to fend for ourselves. Everybody was kind of like at a loss here. What is plan B? Or plan C?

How did you come to be the one administering the injections? Louisiana Attorney General Charles Foti made a point of saying you had administered medication to people who were not your patients.

This was an emergency situation. There were no LifeCare doctors. In an emergency situation, the patients become everybody’s patients. What are you supposed to do if a patient needs to be cleaned and have IV fluids, say, “You’re not my patient, good luck”? That’s absurd. If that’s the case I dare say three-fourths of the population of Memorial Hospital would have been left without a doctor. We’re in medicine because we care about people. This is what we do. We don’t run around murdering people. That’s why what he said is so ludicrous.

When did you leave the hospital and who was still there when you left?

I left Thursday around 6 p.m. in a helicopter. When I left no one was in the hospital. There were a handful of patients on the helipad. I went to [another hospital and then] on a bus to Baton Rouge because my family was there.

How did you feel?

I was tired but I was more in total disbelief that the sick and the poor could be abandoned the way that they were in the United States of America. I never thought I would ever live to see that day. I was sad, heartbroken, kind of amazed and shocked at the lack of organization—the fact that there was no type of coordination. I have friends who practice in the third world and this was less than third world.

What was it like to be arrested in 2006?

I had [performed] surgery that Monday. It was bedlam in the medical community after Katrina. I had surgery Monday, Tuesday, Wednesday, Thursday and clinic on Friday. And the attorney general’s office knew that. I was taking care of indigent patients. He put my patients at risk. I am still angry about that. And then I was basically sitting by myself eating a salad, still in scrubs. I was starving and really dehydrated because I had been on call the weekend and been up 48 hours before. There was a knock on the door. It was four agents from the attorney general’s office.

The whole way [to jail] I was asking God to help my family get through this. I have nieces and nephews, and my hospitalized patients, who found out about this on the 10 o’clock news, which was heinous. Had I known [about the arrest], I could have spoken to my patients. Instead I just don’t show up and they see me on the news. There were cancer surgeries that had to be rescheduled. These patients’ treatments were delayed because of what happened. I am still furious about it. It just really makes me mad.

There is much more, so read the entire article. Again, I ask -- where is the investigation of the public officials who are responsible for attempting to organize this lynch mob against this hero?

Posted by Tom at 12:15 AM | Comments (0) | TrackBack (0)

August 18, 2007

A job well done

University of Houston student-athlete and football player Jerrod Butler was stricken by sudden cardiac arrest on Monday during a weightlifting session at the University of Houston. Butler passed out and stopped breathing.

Members of the UH athletic training staff, led by Mike O'Shea and John Houston, immediately revived Butler, performing CPR and using an automatic external defibrillator. Butler was then rushed the short drive to the Methodist Hospital emergency room at the Texas Medical Center, where he was put on a ventilator and placed in the intensive care unit.

On Thursday, Butler was moved out of the ICU and into a regular room.

It's easy in our busy lives to take professionals such as O'Shea and Houston for granted, but they are the type of dedicated people who make Houston such a special place to live. A tip of the hat to these two fine professionals on a job well done.

Posted by Tom at 12:00 AM | Comments (0) | TrackBack (0)

July 31, 2007

Endurance training to death

As noted in previous posts here and here, the myth that endurance training and long-distance running are good for one's health remains firmly entrenched among most Americans, despite sad reminders such as this. In this timely article, Mark Sisson lucidly explains why endurance training is hazardous to one's health. Here is a snippet:

The problem with many, if not most, age group endurance athletes is that the low-level training gets out of hand. They overtrain in their exuberance to excel at racing, and they over consume carbohydrates in an effort to stay fueled. The result is that over the years, their muscle mass, immune function, and testosterone decrease, while their cortisol, insulin and oxidative output increase (unless you work so hard that you actually exhaust the adrenals, introducing an even more disconcerting scenario). Any anti-aging doc will tell you that if you do this long enough, you will hasten, rather than retard, the aging process. Studies have shown an increase in mortality when weekly caloric expenditure exceeds 4,000. [. . .]

Now, what does all this mean for the generation of us who bought into Ken Cooper’s "more aerobics is better" philosophy? Is it too late to get on the anti-aging train? Hey, we're still probably a lot better off than our college classmates who gained 60 pounds and can't walk up a flight of stairs. Sure, we may look a little older and move a little slower than we'd like, but there's still time to readjust the training to fit our DNA blueprint. Maybe just move a little slower, lift some weights, do some yoga and eat right and there's a good chance you'll maximize the quality of your remaining years… and look good doing whatever you do.

Posted by Tom at 12:00 AM | Comments (0) | TrackBack (0)

July 27, 2007

Fit Nation Map

The map on the left purports to track the increase in the percentage of obese persons in the U.S. over the past 20 years. I don't know about the methodology of the statistical analysis, but the map is pretty darn cool.

Posted by Tom at 12:00 AM | Comments (0) | TrackBack (0)

July 25, 2007

Good news for Dr. Pou

An old saying in criminal defense circles is that a prosecutor could persuade a grand jury to indict a ham sandwich if the prosecutor is inclined to do so.

Fortunately, that was not the case in regard to former Houston area resident, Dr. Anna Pou (previous posts here). Dr. Pou served on the faculty of the University of Texas Medical Branch in Galveston from 1997-2004, where she was the Director of the Division of Head and Neck Surgery from 1999 to 2004. Kevin, M.D. has been doing a good job of tracking developments and comments regarding the case against Dr. Pou, and here is the link to the website that has been established to help raise funds for Dr. Pou's defense.

Following on this recent post on developments in Dr. Pou's case, a New Orleans Parish grand jury today declined to indict Dr. Pou for second-degree murder in connection with the deaths of several elderly patients in the horrifying aftermath of Hurricane Katrina. The decision ends a two-year long criminal investigation into Dr. Pou's heroic treatment of patients at Memorial Medical Center in New Orleans, which was turned into a sweltering, powerless hellhole on Aug. 29, 2005 when the levees failed after the hurricane. Inasmuch as the hospital was not evacuated until several days after the storm, 24 out of 55 elderly and infirm patients died.

The case against this distinguished academic had all the earmarks of a political lynch mob from the beginning. It became quickly apparent that Dr. Pou's arrest was the result of the highly questionable accusations of three employees of LifeCare Hospitals, the company that owned the hospital and whose top administrator and medical director didn't even show up at the hospital during those chaotic days after Katrina. Inasmuch as the accusing LifeCare employees made no effort to evacuate the elderly and sick patients before or after the hurricane, it quickly became clear to any reasonably objective observor that they were attempting to divert attention (and perhaps prosecution) from their own appalling inaction.

But the facts didn't matter to an elderly Louisiana attorney general named Charles Foti, who had campaigned on a plank of "cracking down on abuse of the elderly." Foti engineered the arrest of Dr. Pou and two of her nurses while publicly referring to them as murderers, a charge that he repeated in an episode of 60 Minutes several months later. Although Dr. Pou's lawyer had told Foti that she would surrender to authorities if an arrest warrant were issued for her, Foti had his investigators arrest Dr. Pou and haul her into Orleans Parish Prison on the evening of July 17, 2006, where she was booked on four counts of second-degree murder. Thankfully, the decision on whether to prosecute Dr. Pou was not Foti's, but that of New Orleans District Attorney Eddie Jordan and the local grand jury, which was undoubtedly persuaded by the New Orleans coronor's report that earlier this year concluded that no compelling evidence of homocide existed. But that did not stop Jordan from recently granting immunity to the two nurses who were charged with Dr. Pou in an effort to induce them to testify against Dr. Pou before the grand jury. Sheesh!

So, when does the investigation of the public officials begin who were responsible for attempting to organize this lynch mob?

Posted by Tom at 12:14 AM | Comments (1) | TrackBack (0)

July 23, 2007

Dr. Pou's defense goes on the offensive

The state's threat to prosecute Dr. Anna M. Pou for murder is a sad reflection of the incompetence in the Louisiana state government that permeated the preparations for and the aftermath of Hurricane Katrina. After almost two years now of legal limbo, Dr. Pou's defense team is fighting back:

Dr. Anna Pou - the physician arrested in the deaths of four patients at a New Orleans hospital after Hurricane Katrina - filed suit against the Louisiana Attorney General on Monday, accusing him of using her arrest to fuel his re-election bid.

The suit, filed in state court in Baton Rouge, also seeks to force the state to provide a legal defense for Pou against civil lawsuits filed by families of three of the patients.

Last year, State Attorney General Charles Foti claimed Pou and two nurses killed four people with a ‘‘lethal cocktail'' at Memorial Medical Center during the chaotic conditions after the August 2005 storm. The four were among at least 34 who died at the sweltering, flooded hospital in the days following Katrina. Pou, who is free on bond, has not been formally charged. A New Orleans grand jury is looking into the case.

Foti had Pou arrested, ‘‘called an international press conference the next day to announce the arrest, made extra judicial comments totally contrary to the Rules of Professional Responsibility, and culminated the week's activity with an attorney general fund raiser to showcase his ‘achievements' in the arrest of Dr. Pou and the two nurses,'' the suit says.

Foti was not immediately available for comment . . .

Go Dr. Pou!

Posted by Tom at 12:10 AM | Comments (0) | TrackBack (0)

July 5, 2007

More on the myth of healthy long distance runners

This earlier post noted development of research indicating that long distance running over a long term may be hazardous to your health.

Thus, this article from earlier in the week about arguably the greatest American marathoner caught my eye:

Alberto Salazar, the former champion marathoner who collapsed over the weekend, had his condition upgraded Monday from serious to fair.

A cardiologist at Providence St. Vincent Medical Center said tests now indicate that Salazar had a heart attack while coaching distance runners Saturday at the Nike campus outside Portland, said Lisa Helderop, a hospital spokeswoman.

Salazar, who is alert and talking with his family, told a doctor at the hospital that he has a family history of heart conditions, Helderop said. [. . .]

Salazar, a University of Oregon graduate, won the New York City Marathon three straight years (1980-82) and the 1982 Boston Marathon. He has set six U.S. records and one world record. He is a longtime Nike employee and consultant who trains elite distance runners and has a building named for him on campus.

This recent University of Maryland Medical Center study addresses another health risk of long-distance running. And none of the foregoing even touches on the heightened risk of joint and ligament damage that results from long distance running. Take note, runners.

Posted by Tom at 4:15 AM | Comments (0) | TrackBack (0)

July 2, 2007

The search for a cure

Yale University School of Medicine neurologist Steven Novella, the editor of the Scientific Review of Alternative Medicine, provides this insightful NeuroLogica post that addresses the issue of why medical research has not discovered a cure for cancer despite the enormous resources dedicated to cancer research. In so doing, he clears up several common misconceptions about cancer and the incentives involved in finding a cure. He concludes as follows:

The overall reality is that the standard of scientific medicine is not a monolithic entity, controlled by any one institution, agency, or industry. It is a complex and dynamic set of many forces and interests. It is ultimately driven by science, which is a transparent and public process, and prevents any big brother type of control (this is partly why it is so important that healthcare be based upon science).

Cancer is a very difficult type of disease to treat, and the public has a very distorted view of the nature of cancer and of medical scientific progress in general. This has lead to unrealistic expectations of progress in curing cancer, which then in turn leads to thoughts that cancer research is somehow not working.

I find the same to be true in medicine in general – the public thinks of scientific progress in terms of dramatic “breakthroughs.” Media hype feeds this misconception. The reality is that medical scientific progress is largely a series of very small steps, with a cumulative effect of slow steady improvement in treatments. We have not cured Alzheimer’s disease, ALS, Multiple Sclerosis Parkinson’s disease, and many other diseases as well. But treatments are slowly improving. Slow steady progress does not make good headlines, however, so the myth of miracle medical breakthroughs will likely continue to be promoted by the media.

Read the entire post. Hat tip to Sandy Szwarc.

Posted by Tom at 4:10 AM | Comments (1) | TrackBack (0)

An important distinction in the health care finance debate

Clear Thinkers favorite Arnold Kling, who appears to be everywhere these days in regard to discussions over reform of America's health care finance system, reminds us in this Washington Times op-ed of an important distinction in the health care finance debate -- despite the problems in health care finance, American medical care and research remains the hope of the world:

On one side of me at the graduation [of my daughter] sat [my wife], a breast cancer survivor. On the other side was my father, whose heart condition and blood pressure threatened to take his life before my daughter was ready to graduate kindergarten, much less college. Finally, there was my daughter herself, who since high school has had a chronic intestinal illness sufficiently contained that she could graduate on schedule.

None of these three stars would have been there without medical treatments that only became available since my daughter was born. New drugs played a significant role in each case. In fact, some pharmaceuticals critical for my daughter only were approved for her condition a few years before she was given them. Drugs in the pipeline are likely to play an important role in her future.

In other countries, would the same state-of-the-art medicines and equipment have been available to my father, my wife and my daughter? Perhaps. But it is a safe bet these technologies were not invented elsewhere.

Much of the medical innovation that the world enjoys comes from America. While as an economist I find much to criticize about our health-care system, America's role in medical innovation is crucial not just for Americans, but for the entire world.

Read the entire op-ed.

Posted by Tom at 4:04 AM | Comments (1) | TrackBack (0)

June 29, 2007

A primer on insulin, blood sugar and Type 2 diabetes

Mark Sisson (earlier post here) is now blogging on nutrition and exercise issues, and one of his first posts provides this good overview of the often misunderstood interrelationship between insulin, blood sugar and Type 2 diabetes. As Sisson notes, "we are all, in an evolutionary sense, predisposed to becoming diabetic."

Posted by Tom at 12:12 AM | Comments (0) | TrackBack (0)

June 18, 2007

Steroids, home runs and variables

This post about Barry Bonds from a week or so ago prompted an interesting exchange in the comments between me and Gary Gaffney, a University of Iowa physician who blogs about steroid use over at Steroid Nation. Following on that exchange is this Michael Salfino/Grand Rapids Press article that raises questions regarding the conventional wisdom these days that steroid use dramatically increased home run totals in Major League Baseball:

Between 1995 and 2003, the era where, [steroids critics contend that] home run totals were inflated dramatically by alleged steroid use, each team hit, on average, 173 homers.

Unfortunately for [the steroids critics' argument], home run totals per team post-steroid testing are actually up, not down: 176 homers for the average team in the average year.

Leaguewide, there were 5,250 homers hit on average between 2001 and '03; 5,290 between '04 and '06.

One argument is that between '00 and '02, seven batters slugged 50 or more homers. Between '03 and '05, just one did.

But two batters, Ryan Howard and David Ortiz, hit more than 50 homers last year, and another, Albert Pujols, just missed with 49.

We again share the great insight by Art De Vany, professor emeritus of economics at the University of California-Irvine, that hitting home runs is an act of genius.

So, De Vany concludes, we must expect wide variance in the best years of athletes just like we accept wide variance in the best films of directors, albums of musicians or books by authors relative to their main body of work.

De Vany also concludes that large swings in individual home run performance are irrelevant to the steroids debate.

This year, teams are hitting homers at a 4,632 pace, which would be the lowest, by far, per team, in all the years cited by Kriegel except for '95. The homer rate thus far could be a fluke that will correct itself going forward.

Still, it would be surprising if the year-end total cracked 5,000, about where it stood in '02 and '05. Swings of 10 percent are common in every era. In the modern context, that means a range of anywhere between 4,800 and 5,800 homers should be considered normal.

Professor DeVany comments.

Posted by Tom at 4:25 AM | Comments (0) | TrackBack (0)

June 15, 2007

Investing in fat people?

Following on earlier posts here and here on how the U.S. anti-obesity industry often misrepresents the nature and extent of the health problems related to widespread obesity in American society, Laura Vanderkam reviews NY Times nutrition columnist Gina Kolata's new book, Rethinking Thin: The New Science of Weight Loss--and the Myths and Realities of Dieting (Farrar, Straus, and Giroux, 2007) in which Kolata challenges the conventional wisdom that an obese person's capacity to lose weight and maintain that reduced weight is merely a question of an individual's willpower.

Despite Kolata's book and a growing body of research that questions the anti-obesity crusade, investing in anti-obesity appears to be a potentially lucrative investment opportunity. A case in point is this Merrill Lynch research report on how best to invest in "the emerging obesity epidemic." Table 5 presents "stocks that represent the ML Obesity Theme" which, by the way, includes Whole Foods and Wild Oats Markets.

"The developed world is getting older and fatter," writes ML analyst Jose Rasco. "People are increasingly eating more proteins and processed foods, leading more sedentary lives and gaining weight." Inasmuch as ML projects that the number of obese people worldwide will increase to 700 million in 2015 from 400 million in 2005, there's money to be made in those companies that are fighting obesity or, as ML might say, "why not monetize a trend of more fat people?"

Posted by Tom at 4:05 AM | Comments (1) | TrackBack (0)

June 8, 2007

Snow Fall

Robin Moroney over at The Wall Street Journal's Informed Reader blog picks up on this interesting Ken Dermota/Atlantic ($) article that reports on the weird economics relating to the demand, the supply and the price of cocaine:

Demand for cocaine stays steady, Colombia’s coca fields are destroyed, yet the drug’s street price in the U.S. continues to fall . . . [as] drug smugglers and dealers have eked out efficiencies in their operations to keep their prices low. The U.S. Coast Guard has been able to catch only a small percentage of the drugs entering the country since President Nixon declared a “war on drugs” in 1971. In 2000, the U.S. decided to switch tactics and take the fight to Colombia, which produces 90% of the cocaine sold in the U.S. Since then, it has spent $4.7 billion fighting rebels who grow and sell the crop, as well as spraying coca fields from the air.

The price of cocaine—the pure version, not crack—has kept falling. In the early 1980s, the price of a gram of cocaine was about $600. By the late 1990s the price had fallen to about $200. According to the Drug Enforcement Administration, the street price of a gram of cocaine in 2005 was $20-$25 in New York, $30-$100 in Los Angeles and $100-$125 in Denver.

Some of the price decrease has come from more efficient distribution networks. Some New York smugglers have chosen to eliminate the middleman and pick up their drugs directly from Colombia, offering “factory-to-you” prices. The surging trade with Mexico has increased the nooks and crannies for drugs to be hidden as they cross the border, making smuggling both safer and cheaper.

Labor costs also have decreased. Street vendors take a smaller cut of the drug’s proceeds. A lot of the drug dealers who fell prey to an aggressive imprisonment campaign in the 1990s are now leaving prison. Their felony conviction and minimal job experience means they have few other ways to make money and are willing to take a pay cut.

The falling street price also reflects the lower risk of handling the drug. The violence of the 1980s crack boom has faded and, since 2001, federal drug prosecutions have fallen 25% as agents get diverted to the hunt for terrorists.

While the Atlantic article focuses on why the price of cocaine continues to drop even though the supply sources are declining, what's particularly interesting is that the demand for cocaine is not rising dramatically as the price declines. Given its addictive nature, it makes sense that the demand for cocaine would be somewhat price inelastic, but it seems logical that demand would increase at least to some extent as the price falls. This does not appear to be happening. Sounds like a good exam question for an economics course.

Posted by Tom at 4:14 AM | Comments (0) | TrackBack (0)

June 5, 2007

Texas' medical licensing logjam

The number of insurance companies offering medical malpractice insurance policies has dramatically increased and malpractice insurance premiums have substantially decreased since the 2003 legislation enacting medical malpractice caps in Texas, but the med mal caps have contributed to at least one unanticipated problem:

. . . about 2,250 license applications await processing at the Texas Medical Board in Austin. The wait could be as long as a year for some of the more experienced doctors because it takes longer to review their records.

The fear is that some doctors will give up on Texas and go elsewhere instead of waiting. A $1.22 million emergency funding request was approved during the last days of Texas legislative session for the Texas Medical Board, which licenses physicians. That is on top of the $18.3 million regular biennial appropriation, said Jane McFarland, the board's chief of staff.

The board plans to add nine new employees to its 139-member staff, seven of which will help chop away at the backlog of license applications.

Posted by Tom at 4:05 AM | Comments (0) | TrackBack (0)

May 24, 2007

Proof that Texas legislators don't have enough to do

The lead in to this Ft. Worth Star Telegram article is a dead giveaway that Texas legislators are in a "throw the money around" mood as they near the end of the legislative session:

Many Texas students are too fat, experts say, and face future health problems because of their poor fitness. This week, the Legislature may weigh whether a new annual fitness test can help whip them into better shape. Fitness guru Dr. Kenneth Cooper of Dallas teamed up with Sen. Jane Nelson, R-Lewisville, to author legislation that would require schools to monitor students' health to prevent childhood obesity . . .

According to the bill, students in kindergarten through fifth grade must have “moderate or vigorous" activity for 30 minutes each day. Students in grades six, seven and eight must have physical activity 30 minutes a day for four semesters. Additionally, schools must annually assess the physical fitness of students in grades three through eight. Under the legislation, the Texas Education Agency would be asked to adopt a testing tool that measures aerobic capacity, body composition, muscular strength, endurance and flexibility.

According to the bill, the TEA must also analyze the data for a correlation between physical fitness and academic achievement, attendance, disciplinary problems and obesity . . .

The wording in the bill that describes the required testing tool mirrors language on the Web site for Cooper's FitnessGram, developed in 1982 to measure health and fitness levels of children . . . The FitnessGram would cost about $230 for each child when purchased from its distributor, Human Kinetics. The nonprofit Cooper Institute receives $30 from each sale.

Sandy Szwarc nicely sums up the skimpy clinical evidence upon which the above-described legislation is based:

The bottom line was that [Harvard School of Public Health] researchers were not able to clearly establish a direction between fitness and overweight. Meaning, the slightly lower levels of athleticism among heavier children didn’t necessarily point to that as being the cause for their size, nor that trying to turn them into better athletes will make them slimmer.

There is no credible evidence that the levels of physical activity and fitness among fat children are less than thinner kids to explain their diversity in sizes. There is no credible evidence that school or after-school physical activity programs reduce obesity among children. The medical evidence long ago demonstrated that heredity and genes account for aerobic capacity, upper body strength and athletic prowess. Researchers have also found that different children have different physical aptitudes, just like academic and artistic abilities. Research, for example, in the journal of the North Association for the Study of Obesity, Obesity Research, found that “obese” and nonobese school kids had similar levels of physical activity, while nonobese boys engaged in more sports. The fat children did poorer on propulsion tasks, but showed greater grip strength and similar scores with the other kids on overall fitness.

Posted by Tom at 4:05 AM | Comments (0) | TrackBack (0)

May 16, 2007

Dubious Chronicle advertising

David Barron generally does good work for the Chronicle, particularly in reporting on media developments relating to professional sports and collegiate athletics. And this Barron piece in yesterday's Chronicle about Waco chiropractor John Patterson's work on various professional athletes is filled with all sorts of interesting anecdotes on the miraculous results of Patterson's treatments on such professional athletes as Tracy McGrady, John Smoltz, Earl Campbell and former UT star pitcher and current Oakland A's closer, Huston Street, among others.

But don't you think that any reasonably objective newspaper article would at least mention the fact that there is substantial research (see also here) that has concluded that what Patterson is doing is quackery?

By the way, Street went on the disabled list yesterday with elbow tendonitis.

Posted by Tom at 12:46 AM | Comments (0) | TrackBack (0)

May 11, 2007

More on the futility of dieting

Earlier posts here, here and here discussed the general ineffectiveness of dieting. Now, this Gina Kolata/NY Times article reports that researchers at Rockefeller University are finding that "it is entirely possible that weight reduction, instead of resulting in a normal state for obese patients, results in an abnormal state resembling that of starved nonobese individuals.”

In other words, being fat may just be an inherited condition.

Posted by Tom at 4:00 AM | Comments (0) | TrackBack (0)

May 3, 2007

Changing history

The NY Times' medical reporter, Lawrence Altman, M.D., tells the story of how Houston's famed heart surgeon Michael E. DeBakey changed the course of history by persuading the late Boris Yeltsin that he could survive heart bypass surgery after the Russian president had suffered a heart attack in the fall of 1996. The surgery saved Yeltsin's life and allowed him to live for another decade.

Of course, there are some who would argue that Dr. DeBakey efforts did not change history for the better.

Posted by Tom at 4:10 AM | Comments (0) | TrackBack (0)

May 1, 2007

The Hurwitz conviction

You probably have already heard by now that Dr. William Hurwitz (previous posts here) was convicted this past Friday afternoon on 16 counts of drug trafficking for prescribing opioid prescriptions to his chronic-pain patients. The New York Times' John Tierney -- who deserves an award for his coverage of the trial and the sad case of Dr. Hurwitz -- interviewed three of the jurors after the trial and his findings are disturbing:

[The jurors] said that the jury considered Dr. William Hurwitz to be a doctor dedicated to treating pain who didn’t intentionally prescribe drugs to be resold or abused. They said he didn’t appear to benefit financially from his patients’ drug dealing and that he wasn’t what they considered a conventional drug trafficker.

So why did find him guilty of “knowingly and intentionally” distributing drugs “outside the bounds of medical practice” and engaging in drug trafficking “as conventionally understood”? After attending the trial and talking to the jurors, I can suggest two possible answers:

1. The jurors were confused by the law.
2. The law is a ass (to quote Mr. Bumble from “Oliver Twist”).

I can’t blame the jurors for being confused, because that’s the norm in trials of pain-management doctors. The standard prosecution strategy is to charge the doctor on so many counts and introduce so much evidence that the jurors assume something criminal must have happened. Their natural impulse, after listening to weeks of arguments, is to look for a compromise by digging into the mountain of medical minutiae – and getting in so deep that they lose sight of the big picture.

According to Tierney's inteview, the Hurwitz jury essentially convicted Hurwitz of not examining his patients adequately. Remarkably, the jurors were candid with Tierney that they did not understand the legal standard of "outside the bounds of medical practice." Rather, they just decided "to go with our gut."

Sound familiar?

Dr. Hurwitz's conviction is troubling for medical professionals on several levels, not the least of which is described by a doctor in the following comment to Tierney's post:

The Hurwitz persecution scares the bejabbers out of me. If I refuse to treat pain adequately that is a criminal offense. If I over treat pain that is a criminal offense. If I cannot tell a smooth, practiced, professional liar from real pain that is a criminal offense. I am expected to be all things to all people, omnipotent and infallible - and if I fail I will be stripped of my license or sent to prison.

Just recently I received a phone call that one of my patients was selling my narcotic prescription on the street. Was this real, a crank call, or a sting operation by the prosecutor? My only avenue of survival was to immediately file a complaint against the patient with BAYONET (a narcotics strike force). Welcome to 1984, Hurwitz jurors. So now that you have forced me to survive by turning people in to the secret police, how do you feel about coming to me and discussing your personal issues?

The message is clear. Pain specialists better be careful who they treat -- and undertreat those patients who they elect to take on -- or risk going to jail. The doctor-patient relationship has just become much more complicated. And not for the better.

Posted by Tom at 4:15 AM | Comments (0) | TrackBack (0)

April 30, 2007

Is it the farm subsidy? Or the processed food subsidy?

Michael Pollan, the Knight professor of journalism at the Cal-Berkeley and the author of “The Omnivore’s Dilemma” (earlier post here), has been writing a series of op-eds for the New York Times in which he is addressing in an abbreviated manner various nutritional issues that he covers in his book. In this recent piece, Pollan examines why calorie-intensive processed foods have such a relatively cheap price at the supermarket in comparison to fresh fruits and vegetables:

For the answer, you need look no farther than the farm bill. This resolutely unglamorous and head-hurtingly complicated piece of legislation, which comes around roughly every five years and is about to do so again, sets the rules for the American food system — indeed, to a considerable extent, for the world’s food system. Among other things, it determines which crops will be subsidized and which will not, and in the case of the carrot and the Twinkie, the farm bill as currently written offers a lot more support to the cake than to the root. Like most processed foods, the Twinkie is basically a clever arrangement of carbohydrates and fats teased out of corn, soybeans and wheat — three of the five commodity crops that the farm bill supports, to the tune of some $25 billion a year. (Rice and cotton are the others.) For the last several decades — indeed, for about as long as the American waistline has been ballooning — U.S. agricultural policy has been designed in such a way as to promote the overproduction of these five commodities, especially corn and soy.

That’s because the current farm bill helps commodity farmers by cutting them a check based on how many bushels they can grow, rather than, say, by supporting prices and limiting production, as farm bills once did. The result? A food system awash in added sugars (derived from corn) and added fats (derived mainly from soy), as well as dirt-cheap meat and milk (derived from both). By comparison, the farm bill does almost nothing to support farmers growing fresh produce. A result of these policy choices is on stark display in your supermarket, where the real price of fruits and vegetables between 1985 and 2000 increased by nearly 40 percent while the real price of soft drinks (a/k/a liquid corn) declined by 23 percent. The reason the least healthful calories in the supermarket are the cheapest is that those are the ones the farm bill encourages farmers to grow.

Read the entire piece.

Posted by Tom at 4:15 AM | Comments (0) | TrackBack (0)

April 27, 2007

What was Dr. Hurwitz's motive?

The NY Times' John Tierney, who has done an outstanding job of covering the sad case of Dr. William Hurwitz, provides this insightful post on the utter lack of a motive for Dr. Hurwitz to commit the crime for which he is being prosecuted:

Prosecutors charged that Dr. William Hurwitz was in a conspiracy with some of his patients to illegally distribute drugs, but there was no evidence that the patients had shared the profits when they resold the painkillers he prescribed. The only money he got was from the medical fees he charged. The prosecutors tried to portray his practice as a lucrative operation, and him as a doctor motivated by greed. This is a bit hard to square with what the jury heard about his background. which included stints in the Peace Corps and the Veterans Administration. And it’s really hard to square with his bank account.

In 2003, before the charges in this case had even been brought against him, authorities seized Dr. Hurwitz’s assets. (That’s standard procedure in drug cases like this, and one more reason why doctors have such a hard time mounting a defense.) There wasn’t much to seize. They took all his retirement savings — which amounted to less than $250,000. He was at that point 58 years old and had been practicing medicine for decades. . . .

“It’s so ridiculous to hear the prosecutor talk about this rich doctor,” Mrs. [Nilse] Quercia [Dr. Hurwitz's former wife] told me. “Except for that Keough account they seized, he had nothing but debts and a 1990 Subaru.” His subsequent legal expenses, she said, were paid by friends and relatives and by the law firms now representing him pro bono.

In my experience, when a prosecutor must fabricate a motive for the white collar criminal act that is being prosecuted, it's a pretty darn good indication that a lack of prosecutorial discretion is behind the decision to pursue the charges in the first place.

Posted by Tom at 4:20 AM | Comments (0) | TrackBack (0)

April 10, 2007

Speedy treatment of heart attacks

This Gina Kolada/NY Times article examines one of the most underappreciated aspects of treating heart attack victims -- the importance of speedy treatment:

Studies reveal, for example, that people have only about an hour to get their arteries open during a heart attack if they are to avoid permanent heart damage. Yet, recent surveys find, fewer than 10 percent get to a hospital that fast, sometimes because they are reluctant to acknowledge what is happening. And most who reach the hospital quickly do not receive the optimal treatment — many American hospitals are not fully equipped to provide it . . . [. . .]

What few patients realize . . . is that a serious heart attack is as much of an emergency as being shot.

“We deal with it as if it is a gunshot wound to the heart,” Dr. [Elliott] Antman [director of the coronary care unit at Brigham and Women’s Hospital] said.

Cardiologists call it the golden hour, that window of time when they have a chance to save most of the heart muscle when an artery is blocked.

But that urgency, cardiologists say, has been one of the most difficult messages to get across, in part because people often deny or fail to appreciate the symptoms of a heart attack. The popular image of a heart attack is all wrong. [. . .]

[M]ost people — often hoping it is not a heart attack, wondering if their symptoms will fade, not wanting to be alarmist — hesitate far too long before calling for help.

“The single biggest delay is from the onset of symptoms and calling 911,” said Dr. Bernard Gersh, a cardiologist at the Mayo Clinic. “The average time is 111 minutes, and it hasn’t changed in 10 years.”

Read the entire article, which is a good overview of the early warning signs to look for in diagnosing a heart attack. Heck, even this cool customer is at elevated risk of having one.

Posted by Tom at 4:36 AM | Comments (0) | TrackBack (0)

April 5, 2007

The sad case of Dr. William Hurwitz

For you doctors out there who believe that what happened to Jeff Skilling could never happen to you, take a moment to read the NY Times' John Tierney's chilling opening blog post on the re-trial of Dr. William Hurwitz, the Virginia doctor who is being prosecuted on drug trafficking charges for prescribing pain medications that his patients allegedly abused or sold without his knowledge:

Jonathan Fahey, one of the prosecutors in federal court in Alexandria, Va., told the jurors in his opening statement that Dr. Hurwitz was a drug trafficker — part of a drug-trafficking conspiracy, in fact — because he prescribed large quantities of OxyContin and other pills while ignoring clear “red flags” that his patients were misusing and reselling the pills. The prosecutor said that Dr. Hurwitiz’s prescribing was “without a legitimate medical purpose” and “in its wake it left destruction, devastation and death.” [. . .]

[Defense attorney Richard] Sauber used his opening statement to tell the jury over and over that the case boiled down to one question: Was Dr. Hurwitz a doctor or a drug dealer? Calling him a “passionate advocate for patients who had been unfairly treated,” Mr. Sauber talked about Dr. Hurwitz’s work in the Peace Corps and in Veterans Administration hospitals, and his belief that too many patients were in pain because doctors were afraid to give them proper dosages of opioids. Mr. Sauber also promised to do something that the defense didn’t effectively do in the first trial: use expert testimony to show that the dosages prescribed by Dr. Hurwitz were within the bounds of legitimate medicine.

The Hurwitz case is an appalling reminder of how the Drug Enforcement Agency has pursued a perverse agenda in its pursuit of pain doctors. During Hurwitz's first trial, the DEA actually changed their own guidelines during the trial and removed them from its website because the defense was going to show that Hurwitz prescribed by those guidelines. Meanwhile, DEA head Karen Tandy publicly stated that Hurwitz deserved 25 years in the slammer because he “was no different from a cocaine or heroin dealer peddling poison on the street corner.”

Sound familiar?

Posted by Tom at 4:26 AM | Comments (2) | TrackBack (0)

April 4, 2007

Lessons of the Heart

Following up on recent posts here and here, don't miss this John E. Calfee/American.com op-ed on how recent research into heart disease treatments has not only changed medicine, but also basic science research:

How do we know where heart attacks come from? The answer lies in feedback from pharmaceutical clinical trials to basic research. Long before the stent trials began to upset received wisdom, massive trials of heart drugs had first validated previously controversial hypotheses and then upset the next generation of hypotheses. Eventually, these trials pushed basic research in unexpected directions. [. . .]

So there is a bit more to this week’s news about stents and heart attacks than meets the eye or is described in the media. We are witnessing another episode in the remarkable story of feedback from drug and device development to basic science. And we can expect more drug-tools to wreak more havoc in scientific understanding of human biology.

Read the entire piece, which is an excellent summary on how clinical research spurs development of better drugs, superior treatment and even better-focused research. Check out the new design of American.com, which has quickly developed into one of the most interesting and insightful on-line magazines.

Posted by Tom at 4:15 AM | Comments (1) | TrackBack (0)

March 12, 2007

Thinking about diet and exercise myths

One of my goals this year is to blog more on issues relating to nutrition and exercise, which are two of the most myth-generating subjects in American culture.

Along those lines, contrary to the information about the latest fad diets that bombards most Americans on almost a daily basis, this Sandy Szwarc post explains the reality -- diets do not work, at least for most people most of the time.

Similarly, long cardio workouts are often recommended as a way to burn calories for overweight folks, most of whom look absolutely miserable doing them. As Art DeVany explains, too much cardio actually has the opposite effect -- long workouts will likely make a person fatter.

Posted by Tom at 4:01 AM | Comments (0) | TrackBack (0)

February 28, 2007

The remarkable evolution of open heart surgery

Given the importance of Houston's Texas Medical Center in the development of open heart surgery (see here and here), a couple of recent NY Times articles focusing on open heart surgery caught my attention.

First, in this article, David Schribman compares his recent open heart surgery to the heart surgery that a childhood friend endured 42 years ago.

Next, following on this earlier post, this NY Times article reports that safety concerns are increasing over the long-term risks of stents used in angioplasty procedures. New data is indicating that the sickest heart patients may actually live longer if they receive bypass surgery rather than the angioplasty, which is prompting some well-known heart surgeons and cardiologists to conclude that the pendulum has swung too far away from bypass surgery.

Finally, the Times provides this extraordinary slide show of open heart surgery. The slide show is a powerful reminder that -- despite the now common nature of bypass surgery -- it is still not as routine as changing a flat tire.

Posted by Tom at 4:09 AM | Comments (0) | TrackBack (0)

February 27, 2007

The ruse of dieting

This earlier post made the point that a sound understanding of nutritional principles and moderate eating habits are far more likely to result in proper personal weight management than relying on the dozens of fad diets that are available to the American consumer.

Along those lines, this Sandy Szwarc post reports on some rather startling statistics relating to one such diet program:

A study on one of the largest commercial weight-loss programs was just published in the International Journal of Obesity but has been ignored by the press. Understandably, a major media campaign and flurry of press releases have not trumpeted its findings.

Researchers at four major research centers across the country followed 60,164 adults enrolled in the Jenny Craig Platinum program in 2001-2002 to evaluate how long people were able to stick with this program and how much weight they lost.

They found that a quarter dropped out the first month, 42% after 3 months, 22% after 6 months, and only 6.6% were able to stick with the program for a year.

Unlike Kirstie Alley, the weight loss among people not being paid as celebrity spokespersons was considerably less notable. For a 200 pound woman able to keep with the program an entire year, according to this study, she would have lost half a pound a week....except fewer than 7 out of 100 were able to hang in for a full year. Hardly winning endorsement for the success and palatability of the program.

Read the entire post. Research is increasingly concluding that being overweight does not equate with increased mortality risk. Rather, physical activity and fitness have a far greater impact on lowering mortality risk than one's body mass index or waist measurements. Despite our cultural stereotypes of what “fit” looks like, research on obese adults has shown that about half rate highly fit on maximal exercise testing, which is not much different from slender people.

Thus, there is nothing wrong with wanting to lose a few pounds, but forget about the latest fad diet. Instead, understanding nutrition and modifying eating habits over the long-term is much more likely to produce the calorie deficit that will eventually result in permanent weight loss. But if the goal is to reduce mortality risk, the better bet is simply to increase the exercise and recreation regimen, and more exercise is not necessarily better — a couple of hours total spread over 3-5 days a week is fine.

Posted by Tom at 4:17 AM | Comments (0) | TrackBack (0)

February 24, 2007

Don't sweat the small stuff

Dr. Nortin M. Hadler is a professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and attending rheumatologist at the University of North Carolina Hospitals in Chapel Hill. He also sounds in this ABC News op-ed a lot like my father:

To be well is not the same as to feel well.

Being well requires some sense of invincibility. No one is spared symptoms for long.

It's abnormal to go one year without upper respiratory symptoms or pain.

Lurking in our future are heartache and heartburn, shoulder and knee pain, headache, rashes and skipped heartbeats -- not to mention bothersome fatigue, sore muscles, bowel irregularity, insomnia and so much else to challenge our sense of well-being.

Nearly all of these predicaments can go away as mysteriously as they come about. To be well requires the wherewithal to cope with these ailments for as long as that takes -- and it can take weeks. [. . .]

We all need to get beyond the traditional complaint of "what's wrong with me, Doc, that I have this symptom?" and move on to more rational discourse, such as "is there any important disease that is causing my symptom? If so, can it be treated? If not, can we discern why I can't cope with this episode?"

Read the entire piece. And then get on with coping!

Posted by Tom at 4:21 AM | Comments (0) | TrackBack (0)

February 21, 2007

The dark world of binge eating

Jane Brody is the longtime New York Times fitness and nutrition writer and I have admired her writing for many years. Her column from yesterday -- titled "Out of Control: A True Story of Binge Eating" -- is a must-read not only because it addresses an important health problem, but also because it has a compelling personal touch:

It was 1964, I was 23 and working at my first newspaper job in Minneapolis, 1,250 miles from my New York home. My love life was in disarray, my work was boring, my boss was a misogynist. And I, having been raised to associate love and happiness with food, turned to eating for solace.

Of course, I began to gain weight and, of course, I periodically went on various diets to try to lose what I’d gained, only to relapse and regain all I’d lost and then some.

My many failed attempts included the Drinking Man’s Diet, popular at the time, which at least enabled me to stay connected with my hard-partying colleagues.

Before long, desperation set in. When I found myself unable to stop eating once I’d started, I resolved not to eat during the day. Then, after work and out of sight, the bingeing began.

I learned where the few all-night mom-and-pop shops were located so I could pick up the evening’s supply on my way home from work. Then I would spend the night eating nonstop, first something sweet, then something salty, then back to sweet, and so on. A half-gallon of ice cream was only the beginning. I was capable of consuming 3,000 calories at a sitting. Many mornings I awakened to find partly chewed food still in my mouth.

And, as you might expect, because I didn’t purge (never even heard of it then), I got fatter and fatter until I had gained a third more than my normal body weight, even though I was physically active.

My despair was profound, and one night in the midst of a binge I became suicidal. I had lost control of my eating; it was controlling me, and I couldn’t go on living that way.

Fortunately, I was still rational enough to reach out for help, and at 2 a.m. I called a psychologist I knew at his home. His willingness to see me in the morning got me through the night.

Read the entire column. Brody's honest and forthright story of how she finally came to terms with her obsession and addressed it -- abandoning diets and embracing sound nutritional principles for her life -- provides a hopeful and practical guide for those who are afflicted with this disorder. It is a stark reflection of the state of nutrition in the U.S. today that most of us know someone who is currently grappling with the same problem that Brody overcame.

Posted by Tom at 4:17 AM | Comments (0) | TrackBack (0)

February 14, 2007

Five big health care issues

EconLog's Arnold Kling, who is doing some of the best thinking these days on reforming America's dysfunctional health care finance system, identifies in this TCS Daily op-ed the five big questions in health care:

1. What will we do about the large projected deficit in Medicare?

2. What can we do to reduce government subsidies for extravagant use of medical procedures with high costs and low benefits?

3. What should we do about the health care needs of the very poor?

4. What should we do about the health care needs of the very sick?

5. What should we do about a scenario in which both income inequality and the share of average income devoted to health care rise sharply?

Kling goes on to discuss our social fetish with health insurance, which is really not insurance at all:

If you ask me what kind of health insurance I would like for my family, my instinct is to answer, "None." The only reason we have health insurance now is to avoid the stigma of being called "uninsured."

Somehow, health insurance has become a social fetish. I could travel to the far reaches of the globe, and almost everywhere I would find merchants where my credit is good and my dollars are welcome. But here at home, trying to enter a local hospital with nothing but a wad of cash and a credit card would be like urinating on the sidewalk.

Read Kling's entire piece. As the WSJ's ($) Holman Jenkins pointed out awhile back, government policy has exacerbated these issues and is unlikely to solve them through greater involvement in the system:

The tax code is the original hectoring mommy behind our health-care neuroses. It gives the biggest subsidy to those who need it least. It pays the affluent to buy more medical care than they would if they were spending their own money. It prompts them to launder our health spending through an insurance bureaucracy, creating endless paperwork. It prices millions of less-favored taxpayers out of the market for health insurance. It fosters a misconception that health care is free even as workers are perplexed over the failure of their wages to rise.

Posted by Tom at 4:13 AM | Comments (0) | TrackBack (0)

February 9, 2007

Trying to get in shape the hard way

Sandy Szwarc makes sense while expressing skepticism about the FDA's decision to approve an over-the-counter version of Xenical (orlistat) for sale, the first prescription weight loss drug to be available without a prescription:

Even the FTC’s scientific expert panel reviewing the evidence for weight loss advertisements, . . . determined that any claims that a weight loss product will cause weight loss by blocking the absorption of fat or calories were false and fraudulent advertising. . . . [E]ven with the prescription strength Xenical, people can’t malabsorb enough fat a day to lose a pound a week and there are limits beyond which significant gastrointestinal problems occur. The panel’s scientific analysis stated: “The biological facts do not support the possibility that sufficient malabsorption of fat or calories can occur to cause substantial weight loss.”

Meanwhile, this NY Times article reports that one of the formerly most popular ways to attempt to lose weight has fallen out of favor:

[I]f current trends continue, aerobics will be as rare as, . . . those vibrating belts that were supposed to jiggle away fatty hips and gravity boots that were supposed to — what was it they were supposed to do? For now, the popularity of aerobics is sharply down from when it was “the mainstay of fitness in America,” said Mike May, a spokesman for the Sporting Goods Manufacturers Association.

It’s why you may have noticed — if you have shown up at your gym attired in your best leg warmers with a sweatshirt off one shoulder — the lack of aerobics classes on the menu. Fewer than half of the 300 gyms and health clubs recently surveyed by IDEA offered aerobics classes, a number that is “continuing to decline,” according to the summation of the report.

At its peak in the mid-’80s, an estimated 17 million to 20 million did aerobics, Mr. May said. But only five million did in 2005, according to a report by the sporting goods association. “We expect the 2006 numbers to be significantly lower,” Mr. May said. “Aerobics are increasingly out of favor.”

The legacy of injuries is one reason. Many of the original instructors like Mr. Blahnik won’t teach aerobics — because they can’t. “Those hardest hit by all those aerobics were often the teachers, because they were pushing harder than anyone else and doing the classes a dozen times a week,” Dr. Metzl said. “Our bodies just weren’t meant to withstand all that pounding.”

By the way, Art DeVany has compiled this category of blog posts that explores the damaging physical effects of distance running and endurance training. More exercise does not always equate with better health.

Posted by Tom at 4:31 AM | Comments (0) | TrackBack (0)

February 5, 2007

Update on the case of Dr. Pou

Speaking of prosecutorial excess, the case of Dr. Anna Pou -- the former University of Texas Health Science Center professor and physician who was arrested last year in Louisiana on wrongful death charges for her actions in attempting to save lives during the chaotic aftermath of Hurricane Katrina -- was back in the news last week. The New Orleans coronor announced that he had not found evidence that would show that the cases were homicides, although he noted that he was continuing to gather evidence and had reached no final conclusion.

Dr. Pou's case was transferred to Orleans Parish after Louisiana Attorney General Charles Foti had labeled her and two nurses who were assisting her during the chaos as murderers. Just to make sure he got the most publicity possible for his lack of prosecutorial discretion, Foti repeated those charges on 60 Minutes several months ago. Ultimately, the decision on whether to prosecute will come down to Eddie Jordan, the District Attorney of New Orleans, who is still planning on presenting evidence to a grand jury. With the the coroner’s current classification, what on earth is there to present to a grand jury?

Posted by Tom at 5:21 AM | Comments (0) | TrackBack (0)

January 30, 2007

Food myths

Americans love their myths and their food, so it makes sense that some of our most active myth-making occurs in the realm of eating and nutrition.

Michael Pollan, author of "The Omnivore’s Dilemma," (Penguin 2006) provides this excellent NY Sunday Times magazine piece in which he reviews the food and nutrition myths that have been developed and dispelled over just the past two decades in America. It's a fascinating story, particularly how Americans' willingness to accept the latest food or nutrition fad co-exists with a huge fast-food industry that is largely based on high-calorie processed food of dubious nutritional value.

Pollan is spot on in his observation that most Americans know just enough about nutrition to be dangerous, which is also the case with medical matters generally. Few people can accurately recount how many calories they consume in a day, and even fewer still can tell you how many calories they need to consume to lose weight or maintain their optimum weight (do you know what 200 calories looks like?). Similarly, few of those overweight folks torturing themselves on the treadmills or stationary bicycles at the local gym have a clue of how long they would need to exercise to work off the excess calories that they have consumed. Despite their tenacity, most of those overweight exercisers almost always overestimate the amount of calories expended during exercise.

As my wise father used to say: "What would you rather do? Eat one less helping of mashed potatoes? Or go ride the stationary bicycle for an hour?"

By the way, the following are a couple of terrific resources on nutrition that approach the subject from very different, but quite insightful, perspectives -- Junkfood Science by nutritionist Sandy Szwarc, who exposes many food myths that are based on studies of questionable merit, and Art De Vany's blog, where he frequently explores the physiological impact of diet, obesity and exercise.

Posted by Tom at 4:31 AM | Comments (0) | TrackBack (0)

January 25, 2007

Thinking beyond the UH Medical School

BlogHouston.net's Kevin Whited notes this Chronicle/Todd Ackerman article about the University of Houston floating a proposed new Texas Medical Center-based medical school in a collaborative project with The Methodist Hospital and Cornell University's Weill Medical School.

Unfortunately for UH, the proposal has zilch chance of floating for much more than a few minutes amidst the shark-infested waters of Texas educational politics. Heck, the political forces in Texas cannot even agree to provide adequate funding of UH's uncriticizable goal of becoming the state's third tier I research university. The University of Texas, Texas A&M University, and Baylor College of Medicine -- Methodist's former longtime partner -- are just a few of the powerful political forces that would almost certainly line up against the UH-Methodist proposal.

Yet, the UH-Methodist proposal has merit, so here's a proposed modification. Rather than start another medical school from scratch, let's merge the University of Houston system with the Texas A&M system and have A&M expand its fledgling medical school into the Texas Medical Center from its current central Texas outpost. From a broader standpoint, the merger makes sense because it gives the A&M system something that it desperately needs -- a major urban presence -- while also giving UH something that it has always lacked -- that is, access to adequate endowed capital. Such a merger would also provide A&M with the law school that it has always coveted and would greatly facilitate UH's elevation into a tier I research institution, which is something that would substantially benefit the Houston area.

While the University of Texas would almost certainly oppose such a merger, perhaps a deal could be struck at the same time to merge the Texas Tech University system into the UT system while organizing the remainder of Texas' non-affiliated public universities into a third university system for funding and administrative purposes. Such a structure would give Texas a similar structure to that of the reasonably successful California model, which has generated far more first rate, tier I research universities (10) than the current dysfunctional Texas system (2). Indeed, almost anything would be a huge improvement over the current Texas system, which allocates a disproportionate amount of endowed capital to the UT and A&M systems while starving the remainder of Texas' public universities.

Make sense? You bet. Chances of happening? Probably not much. But just as UCLA and Cal-Berkeley co-exist productively in the same university system in California, UH and A&M could do the same in Texas. And just as two major university systems work side-by-side together to educate Californians, a similar structure would be a substantial improvement in the educational system of Texas.

Posted by Tom at 4:54 AM | Comments (1) | TrackBack (0)

January 12, 2007

The myth of healthy marathoners

The Chevron Houston Marathon takes place Sunday morning, and this Dale Robertson/Chronicle article tells the story of Dolph Tillotson, the Galveston Daily News publisher who almost died of a heart attack while training at Memorial Park in preparation for the 2004 marathon. Tillotson has now recovered to the extent that he is going to try and complete the marathon on Sunday, which is certainly a remarkable comeback.

But is Tillotson's long-distance running making him healthier? Art DeVany argues that it does not and, in this recent post, notes a study from the Annals of New York Academy of Sciences that indicates that long-distance running is more dangerous to one's health than conventional wisdom suggests:

Ann N Y Acad Sci. 1977;301:593-619. Related Articles, Links

Coronary heart disease in marathon runners.

Noakes T, Opie L, Beck W, McKechnie J, Benchimol A, Desser K.

Six highly trained marathon runners developed myocardial infarction. One of the two cases of clinically diagnosed myocardial infarction was fatal, and there were four cases of angiographically-proven infarction. Two athletes had significant arterial disease of two major coronary arteries, a third had stenosis of the anterior descending and the fourth of the right coronary artery. All these athletes had warning symptoms. Three of them completed marathon races despite symptoms, one athlete running more than 20 miles after the onset of exertional discomfort to complete the 56 mile Comrades Marathon. In spite of developing chest pain, another athlete who died had continued training for three weeks, including a 40 mile run. Two other athletes also continued to train with chest pain. We conclude that the marathon runners studied were not immune to coronary heart disease, nor to coronary atherosclerosis and that high levels of physical fitness did not guarantee the absence of significant cardiovascular disease. In addition, the relationship of exercise and myocardial infarction was complex because two athletes developed myocardial infarction during marathon running in the absence of complete coronary artery occlusion. We stress that marathon runners, like other sportsmen, should be warned of the serious significance of the development of exertional symptoms. Our conclusions do not reflect on the possible value of exercise in the prevention of coronary heart disease. Rather we refute exaggerated claims that marathon running provides complete immunity from coronary heart disease.

DeVany -- who has been studying physiology and exercise protocols for years -- has accumulated a series of posts regarding the unhealthy nature and outright dangers of endurance training. The reality is that many endurance runners are not particularly healthy people, suffering from lack of muscle mass, overuse injuries, dangerous inflammation and dubious nutrition.

Tillotson obviously has great desire and discipline to be able to return to marathon running after almost dying of a heart attack. But his judgment in doing so is open to serious question.

Posted by Tom at 4:33 AM | Comments (1) | TrackBack (0)

January 4, 2007

The unintended consequences of the anti-steroids crusade

As noted in this earlier post, I have long had reservations regarding the anti-steroids campaign that is promoted by various regulatory bodies and the media. As Peter Henning noted over the holiday season in this extensive post, the Ninth Circuit Court of Appeals recently issued an important decision in the Balco case in which the appellate court overturned three lower court orders that had declared government searches unconstitutional and directed the government to return the drug tests to the businesses that were searched. In United States v. Comprehensive Drug Testing, Inc., a divided Ninth Circuit panel reversed the lower court rulings and upheld the search warrants, including seizure of computer records, and ordered the lower courts to segregate records that fall outside the scope of the warrants so that they can be reviewed by a federal magistrate. The appellate decision also reversed the district judge's order quashing the subpoena issued after the search, and went on to declare that the government may issue a subpoena for documents held by a third party even after a search for the same records.

In this lucid ReasonOnline op-ed, Jacob Sullum sums up why all of this is quite troubling:

The 9th Circuit's loose treatment of "intermingled" data allows investigators to peruse the confidential electronic records of people who are not suspects, hoping to pull up something incriminating. It replaces a particularized warrant based on probable cause with a fishing license.

The mob believes that the athletes who use steroids are cheating criminals who should be punished. Let's just hope that the laws that protect us from government's overwhelming prosecutorial power aren't trampled in the process of upholding the myth of fair play in professional sports.

Posted by Tom at 4:55 AM | Comments (1) | TrackBack (0)

The epidemic of diagnosis

Following on the strong NY Times medical-related stories of Lawrence K. Altman (here, here and here) over the holiday season, Drs. H. Gilbert Welch, Lisa Schwartz and Steven Woloshin contribute this op-ed to the Times in which they make the salient point that the American health care system is a hypochondriac's dream:

For most Americans, the biggest health threat is not avian flu, West Nile or mad cow disease. It’s our health-care system.

. . . The larger threat posed by American medicine is that more and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses.

Americans live longer than ever, yet more of us are told we are sick.

How can this be? One reason is that we devote more resources to medical care than any other country. Some of this investment is productive, curing disease and alleviating suffering. But it also leads to more diagnoses, a trend that has become an epidemic.[ . . .]

. . . the real problem with the epidemic of diagnoses is that it leads to an epidemic of treatments. Not all treatments have important benefits, but almost all can have harms. Sometimes the harms are known, but often the harms of new therapies take years to emerge — after many have been exposed. For the severely ill, these harms generally pale relative to the potential benefits. But for those experiencing mild symptoms, the harms become much more relevant. And for the many labeled as having predisease or as being “at risk” but destined to remain healthy, treatment can only cause harm.

Read the entire article. Then take a chill pill! ;^)

Posted by Tom at 4:07 AM | Comments (0) | TrackBack (0)

January 2, 2007

Reviewing medical advances

Fresh off his fascinating article on Dr. Michael DeBakey's confrontation with death (here and here), the NY Times' Lawrence K. Altman reminds us in this article that -- despite the dysfunctional U.S. health care finance system -- medical advances are continuing at an increasing rate:

As a reporter for The New York Times for 37 years, I have witnessed many important medical events, from new treatments to new diseases. In reflecting on that panorama, it is clear that technology has accounted for the greatest changes in medicine. Technology has improved laboratory testing; allowed for the development of CT scans, magnetic resonance imaging exams and positron emission tomography, or PET, imaging to improve diagnostic accuracy; and produced new drugs and devices. Basic science, too, has deepened our understanding of disease, and much of that work depends on technology.

At the same time, the care for many ailments has been greatly improved by ancillary developments like better nursing care, newer antibiotics, transfusions of platelets to prevent bleeding, the insertion of monitoring tubes in major veins, and better organization of some services. [. . .]

Few people appreciate that medicine has advanced more since World War II than in all of earlier history. Newer drugs and devices and better understanding of disease mechanisms have vastly improved the care of patients. For male babies born in this country in 1960, the life expectancy was 66.6 years; for female babies, it was 73.1 years. In 2004, the figures, respectively, were 75.2 and 80.4. Medical advances account for much, though not all, of the gain.

Altman's point regarding the importance of medical advances reminds me of a similar one that Donald J. DiPette, the chairman of the Texas A&M Internal Medicine Department, made while giving the Walter M. Kirkendall Lecture at the University of Texas Health Science Center this past spring. Given the advances in treatment of hypertension over the past 60 years, Dr. DiPette noted that President Franklin D. Roosevelt would have never been allowed to participate in the Yalta Conference at the end of World War II had his doctors known then what doctors knew a decade later about the traumatic implications of acute hypertension. In short, a better understanding of hypertension at the time of Yalta almost certainly would have changed the course of human history.

Posted by Tom at 4:16 AM | Comments (1) | TrackBack (0)

December 30, 2006

Reacting to the DeBakey surgery story

The reactions to last weekend's fascinating story about the surgery to repair a dissecting aortic aneurysm in 97-year old Medical Center icon, Dr. Michael DeBakey, are as interesting as the story itself. The following are a few comments selected from letters to the NY Times regarding the story:

"Dr. Michael E. DeBakey’s surgery may have been a technical advance of heroic and dramatic proportions, but it was a setback for patients’ rights. Dr. DeBakey is the epitome of the informed patient, and a document evidently existed that said he did not want surgery for his disease.

Progressing into a coma as one dies is a normal part of the terminal stages of many illnesses. Directives exist to prevent such an incapacitated patient from becoming a victim of the grieving spouse or the frightened caregiver.

Because of Dr. DeBakey’s stature and publicity about his case, this surgery may decrease patients’ right to die in a manner they desire, an unfortunate result of a remarkable feat."

"Your article about Dr. Michael E. DeBakey’s aortic aneurysm operation was described as emblematic of the difficulties of end-of-life care, but it is as much or more emblematic of the difficulty patients encounter in having their wishes to forgo treatment respected. No one in the world had better capacity to refuse this operation than Dr. DeBakey, and he did.

. . .After the world’s best medical care, months in the hospital and a million dollars, Dr. DeBakey and his family had a happy outcome.

But for those thousands of ordinary patients who must struggle against family, church and state to refuse invasive, risky, experimental or simply unwanted care, it is not necessarily a happy ending."

"I wonder if Katrin DeBakey would have been so eager for her husband’s surgery if she had had to provide all the postoperative care herself as the rest of us have to do.

Almost any elderly patient with good insurance and an educated and younger spouse making decisions can get good high-tech surgery, but the system fails when the hospital dumps the patient back home on the spouse after only two days of postoperative hospital care.

In Mrs. DeBakey’s case, her husband received months of in-hospital intensive care, emergency care, more surgery, physical therapy and psychological support.

The rest of us caregivers would have long since passed the breaking point from dealing on our own with medical emergencies, unavailable doctors, no home nurses, no respite time and the psychiatric problems of many elderly male patients — rage and depression."

"The article about Dr. Michael E. DeBakey illustrates many central issues that arise in determining types of care for gravely ill patients and whether to perform a risky but potentially lifesaving procedure.

The case exposes the standards of patient autonomy and informed consent — foundational principles of ethical medicine — to be impossible ideals. Even Dr. DeBakey, likely the person most thoroughly informed about the procedure, regretted his prior decision to forgo the surgery.

Another problem exposed by this case is the persistent misuse of the do-not-resuscitate order, interpreting it to signify more general wishes about less aggressive care instead of its actual, more restricted meaning: not resuscitating in the event of cardiac arrest."

As one of the other letter-writers pointed out, the story also reflects that Dr. DeBakey is the consummate educator, using his experience to prompt consideration and discussion of important medical and ethical issues in caring for patients who are close to death. He is truly one of Houston's treasures.

Posted by Tom at 7:09 AM | Comments (0) | TrackBack (0)

November 16, 2006

Re-thinking angioplasty in certain situations

Following on a trend noted in previous posts here and here, this NY Times article (see also here) reports that findings from a major new study suggest that noninvasive treatment with beta-blockers and other heart drugs turns out to be at least as good as angioplasty for patients whose arteries remain blocked at least three days after a heart attack. The findings -- which were presented earlier this week at the annual scientific meeting of the American Heart Association and published simultaneously online by the New England Journal of Medicine -- supplement an increasing body of research that is indicating that heart-attack patients whose disease is stable and whose symptoms are under control should be wary of taking the risk of invasive treatment, which can result in infection and bleeding.

Over the past 20 years or so, treatment of heart attacks has been transformed by the ability of doctors to break up blood clots that cause the heart attacks with clot-busting drugs and angioplasty procedures. By quickly restoring blood flow to the heart muscle following an attack, doctors have been able to save lives and minimize damage that can lead to total heart failure. However, a nagging problem has been that about a third of the million or so Amerians who suffer a heart attack each year do not arrive at a hospital within the 12-hour window after the attack during which the patients are most likely to benefit from these techniques. In those patients who stabilize on their own after an attack and then are not diagnosed with blocked arteries until days after the attack, the conventional wisdom has been to go ahead and perform the angioplasty, anyway.

The trial, which was funded by the National Heart, Lung and Blood Institute, involved about 2,200 men and women who had a totally blocked artery three to 28 days after suffering a heart attack. They were assigned randomly to receive either just the best-available drug therapy or drug therapy plus angioplasty and stent treatment. Blocked arteries were opened successfully in about 90% of the angioplasty patients and they opened spontaneously in about 25% of the patients taking just medication.

After four years, 17.2% of patients in the angioplasty group had died, suffered another heart attack or developed serious heart failure. In comparison, 15.6% in the group on medication alone had the same results. Although the relatively small difference could have resulted from mere chance, researchers suggest that the findings do not support the the higher risk of aggressive intervention in such patients.

The bottom line: People with chest pains should get to the hospital as soon as possible because quick application of clot-busting drugs and angioplasty remains the best way to preserve the heart muscle. But if the patient fails to do so and stabilizes on their own, then the benefit of an angioplasty later may not be worth the risk.

Posted by Tom at 4:46 AM | Comments (0) | TrackBack (0)

October 31, 2006

Calorie restriction and longevity

All the rage these days in longevity circles is calorie restriction, so this Julian Dibbell/New Yorker article reports on Dibbell's two-month test on the the ultra-extreme Calorie Restriction Diet -- an 1,800 calorie daily diet:

I’ve been starving for the past two months, actually, and that’s precisely what the party is about: My dinner guests—five successful urban professionals who for years have subsisted on a caloric intake the average sub-Saharan African would find austere—have been at it much, much longer, and I’ve invited them here to show me how it’s done. They are master practitioners of Calorie Restriction, a diet whose central, radical premise is that the less you eat, the longer you’ll live. Having taken this diet for a nine-week test drive, I’m hoping now for an up-close glimpse of what it means to go all the way. I want to find out what it looks, feels, and tastes like to commit to the ultimate in dietary trade-offs: a lifetime lived as close to the brink of starvation as your body can stand, in exchange for the promise of a life span longer than any human has ever known.

Seat belts, vaccines, clean tap water, and other modern miracles have dramatically boosted average life expectancies, to be sure—reducing annually the percentage of people who die before reaching the maximum life span—but CR alone demonstrably raises the maximum itself. In lab studies going back to the thirties, mice on severely limited diets have consistently lived as much as 50 percent longer than the oldest of their well-fed peers—the rodent equivalent of a human life stretched past the age of 160. And it isn’t just a mouse thing: Yeast cells, spiders, vinegar worms, rhesus monkeys—by now a veritable menagerie of species has been shown to benefit from CR’s life-extending effects.

The WSJ chimes in with this article ($), which focuses on a group of scientists who are attempting to mimic calorie restriction's antiaging effects with medicines. At the same time, this NY Times article reports on a Wisconsin-based research project that indicates that rhesus monkeys on a calorie restricted diet are much healthier than their counterparts that are eating a normal diet. Meanwhile, this NY Times article reports on a researcher's work that indicates that the 65% or so of Americans who are overweight or obese got that way, in part, because they didn’t realize how much they were eating.

After all this, please excuse me while I go get a gelato. ;^)

Posted by Tom at 4:12 AM | Comments (1) | TrackBack (0)

October 25, 2006

A fascinating peek at the descent into Alzheimer’s

When he learned in 1995 that he had Alzheimer’s disease, William Utermohlen, an American artist based in London, began his final project -- drawing self-portraits during his descent into dementia and ultimately Alzheimer's. This NY Times article reports that Utermohlen's work is being exhibited this week by the Alzheimer's Association at the New York Academy of Medicine in Manhattan:

The paintings starkly reveal the artist’s descent into dementia, as his world began to tilt, perspectives flattened and details melted away. His wife and his doctors said he seemed aware at times that technical flaws had crept into his work, but he could not figure out how to correct them.

“The spatial sense kept slipping, and I think he knew,” Professor [Patricia] Utermohlen [William Utermohlen's wife] said. A psychoanalyst wrote that the paintings depicted sadness, anxiety, resignation and feelings of feebleness and shame. [. . .]

Mr. Utermohlen, 73, is now in a nursing home. He no longer paints.

His work has been exhibited in several cities, and more shows are planned. The interest in his paintings as a chronicle of illness is bittersweet, his wife said, because it has outstripped the recognition he received even at the height of his career.

Colleen Carroll Campbell, who has written extensively about Alzheimer's, observes that the disease "embodies everything we fear most about aging -- weakness and dependence, humiliation and oblivion." Nearly half of Americans over the age of 35 know someone personally who is at some stage of dementia, and as Americans are living longer, Alzheimer's is claiming more victims. About 4.5 million Americans suffer from Alzheimer's today, which is more than double the number who had the disease just 25 years ago. Utermohlen's paintings provide us with an important perspective on this insidious disease as we confront the difficult issues that result from it.

Posted by Tom at 4:15 AM | Comments (0) | TrackBack (0)

August 18, 2006

Merck's bad day

As with the baseball season, Merck & Co.'s defense of the Vioxx litigation is a marathon and not a sprint (previous posts here). Yesterday's sprint was not good for Merck, but my sense is that it's still way too early to write off Merck's defense strategy as a failure at this point.

The bad news for Merck was that a federal jury in New Orleans awarded $51 million to a former FBI agent who was taking Vioxx when he suffered a heart attack, while a New Jersey judge threw out a verdict in Merck's favor from a trial there last fall. The NJ judge has a reputation of being plaintiffs-friendly, so that ruling was not all that much of a surprise and, despite the federal venue of the New Orleans trial, New Orleans is still a plaintiffs-friendly environment. After a year of Vioxx trials, the scorecard reflects that Merck and the plaintiffs each have four victories, and there are at least another eight or so Vioxx trials scheduled in both state and federal court through the end of this year.

Ted Frank, who has been following the Vioxx litigation closely, has the best analysis of yesterday's developments in the overall context of the Vioxx litigation (see also here and here). Peter Lattman also has an interesting post in which he includes an email exchange with Houston plaintiff's lawyer, Mark Lanier, who was the first lawyer to hammer Merck in a Vioxx trial.

Posted by Tom at 5:35 AM | Comments (0) | TrackBack (0)

August 1, 2006

The story behind the arrest of Dr. Pou

As noted in this previous post, the arrest in Louisiana of former University of Texas Health Science Center professor and physician Dr. Anna Pou on wrongful death charges for her actions in attempting to save lives during the chaotic aftermath of Hurricane Katrina is an egregious example of prosecutorial misconduct.

As is typical in such cases, word is now filtering out about the real motivations for the prosecution. Not only is an elderly Louisiana attorney general who campaigned on a plank of "cracking down on abuse of the elderly" at the center of the dubious decision to arrest, this NY Times article reports that Dr. Pou's accusers are three employees of LifeCare Hospitals, the company that owned the facility where 24 out of 55 elderly patients died in the aftermath of Katrina and whose top administrator and medical director didn't even show up at the hospital during those chaotic days. It turns out that the accusing LifeCare employees didn't make any effort to evacuate the elderly and sick patients, either. Does this have the smell to you of someone attempting to distract attention (or perhaps avoiding prosecution) from their own indiscretions?

Dr. Kevin Pho of Kevin, M.D. is doing a good job of keeping up with the reactions and commentary around the web to the case against Dr. Pou and the nurses. The case against Dr. Pou is the other side of the same coin that the government flips when it criminalizes risk-taking by businesspersons, so stay tuned to developments in this troubling prosecution.

Posted by Tom at 8:49 AM | Comments (1) | TrackBack (0)

July 25, 2006

Thinking about progress in health care

This NY Times article tells the fascinating story about the assassination of President James A Garfield back in 1881 while noting an exhibit commemorating the 125th anniversary of Garfield’s assassination at the National Museum of Health and Medicine on the campus of the Walter Reed Army Medical Center.

President Garfield was shot on July 2, 1881 in Washington by a disgruntled federal job-seeker, Charles J. Guiteau, who made his move while Garfield was waiting for a train. What is not as well-known is that neither of the shots that hit Garfield should have fatal even by the more primitive medical standards of the 1880's. As my late father once observed to me while discussing Presidential assassinations, "Garfield's assassin just shot him. Garfield's doctors killed him."

The Times article reminds me of another interesting medical case that Dr. Donald J. DiPette, chair of the Department of Internal Medicine at Texas A&M University Medical School, presented earlier this year during the Walter M. Kirkendall Lecture that the University of Texas Medical School conducts annually in honor of my father.

Dr. DiPette's subject was how advances in clinical research on hypertension had contributed to our understanding and knowledge of related medical problems that are related to high blood pressure, and he used a case study of a man in his mid-50's in the late 1930's who was showing signs of acute hypertension as an example of how that understanding can change the world.

The negative impact of hypertension on an individual's health was not well-understood in the late 1930's and 40's, and Dr. DiPette showed how the patient's health in the case study deteriorated at an accelerated rate as his blood pressure readings increased markedly from 1937 to 1945. One evening in early 1940, he collapsed unconscious at the dinner table. The patient's doctors at the time were unsure why.

By 1945, the patient -- who was still working in an important and high-pressure job -- had blood pressure that was off the charts and was experiencing a combination of associated medical problems that would have landed him in a hospital these days. Nevertheless, the patient continued to work and, about a month after a particularly important work-related meeting, the patient died of a massive stroke.

Only at the end of his lecture did Dr. DiPette reveal the name of the patient in his case study -- President Franklin D. Roosevelt.

Dr. DiPette's point was that President Roosevelt's acute hypertension clearly affected his performance at the Yalta Conference, and his doctors would likely have never allowed FDR to participate in that history-changing event had they known what we know now about the effects of hypertension. Thus, lack of knowledge about hypertension -- which finally began to be understood less than a decade after FDR's death -- literally changed the course of the 20th century.

Remember that as you contemplate the negative impact on clinical research of this, this and this.

Posted by Tom at 6:33 AM | Comments (2) | TrackBack (0)

July 20, 2006

The doctor at the center of the Hurricane Katrina wrongful death prosecution

Dr. Anna Pou, the New Orleans doctor who heroically served severely-ill patients during the chaotic aftermath of Hurricane Katrina last summer, is at the center of the highly-publicized and controversial decision of Louisiana criminal authorities earlier this week to arrest Dr. Pou and two assisting nurses and charge them with second-degree murder in the deaths of four patients who died during that horrible time. She is also a former Houston-area resident, having served on the faculty of the University of Texas Medical Branch in Galveston from 1997-2004, where she was the Director of the Division of Head and Neck Surgery from 1999 to 2004.

Today, this excellent NY Times article places in perspective the arrest and prosecution of this outstanding physician, who is a diplomate of the American Board of Otolaryngology, Fellow of the American College of Surgeons, and a member of the American Head and Neck Society. Dr. Pou has authored more than forty publications, has also served on multiple committees of the American Academy of Otolaryngology, and has lectured in national and international forums on topics in otolaryngology, head and neck oncology, and microvascular reconstructive surgery.

In short, Dr. Pou is no murderer. This prosecution has all the earmarks of yet another lynch mob that is more interested in myths than reality, so watch it closely.

Posted by Tom at 7:34 AM | Comments (9) | TrackBack (0)

May 25, 2006

Thinking about heroin addiction

Theodore Dalrymple -- the pen name of British psychiatrist and author, Anthony Daniels (previous posts here) -- has written a new book, Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy (Encounter 2006) in which he challenges the conventional medical wisdom regarding opium addition. In this Wall Street Journal ($) op-ed, Dalrymple provides interesting insight into the nature of addiction:

I have witnessed thousands of addicts withdraw; and, notwithstanding the histrionic displays of suffering, provoked by the presence of someone in a position to prescribe substitute opiates, and which cease when that person is no longer present, I have never had any reason to fear for their safety from the effects of withdrawal. It is well known that addicts present themselves differently according to whether they are speaking to doctors or fellow addicts. In front of doctors, they will emphasize their suffering; but among themselves, they will talk about where to get the best and cheapest heroin.

When, unbeknown to them, I have observed addicts before they entered my office, they were cheerful; in my office, they doubled up in pain and claimed never to have experienced suffering like it, threatening suicide unless I gave them what they wanted. When refused, they often turned abusive, but a few laughed and confessed that it had been worth a try. Somehow, doctors -- most of whom have had similar experiences -- never draw the appropriate conclusion from all of this. Insofar as there is a causative relation between criminality and opiate addiction, it is more likely that a criminal tendency causes addiction than that addiction causes criminality.

Furthermore, I discovered in the prison in which I worked that 67% of heroin addicts had been imprisoned before they ever took heroin. Since only one in 20 crimes in Britain leads to a conviction, and since most first-time prisoners have been convicted 10 times before they are ever imprisoned, it is safe to assume that most heroin addicts were confirmed and habitual criminals before they ever took heroin. In other words, whatever caused them to commit crimes in all probability caused them also to take heroin: perhaps an adversarial stance to the world caused by the emotional, spiritual, cultural and intellectual vacuity of their lives.

It is not true either that addicts cannot give up without the help of an apparatus of medical and paramedical care. Thousands of American servicemen returning from Vietnam, where they had addicted themselves to heroin, gave up on their return home without any assistance whatsoever. And in China, millions of Chinese addicts gave up with only minimal help: Mao Tse-Tung's credible offer to shoot them if they did not. There is thus no question that Mao was the greatest drug-addiction therapist in history.

Substitution of one drug for another is at best equivocal as a means of treating drug addicts. No doubt if you gave every burglar $10 million, each would burgle far less in the future; but this treatment of the disease of burglary would scarcely discourage burglary as a social, or rather antisocial, phenomenon. And the fact that there would be a dose-response relationship between the amount of money given to burglars and the number of burglaries they subsequently committed does not establish burglary as a real disease or money as a real treatment for it.

Why has the orthodox view swept all before it? . . . [A]ddicts and therapists have a vested interest in the orthodox view. Addicts want to place the responsibility for their plight elsewhere, and the orthodox view is the very raison d'être of the therapists. Finally, as a society, we are always on the lookout for a category of victims upon whom to expend our virtuous, which is to say conspicuous, compassion. Contrary to the orthodoxy, drug addiction is a matter of morals, which is why threats such as Mao's, and experiences such as religious conversion, are so often effective in "curing" addicts.

Posted by Tom at 6:18 AM | Comments (3) | TrackBack (0)

May 21, 2006

A real hero's story

Following on this post from a couple of months ago on Virginia Postrel's donation of a kidney to a friend, don't miss Virginia's inspiring Texas Monthly ($) article on the experience.

Interestingly, the most important part of Virginia's successful donation was her stubborness in going through with it:

Most important, it turned out, I had the right personality. Donating a kidney isn’t, in fact, a matter of just showing up. You have to be pushy. Unless you’re absolutely determined, you’ll give up, and nobody will blame you—except, of course, the person who needs a kidney. When I went to see my Dallas doctor for preliminary tests, the first thing she said was “You know, you can change your mind.”

To me, giving Sally a kidney was a practical, straightforward solution to a serious problem. It was important to her but not really a big deal to me. Until the surgery was scheduled—for Saturday, March 4—and I started telling people about it, I had no idea just how weird I was.

Normal people, I found, have a visceral—pun definitely intended—reaction to the idea of donating an organ. They’re revolted. They identify entirely with the donor but not at all with the recipient. They don’t compare kidney donation to other risky behavior, like flying a plane or running 31 miles to the bottom of the Grand Canyon and back, as my brother did last summer.

What a gal!

Posted by Tom at 7:24 AM | Comments (2) | TrackBack (0)

April 20, 2006

Diet and Alzheimer's

A new Annals of Neurology study headed by Nikolaos Scarmeas of the Columbw.pbs.org/wgbh/amex/bubble/index.html">David Vetter (a/k/a the "bubble boy"), who had severe combined immunodeficiency and lived inside a sterile plastic chamber for his 12 year life:

When David Vetter died at the age of 12, he was already world famous: the boy in the plastic bubble. Mythologized as the plucky, handsome child who had defied the odds, his life story is in fact even more dramatic. It is a tragic tale that pits ambitious doctors against a bewildered, frightened young couple; it is a story of unendingly committed caregivers and resourceful scientists on the cutting edge of medical research. This American Experience raises some of the most difficult ethical questions of our age. Did doctors, in a rush to save a child, condemn the boy to a life not worth living? Did they, in the end, effectively decide how to kill him?

Here is a Steve McVicker/Houston Press story from nine years ago that raises many of the same questions as those addressed in the PBS show.

Posted by Tom at 7:48 AM | Comments (3) | TrackBack (0)

March 16, 2006

Inhibiting the production of vaccines

The ever-observant Walter Olson points us to this interesting Theodore Dalrymple review of the new book The Cutter Incident: How America’s First Polio Vaccine Led to the Growing Vaccine Crisis (Yale University Press 2005) by Paul Offit, a professor of pediatrics at the University of Pennsylvania.

Dr. Offit's book tells the story of how a heartbreaking disaster caused by mass immunization during research — a disaster that helped lead to the major medical and scientific breakthrough of virtually eliminating polio from much of the world -- led to a legal ruling that has subsequently inhibited pharmaceutical companies from developing and manufacturing vaccines. During the early stages of polio immunization, the Cutter Company followed the then-imperfect instructions regarding production of the vaccine to the letter, but those instructions -- together with the then-imperfect scientific knowledge regarding the vaccine -- proved inadequate to guarantee the vaccine’s safety. As a result, the live polio virus survived in some of the company's vaccine, which was distributed to a large number of people. Seventy thousand of those immunized by the faulty vaccine experienced the transient flu-like symptoms of mild polio, 200 wound up being paralyzed by polio, and 10 died from the disease.

Some of the victims then hired the most flamboyant plaintiffs’ lawyer of the time, Melvin Belli, who proceeded to sue the Cutter Company for all that it was worth. Although the trial was essentially a draw, the outcome nevertheless established a principle that would be nearly fatal to the production of vaccines in America:

The trial established beyond reasonable doubt that Cutter had not been negligent. But the judge stated—as a matter of law, so that the jury was powerless to disagree—that the company was liable for damages, even if it had done nothing wrong, simply because its product had harmed its recipients. This principle of absolute liability soon found itself defended in legal journals on the grounds that a large company was best able, via its insurance, to distribute the costs of risks among all the relevant parties, and society as a whole would benefit from the arrangement.

Quite apart from its repugnance to natural justice, this principle has been disastrous to the manufacture of vaccines. It opened the way for huge claims against the manufacturers. Since the courts are often cavalier in their complete disregard of scientific evidence, awarding huge damages against companies not only innocent of any negligence but whose products have done no objectively demonstrable harm, it is not surprising that pharmaceutical companies have largely withdrawn from the vaccine market. For them, the potential profits are small, and the risks great. SmithKlineGlaxo, for example, one of the world’s largest vaccine producers, withdrew its safe and effective vaccine against Lyme disease because of the expense of defending it against speculative tort actions of no merit. One almost wishes that an epidemic of Lyme disease would strike the whole tribe of tort lawyers.

Posted by Tom at 6:56 AM | Comments (1) | TrackBack (1)

March 10, 2006

A real hero

While enduring Andy Fastow's explanations this past week on how he was a hero at times while working at Enron, I've been meaning to note the story of a real hero, Dallas-based blogger and writer, Virginia Postrel.

Check out Virginia's posts here, here and here for the story.

What a gal!

Posted by Tom at 8:33 AM | Comments (3) | TrackBack (0)

January 5, 2006

Belly to Hip Ratio more important than BMI?

This Washington Post article reports on a new study published in The Lancet that indicates the relationship between belly size and hip size is more useful measure of health risk than the commonly-used body mass index (BMI):

According to a study published in The Lancet, a calculation comparing waist circumference to hip circumference is a better predictor of heart attack risk than . . . [b]ody mass index, [which] is often used to screen for obesity and to assess risk for a variety of diseases and conditions, including diabetes, metabolic syndrome and heart attack.

[T]he Lancet study, described by the authors as the largest and most conclusive to date, found that "BMI is a very weak predictor of the risk of a heart attack," said Salim Yusuf, lead author and director of the Population Health Research Institute at McMaster University in Hamilton, Ontario. "Measuring the girth of the waist and [the] girth of the hip is far more powerful."

The authors suggested people forgo calculating BMI. "I'd say just do the waist-to-hip ratio," Yusuf said. "There really is no additional value [in] doing the BMI."

The study indicates that even relatively lean people with a BMI that is quite low still have increased risk for heart attack based on the presence of abdominal fat. It remains unclear why location of fat in the abdominal area poses a greater health risk than fat carried around the hips, but recent studies have also linked waist-to-hip ratio to increased risk of diabetes and hypertension. The findings reported in Lancet study indicate that men with waist-to-hip ratios greater than 0.95 are at heightened risk for a heart attack and that females with ratios above 0.8 are at increased risk, and that the the risk "rose progressively with increasing values for waist-to-hip ratio, with no evidence of a threshold."

Speaking of health-related matters, the Chronicle has added a health-related blog by medical reporter Leigh Hopper to its growing list of weblogs. Chronicle technology reporter Dwight Silverman spearheaded the Chronicle's blog initiative last year, and now other prominent newspapers are emulating the Chronicle's blog idea. Kudos to Dwight and the Chronicle for contributing greatly to this productive trend of enhancing communication between media and its customers.

Posted by Tom at 6:28 AM | Comments (0) | TrackBack (0)

December 15, 2005

New study links Alzheimer's to diabetes

A new Brown University Medical School study published in the Journal of Alzheimer's Disease supports a growing body of clinical evidence indicating that Alzheimer's may be a new form of diabetes. The study found that brain levels of insulin and related cellular receptors fall precipitously during the early stages of Alzheimer's and that insulin levels continue to drop progressively as the disease becomes more severe. Previous posts on Alzheimer's-related matters are here.

Posted by Tom at 5:55 AM | Comments (0) | TrackBack (0)

November 28, 2005

Aspirin as Vioxx?

In one of my earlier posts about the Merck/Vioxx case, I observed somewhat facetiously that the risks associated with aspirin would probably deter any pharmaceutical company today from making the investment necessary to bring the drug to market. In this Medical Progress Today piece, pharmaceutical expert Derek Lowe confirms that my speculation is almost certainly correct:

[I]f you were somehow able to change history so that aspirin had never been discovered until this year, I can guarantee you that it would have died in the lab. No modern drug development organization would touch it.

Thanks in part to advertisements for competing drugs, people know that there are some stomach problems associated with aspirin. Actually, its use more or less doubles the risk of a severe gastrointestinal event, which in most cases means bleeding seriously enough to require hospitalization. Lower doses such as those prescribed for cardiovascular patients and various formulation improvements (coatings and the like) only seem to improve these numbers by a small amount. Such incidents, along with others brought on by other oral anti-inflammatory drugs, are the most common severe drug side effects seen in medical practice.

It doesn't take too long to see these effects in a research program. Aspirin causes gastric lesions in rats and dogs, which are the standard small and large animal models for drug toxicity. This side effect occurs at levels which would raise red flags for any new compound. What would a present-day research organization do about it? If we stipulate that they could determine that aspirin worked by inhibiting cyclooxegenase enzymes, they would surely try to break the vascular effects of the drug apart from its anti-inflammatory effects. They would try to find new compounds that selectively inhibited only one of the enzyme subtypes. They would, in other words, produce Vioxx, and Celebrex, and the other COX-2 inhibitors, and this is just why these drugs were developed.

Read the entire piece. By the way, the third Vioxx trial against Merck cranks up this week in Houston federal court. And Ted Frank wonders why Mark Lanier has still not moved for entry of a judgment on the $253 million jury verdict in the Ernst case?

Posted by Tom at 5:22 AM | Comments (0) | TrackBack (0)

November 10, 2005

Sleep apnea and strokes linked

A Yale University study of 1,022 patients over the age of 50 published in this week's New England Journal of Medicine concludes that obstructive sleep apnea more than doubles the risk of a stroke or death and that severe cases of sleep apnea more than triple the risk, even after even adjustment for other stroke-risk factors such as diabetes, hypertension and obesity. A number of previous studies have found links between sleep apnea and serious cardiovascular disease, but a link between sleep apnea and strokes had not yet been established. Strokes are the third leading cause of death in the U.S. after heart disease and cancer.

About 20% of American adults suffer from at least some form of sleep apnea, although physicians generally do not recommend treatment unless the condition involves five or more pauses in breathing per hour of sleep along with other symptoms, such as daytime drowsiness. Although only about a fifth of sleep apnea cases are considered severe, researchers and physicians estimate that more than half of the severest cases in the United States still go undiagnosed. Obstructive sleep apnea involves the muscles in the throat becoming so relaxed that the airway becomes all or partially closed, and with regard to the rarer central sleep apnea, the body temporarily stops making any effort to breathe. Common symptoms include daytime drowsiness and loud snoring, choking or gasping during sleep, although the episodes often fail to wake the person suffering from the condition.

Interestingly, one question that the Yale study does not answer is whether treating sleep apnea will reduce the incidence of strokes. In the Yale study, of the 72 sleep apnea patients who died of strokes, many of these patients were undergoing various forms of treatment for the condition. However, even with treatment, the group still had an elevated risk of stroke and death, which raises the question of whether treating sleep apnea will actually decrease the stroke risk measurably.

Posted by Tom at 5:45 AM | Comments (0) | TrackBack (0)

November 9, 2005

The anti-obesity industry

Coming off his Texas barbeque excursion, Marginal Revolution's Tyler Cowen notes that J. Eric Oliver, a political science professor at the University of Chicago, has entered the debate a new book called Fat Politics (Oxford 2005), in which Professor Oliver argues that a handful of doctors, government bureaucrats and health researchers -- funded by the drug and weight-loss industry -- have campaigned to classify more than sixty million Americans as "overweight," to inflate the health risks of being fat, and to promote the idea that obesity is a killer disease. The Publishers Weekly review of the book notes the following:

It's not obesity, but the panic over obesity, that's the real health problem, argues this scintillating contrarian study of the evergreen subject of American gluttony and sloth. Political scientist Oliver condemns what he feels is a self-interested "public health establishment" -- obesity researchers seeking federal funding, pharmaceutical and weight-loss companies peddling diet drugs and regimens, bariatric surgeons and other health-care providers angling for insurance reimbursement -- for spuriously characterizing fatness as a disease. He debunks the dubious science and alarmist PR that fuels their campaign, taking on arbitrary Body-Mass Index standards that slot even Michael Jordan in the overweight category, state-by-state maps of obesity rates that make fatness look like a contagion spreading over the countryside, and flimsy research studies that vastly exaggerate the danger and costs of weight gain. Oliver also examines American attitudes towards obesity, probing the abhorrence of fatness implicit in the Protestant ethic and, less plausibly, tying our contemporary feminine ideal of the emaciated supermodel to a confluence of sociobiology and the economics of the urban sexual marketplace. Arguing that fatness is perfectly compatible with fitness, he contends that scapegoating obesity drives Americans to experiment with dangerous crash diets, appetite suppressants and weight-loss surgeries, while distracting us from underlying harmful changes in the American lifestyle -- mainly our incessant snacking on junk food and shunning of exercise and physical activity, of which weight gain is perhaps merely a "benign symptom." Oliver provides a lucid, engaging critique of obesity research and a shrewd analysis of the socioeconomic and cultural forces behind it. The result is a compelling challenge to the conventional wisdom about our bulging waistlines.

Here is also an LA Times review of the book and several prior posts that have examined the issues relating to the increasingly obese nature of America's population.

As several of the earlier posts note, Professor Oliver's thesis has a ring of truth to it, although most of us are conflicted by our anecdotal experiences in which we notice large numbers of overweight and out-of-shape people in the course of our daily lives. In many respects, the core problem is widespread ignorance about nutrition, the difference between exercise and recreation, and the fact that exercise is a poor means of weight-control, at least in the short term. My late father used to comment that, if you are riding a stationary bike for an hour to lose weight, then you could achieve the same benefit in terms of reducing calories for a lot less effort by simply eating one less helping of mashed potatoes at dinner.

Posted by Tom at 6:31 AM | Comments (4) | TrackBack (0)

October 6, 2005

And you thought the recent hurricanes were bad?

As the U.S. goes about recovering from the double whammy punch of the two hurricanes that hit the Gulf Coast region over the past month or so, this NY Times article reminds us that a potentially much more serious threat to our well-being is looming on the horizon:

"Two teams of federal and university scientists announced today that they had resurrected the 1918 influenza virus, the cause of one of history's most deadly epidemics, and had found that unlike the viruses that caused more recent flu pandemics of 1957 and 1968, the 1918 virus was actually a bird flu that jumped directly to humans.

The work, being published in the journals Nature and Science, involved getting the complete genetic sequence of the 1918 virus, using techniques of molecular biology to synthesize it, and then using it to infect mice and human lung cells in a specially equipped, secure lab at the Centers for Disease Control and Prevention in Atlanta.

The findings, the scientists say, reveal a small number of genetic changes that may explain why the virus was so lethal. The work also confirms the legitimacy of worries about the bird flu viruses that are now emerging in Asia.

The new studies find that today's bird flu viruses share some of the crucial genetic changes that occurred in the 1918 flu. The scientists suspect that with the 1918 flu, changes in just 25 to 30 out of about 4,400 amino acids in the viral proteins turned the virus into a killer. The bird flus, known as H5N1 viruses, have a few, but not all of those changes."

Here is a companion NY Times article on the growing political concern in Washington over the prospects of an epidemic. The 1918 flu pandemic killed an estimated 25 to 50 million people and, as the articles report, we are not much better protected from the virus now as the world was then. Even the mere reconstruction of the virus for research purposes has raised concerns:

Richard H. Ebright, a molecular biologist at Rutgers University, said he had concerns about the reconstruction of the virus and about publication of procedures to reconstruct the virus. "There is a risk verging on inevitability, of accidental release of the virus; there is also a risk of deliberate release of the virus," he said, adding that the 1918 flu virus "is perhaps the most effective bioweapons agent ever known."

During a closed door Senate briefing last week, Secretary of Health and Human Services Michael O. Leavitt and other senior government health officials warned of the implications of such a flu pandemic in the U.S.:

Mr. Leavitt warned in the briefing last week that an outbreak could cause 100,000 to 2 million deaths and as many as 10 million hospitalizations in the United States, one person who was present said. Those numbers have been presented publicly many times before. But hearing them in closed session gave them urgency, some who were at the meeting said.

Since 1997, avian flu strains have infected thousands of birds in 11 countries, primarily in Southeast Asia. So far, it is probable that virtually all of the 100+ people who have been infected with the disease (about 60 of whom have died) received the virus directly from infected birds. Thus, at least to date, there has been no or very little transmission between people, which is a requirement for an epidemic. Moreover, if the virus does begin being transmitted between humans, then there is a possibility that the mutated virus may be weaker and less lethal than the viral strain contracted directly from birds.

However, this remains a huge potential public health problem and not one that should be ignored merely because the pandemic may not occur or may be years away. Here's hoping that the federal government does a better job planning for this potential problem than it did for a direct hit by a category 4 hurricane on New Orleans.

Update: Eric Berger chimes in with this informative post over at his very smart SciGuy blog.

Posted by Tom at 6:24 AM | Comments (1) | TrackBack (0)

September 29, 2005

A key tip for dealing with rattlesnakes

One of the best parts of the Houston Chronicle for many years has been the newspaper's Hunting and Outdoors section of its sports section. Inasmuch as my reaction to finding a rattlesnake would have been the same as the fellow's reaction as described in the following Chronicle article, I was glad to learn something from the Chronicle piece about dealing with dead rattlesnakes:

Even a dead rattlesnake can hurt you. Just ask Trey Hanover of College Station.

On Labor Day weekend, Hanover and his father, Tommy Hanover, were working on their deer lease when they killed a big rattler. They shot the snake's head off with a shotgun and loaded the carcass in the truck to show other hunters on their lease that they needed to be careful.

"We hung the snake on the fence at the camphouse," Tommy Hanover said. "When we got ready to leave, Trey picked up the snake and threw it out in the pasture for the buzzards to eat."

By the time he'd driven to College Station, Trey Hanover's eyes were very irritated. By the next morning, his eyes were swollen shut. The doctor who examined Hanover said it looked like he'd suffered a chemical burn.

It took them a while to figure out that the shotgun load that vaporized the rattlesnake's head splattered the snake's venom over its body.

When Hanover handled the snake, he got the venom on his hands and later rubbed it in his eyes, made itchy by dust and ragweed. Sixteen days later, the vision in his right eye was back to normal. His left eye was still a little cloudy, but the doctor thought it would return to normal as well.

"We learned a valuable lesson about handling rattlesnakes — even dead ones," said Tommy Hanover.

Posted by Tom at 7:03 AM | Comments (1) | TrackBack (0)

August 24, 2005

Stop daydreaming!

According to this Washington Post article, now daydreaming may be hazardous to your health:

The brain areas involved in daydreaming, musing and other stream-of-consciousness thoughts appear to be the same regions targeted by Alzheimer's disease, researchers are reporting today in an unusual study that offers new insights into the roots of the deadly illness.

While some unknown third factor may be responsible for triggering daydreaming as well as Alzheimer's, . . . a causative link between the two would explain a mystery that has long bothered scientists: why Alzheimer's generally affects memory first. . . [T]the undirected thought patterns that most people slip into readily may result in the kind of "wear and tear" that ends in Alzheimer's disease, . . .

This theory, however, clashes with the evidence that intellectual activity plays a protective role against Alzheimer's disease. Far from the "wear and tear" model, other research has suggested that the brain runs on a "use it or lose it" system.

The best observation in the article is from a scientist who cautions that the findings are preliminary and should be taken with a grain of salt:

"I look forward to the public health campaign to stop people from engaging in these dangerous, risky behaviors," he quipped. "Maybe we can equip ourselves with anti-daydreaming monitors that shock us when we slip into reverie."

Read the entire article.

Posted by Tom at 7:28 AM | Comments (0) | TrackBack (0)

August 19, 2005

Merck gets hammered

As anticipated by this prior post, a Brazoria County jury found that Merck & Co. was liable for $253 million in damages ($24 million in actual damages, plus $229 million in punitive damages) as a result of its negligence in the death of a 59-year-old Robert Ernst, who at the time of death was taking Merck's prescription painkiller Vioxx that over 20 million Americans took regularly before it was pulled from the market last year over concern that it might cause increased risk of strokes and heart attacks. The prior posts on the Merck/Vioxx trial are here, here, and here.

Inasmuch as Merck is currently facing another 4,200 Vioxx lawsuits, the verdict is not exactly a rousing start for Merck in the defense of the lawsuits. Merck's defense in the lawsuit seemed to be reasonably strong -- that is, Mr. Ernst, who had only taken Vioxx for eight months, died of arrhythmia that Vioxx has not been shown to cause. However, the Brazoria County coroner testified -- over Merck's strenuous objection because of the plaintiff's failure to designate the coroner as an expert prior to trial -- that Mr. Ernst's arrhythmia could have been caused by a heart attack. That testimony seemed to hurt Merck badly, as the Chronicle interviewed an alternate juror who had been dismissed from the trial immediately before deliberations began who remarked that Merck "wasn't doing the right thing by marketing the drug the way they were." Plaintiff's lawyer Mark Lanier accused Merck of dragging its feet after the Food and Drug Administration told it in late 2001 to put a label on Vioxx warning of potential heart risks, and during closing arguments, Mr. Lanier contended that Merck saved $229 million by waiting months to add the warning label. Not surprisingly, that's the amount of of punitive damages awarded by the jury.

Estimates of Merck's potential liability in the Vioxx cases range from $4 billion to $20 billion, which could be as large as a third of Merck's market capitalization. Although the price of Merck's shares dropped 8% today on the news of the verdict, that's not as bad as the 25% plus decline that occurred last September on the day Merck withdrew Vioxx from the market. Moreover, media reports on the jury's verdict have not differentiated between the plaintiff's economic and non-economic damages, but that distinction will be important to Merck's ultimate liability in this case when the court applies Texas' statutory cap on punitive damages to the jury verdict. You can be reasonably certain that the ultimate amount recovered will be far less than the jury verdict. Given that, and in view of the fact that Brazoria County is going to be one of the more plaintiff-friendly jurisdictions for a Vioxx trial, the market may be overreacting a bit to the verdict, although that's about the best spin that Merck can put on this result.

As usual, Professor Ribstein has insightful comments on the absurdity of all this, as does Ted Frank, Professor Bainbridge, Kevin M.D., Derek Lowe, Jonathon Wilson, and Walter Olsen.

Posted by Tom at 5:31 PM | Comments (8) | TrackBack (5)

August 4, 2005

Brain dead woman gives birth

Don't miss Tom Mayo's interesting analysis of the difficulty that the mainstream media has in explaining the context under which Susan Torres, a brain dead Virginia woman, gave birth to a baby girl this past Tuesday. Tom observes about the headline for the AP/Yahoo story:

Once dead, a patient can't die again. But, amazingly, 37 years after the Ad Hoc Harvard Medical School report on "irreversible coma," the public's resistance to the notion of neurological criteria for death is curiously persistent.

Posted by Tom at 9:07 AM | Comments (0) | TrackBack (0)

July 12, 2005

Strong medicine with serious side effects

This post from yesterday made the point that that most medications are toxins that often have serious side effects, but that the risk of those side effects has to be weighed against the benefit that patients derive from the medications. However, the side effect noted in this article is, might we say, a bit difficult to weigh:

A Mayo Clinic study published Monday in July�s Archives of Neurology describes 11 other Parkinson�s patients who developed the unusual problem [of becoming compulsive gamblers] while taking Mirapex or similar drugs between 2002 and 2004. Doctors have since identified 14 additional Mayo patients with the problem, . . .

Posted by Tom at 5:31 AM | Comments (0) | TrackBack (0)

July 11, 2005

The first Vioxx trial

Jury selection begins today in Angleton, Texas in the first personal injury/wrongful death trial against Merck & Co. for alleged non-disclosure of the risks of taking the pain relieving drug Vioxx. Angleton is a small town in a plaintiff-friendly county about an hour south of downtown Houston. Talented Houston-based personal injury trial lawyer Mark Lanier has been receiving quite a bit of free publicity about the upcoming trial (here is the NY Times article and an earlier WSJ ($) article is here), and here are several previous posts on Merck and Vioxx.

Mr. Lanier's effectiveness as a trial lawyer is in no small part attributable to the fact that he is a devout Christian who regularly teaches a Bible Study class at his church in Houston. Such familiarity with the Bible typically resonates with jurors in small Texas towns, who often rationalize tenuous liability and damage issues through Biblical associations.

Curiously, as Professor Ribstein has pointed out, Mr. Lanier's case against Merck is based largely on the very un-Biblical concept of resentment and not the truth. Merck pulled Vioxx from the market in October, 2004 after a study showed that it increased the risk of heart attack or stoke, but not necessarily the risk of death. That move prompted Cleveland Clinic cardiologist Eric Topol to go postal over Merck's handling of the drug, contending that Vioxx resulted in 15 cases of heart attack or stroke per 1,000 patients.

Unfortunately, what Dr. Topol failed to mention is that the foregoing number of cases relating to Vioxx was precisely seven more cases of heart attack or stroke per 1,000 patients taking the similar medication, Naprosyn. Moreover, as MedPundit points out, Dr. Topol neglected to mention that aspirin -- which is regularly prescribed without controversy for heart attack and stroke prevention -- results in a clinically significant case of bleeding in every 3 out of 1,000 patients. Thankfully, aspirin has not been pulled from the market, at least yet.

Moreover, the statistical bungling got even worse. David Graham, the associate director for science in FDA's office of drug safety, took the results of these studies and without any sub-group analysis calculated that 27,785 heart attacks may have occurred between 1999 and 2003 as a result of Vioxx use based on the number of Vioxx prescriptions. That was music to the ears of the plaintiffs personal injury bar, but the music was a bit tinny given that his conclusion was not based on the number of Vioxx users who truly should have been counted. Rather, it is based on the the number of patients who were on Vioxx continuously for more than 18 months as indicated in the studies that showed an increased risk of cardiovascular problems. Thus, the statistical evidence is quite shaky that short-term or periodic use of Vioxx contributes to an increase risk of cardiovascular problems. Not surprisingly, the initial trials of Vioxx were all shorter than 18 months and they did not find any meaningful evidence of increased risk.

As my late father often observed, the truth is that medicines are toxins that have side effects that sometimes kill people. Vioxx was developed to address the problem of patients who regularly die as a result of the use of non-steroidal anti-inflammatory medications for chronic pain. Studies reflect that about 16,500 patients die and another 100,000 are hospitalized annually as a result gastrointestinal bleeding from the use of these NSAID medications for chronic pain. The number of people who have suffered heart attacks and strokes as a result of the long-term use of Vioxx pale in comparison to these numbers.

The foregoing is not meant to be a defense of Merck or other drug companies. It's simply to point out that Vioxx is not unusual -- most medications have potentially serious side effects. Perhaps there should be more rigorous FDA approval process for new drugs and maybe the FDA should be given the power to require drug companies to fund research to evaluate possible side effects that emerge after a drug is approved and large numbers of patients begin using it. However, those moves are more likely to result in a longer approval process for new drugs and even higher cost for most medications than better patient safety. Moreover, increased regulation raises the sticky issue of establishing parameters to decide if and when a certain side effect in a new drug would require pulling that drug from the market. Stated another way, just when do the risks of a medication outweigh the benefits of the drug in treating a certain disease or medical condition?

Thus, these are the issues that we need to be discussing in regard to medications such as Vioxx. However, the reality is that analysis of such issues is unlikely to be anywhere near as appealing to the jury in Angleton as Mr. Lanier's morality play. Where is the Biblical justification for that?

Posted by Tom at 5:40 AM | Comments (3) | TrackBack (5)

July 1, 2005

Piling on Merck

Texas attorney general Greg Abbott announced yesterday that he has filed a lawsuit against Merck & Co. in state court alleging that the company bilked Texas out of about $170 million in Medicaid payments by misrepresenting the safety of its Vioxx painkiller. Although a flurry of personal injury lawsuits have been filed against Merck throughout the country after the company pulled the Vioxx drug late last year, Texas is apparently the first state to file such a suit against the company.

A one-time popular arthritis drug, Merck voluntarily withdrew Vioxx from the market last fall after a study of cancer patients correlated use of the drug with an increased risk of heart attack and stroke. As is typical in such situations, the numerous private lawsuits that have been filed against Merck allege that the company knew of potential problems with Vioxx, but disregarded them and marketed the profitable drug anyway.

Greg Abbott is one of the genuine good guys in Texas politics, but he is wandering far afield with this latest salvo against Merck. As Dr. Rangel has noted here and here, lawsuits such as this follow a troubling pattern of attempting to feed off of the sensationalism and publicity of a side effect of a new and popular drug. It's not at all clear that Merck did the right thing in pulling Vioxx off the market, but the mainstream media and plaintiffs' personal injury lawyers have seized on the company's removal of the drug from the marketplace by drumming the theme that Vioxx is an excessively dangerous drug that could kill you. Not mentioned in such propaganda is the fact that there are plenty of other medications on the market that have side effects that are more common and worse than those of Vioxx, but those drugs remain on the market for patients who are willing to risk the side effects of the drugs to obtain the benefits from them.

As one doctor observed in the Wall Street Journal awhile back, given the known side effects of aspirin, that drug "probably couldn't gain FDA approval today."

Posted by Tom at 5:38 AM | Comments (2) | TrackBack (0)

June 23, 2005

New study promotes change in treating lung cancer

This NY Times article reports on a new research study to be published today in the New England Journal of Medicine that is strong evidence that chemotherapy greatly improves the chances of survival for early-stage lung-cancer patients. Lung cancer is by far the leading cause of death from cancer, exceeding annual deaths from colon, breast, pancreatic and prostate cancer combined.

Lung cancer has long been one of most difficult cancers to treat. A high percentage of lung cancer victims are are smokers or former smokers, and because there is no systematic screening process for lung cancer, almost half of the 175,000 annual lung cancer cases are not discovered discovered until the cancer is metastatic (i.e., spreading), which makes survival unlikely. Currently, only about 15% of lung cancer victims survive beyond five years.

The standard treatment for early-stage lung cancer has long been surgery to remove the lobes containing the tumor, but that treatment has resulted in only a 54% survival rate beyond five years. Until this new study, no published research studies had shown a substantial benefit from chemotherapy after surgery for early-stage lung-cancer patients, who represent nearly a third of all cancer cases.

The results of the 10-year trial of 482 patients with early-stage lung cancer show that intravenous chemotherapy drugs improved five-year survival rates to almost 70%. That 15-point improvement will make doctors and patients much more willing to consider follow-on chemotherapy, which sometimes requires hospitalization. "There's never been a lung-cancer trial that showed this benefit of treatment in any stage of disease," commented Katherine M.W. Pisters, M.D., an oncologist at Houston's M.D. Anderson Cancer Center in the Texas Medical Center, who has an op-ed on the study in the current issue of the Journal. In response to the findings, the American College of Clinical Oncology and the American College of Chest Physicians are currently rewriting their official guidelines to physicians to recommend chemotherapy for early-stage lung-cancer patients.

The study was funded by the American and Canadian governments' National Cancer Institutes, and received $1.6 million from GlaxoSmithKline PLC.

Posted by Tom at 5:56 AM | Comments (0) | TrackBack (0)

June 18, 2005

New Chron blog reports on medical research funds

The Houston Chronicle has added another blog -- Eric Berger's SciGuy -- to its impressive and expanding Chronicle bloglist that Chronicle tech writer Dwight Silverman has spearheaded. Kudos to Dwight and the Chronicle editors for being pioneers in this emerging method of delivering their product to customers.

In this post, Mr. Berger notes the National Institutes of Health annual ranking of U.S. medical schools by the amount of research funding, which is a key indicator of a medical school faculty's research capabilities. Here is a listing of medical schools of local interest:

1. John Hopkins University, Baltimore, Md., $449 million
11. Baylor College of Medicine, $248 million
21. UT Southwestern Med. Center, Dallas, $172 million
35. Cornell Univ. Medical School (Methodist Hospital) $124 million
39. UT Medical Branch at Galveston, $104 million
48. UT Health Science Center at San Antonio, $80 million
64. UT Health Science Center at Houston, $51 million

In addition, although not a medical school, UT's M.D. Anderson Cancer Center in the Texas Medical Center generated another $145 million in research last year. Consequently, as Mr. Berger notes, the institutions in the Texas Medical Center pump almost half a billion of research funds into the local economy.

By the way, the NIH list dovetails nicely with the ranking of university endowments that was noted in this earlier post. Given the size of Baylor Medical School's endowment and annual research funding, one has to respect the risk that Baylor took in ending its longtime partnership with the even better-endowed Methodist Hospital ($2.3 billion endowment). Hopefully, the competition between the two institutions for research funds will enhance the amount and quality of research being performed at the Texas Medical Center.

Posted by Tom at 10:08 AM | Comments (0) | TrackBack (0)

May 26, 2005

Study favors bypass surgery over angioplasty

The New England Journal of Medicine yesterday published the findings of a large-scale study that indicate that angioplasty -- an increasingly popular invasive procedure for patients with blocked coronary arteries -- carries a higher risk of death over the long term than open-heart bypass surgery. The researchers were led by Edward L. Hannan, chairman of the Department of Health Policy Management and Behavior at the University at Albany School of Public Health.

The study is particularly significant because it raises questions regarding the shift in treatment for blocked coronary arteries over the past decade or so -- the shift away from coronary bypass surgery in favor of angioplasty, which involves sliding a balloon into an artery through a small incision and then propping it open with a wire-mesh stent.

Inasmuch as angioplasty procedures require a far shorter recovery time and lower risk of in-hospital complications than bypass surgery, it is currently performed more than one million times a year in the U.S., which is about three times the rate of bypass operations. Bypass surgery generally costs between $25,000 to $35,000 while angioplasties run from around $10,000 to $15,000.

The study involved a review of almost 60,000 patients from 1997 through 2000 with serious heart disease in two government databases in New York state. Researchers concluded that those with three blocked arteries who received stents were 1.56 times as likely to die within three years as those who had bypass surgery. Similarly, those with two blocked arteries who got stents were 1.33 times as likely to die as those who had bypass surgery. Finally, over a third of the angioplasty patients required either surgery or additional stents within three years, while only 5% of the bypass surgery patients required either angioplasty or further surgery within the same period. The researchers note that the study does not include findings on the newer generation of drug-coated stents, which some cardiologists believe will improve the outcome for angioplasty.

This large scale study adds to an increasing number of smaller studies finding advantages of bypass surgery over angioplasty for long-term survival. Last year, a Cleveland Clinic study that followed 6,000 patients found that the risk of death over time was more than twice as high in the angioplasty group of relatively high-risk patients.

Both the Cleveland Clinic and New York studies involved review of registry data and not the controlled clinical trials that scientists consider the best form of evidence. In registry studies, researchers must adjust existing data for various factors, which can lead to debate and criticism over the effect such adjustments have on the ultimate findings of the study. Nevertheless, registry data studies allow the reearchers to involve much larger patient groups than clinical trials and to evaluate medical practices that are being most commonly performed in the medical marketplace.

Posted by Tom at 5:10 AM | Comments (1) | TrackBack (0)

New study on drinking water while exercising

This New York Times article reports on a just released New England Journal of Medicine study that indicates athletes who drink as much liquid as possible during intense exercise to avoid dehydration face an even greater health risk than dehydration.

The study reports that an increasing number of people who engage in intense exercise or recreation are severely diluting their blood by drinking too much water or sports drinks, risking serious illness and, in some cases, death.

The condition -- called Hyponatremia -- occurs because, during intense exercise, the kidneys cannot excrete excess water. Accordingly, as intense exercisers continue to exert themselves and drink more fluid, the extra water moves into their cells, including brain cells. The expanded brain cells eventually have no room to expand further and press against the skull and compress the brain stem, which controls vital functions such as breathing.

Indeed, the mantra from docs to intense exercisers over the past generation -- i.e., avoid dehydration at any cost -- may be part of the culprit. As the Times article notes:

"Everyone becomes dehydrated when they race," [said one of the researchers involved in the study]. "But I have not found one death in an athlete from dehydration in a competitive race in the whole history of running. Not one. Not even a case of illness."

On the other hand, he said, he knows of people who have sickened and died from drinking too much.

To make matters even more complicated, Hyponatremia can be treated,
but doctors and emergency workers often pressume that a person feeling ill after intense exercise is simply suffering from dehydration. Thus, they give the exerciser intravenous fluids, which makes the Hyponatremia worse and can kill the patient.

I guess those old high school football coaches of mine back in the late 1960's who didn't allow my teammates and I so much as a drink during two-a-days in the summer heat knew more than they were letting on? ;^)

Posted by Tom at 5:32 AM | Comments (0) | TrackBack (0)

April 7, 2005

Possible relief from the worst television commercials ever?

This BBC News article reports on a University of Minnesota Medical School study that links use of Viagra to vision loss:

[Researchers at the University of Minnesota Medical School] writing in the Journal of Neuro-ophthalmology, said it brought the total number of reported cases to 14. But Pfizer, the makers of the drug which has been used by more than 20m men since its launch in 1998, said the cases were a coincidence. The seven men, aged between 50 and 69 years old, had all suffered from a swelling of the optic nerve within 36 hours of taking Viagra for erectile dysfunction.

If the plaintiffs' lawyers can use this information to prompt Pfizer to use Viagra's advertising budget for defense costs rather than advertising, then I will be strong advocate of the plaintiffs' bar in this case. Hat tip to the HealthLawProf Blog for the link to the BBC News article.

Posted by Tom at 7:45 AM | Comments (0) | TrackBack (0)

April 6, 2005

Promising new drug to treat alcoholism

A new Journal of the American Medical Association ($) article (abstract here) described in this summary reports on a once-monthly, injectable medication that has been shown to reduce heavy drinking substantially among alcoholics.

The drug is a formulation of naltrexone, a drug that is currently approved to treat alcohol dependence. However, the drug is currently rarely prescribed because it must be taken daily, which most alcoholics simply will not do. Cambridge, Mass.-based Alkermes Inc. filed an application with the Food and Drug Administration earlier this month to approve the drug, which will be known under its brand name of Vivitrex. According to the study, Vivitrex -- which must be taken only monthly -- has the "potential to improve intervention strategies for alcohol dependence." Alkermes funded the JAMA-Vivitrex study and the development of the drug was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism, a unit of the National Institutes of Health.

The NIAAA estimates that up to 18 million Americans have an alcohol-related disorder. Alcohol dependence is defined as women who consume four or more drinks a day on a regular basis and men who consume five or more drinks, which researchers used to define a "heavy drinking" day in the JAMA study involving Vivitrex.

James C. Garbutt of the University of North Carolina at Chapel Hill headed up the study, which involved 624 alcoholic adults. The patients received either an intramuscular injection of 380 milligrams of Vivitrex, 190 milligrams of Vivitrex, or a placebo (i.e., a fake injection), and all of the patients received counseling. Overall, the study showed that the number of "heavy drinking" days was cut by 25%, a drop that researchers deemed "significant" among those using the highest dose of the drug.

Posted by Tom at 5:45 AM | Comments (0) | TrackBack (0)

March 24, 2005

The Schiavo case

A number of friends have asked me why I have not blogged on the Terri Schiavo case, to which I have stolen Eugene Volokh's reply that "I know nothing about the Schiavo matter, and -- despite that -- have no opinion."

As we have seen with the Enron case, when a case becomes as sensationalized in the MSM as the Schiavo case has over the past several weeks, battle lines get drawn politically, increasingly shrill views compete for the public's limited attention, and wise perspectives tend to get lost in the shuffle. Bloggers can find thoughtful views -- such as those of Professors Bainbridge and Ribstein -- but, let's face it, the vast majority of the public do not read blogs.

At any rate, I wanted to pass along a couple of informative articles on the Schiavo case that will appear in next month's New England Journal of Medicine. Timothy Quill, M.D. is a nationally-recognized expert in palliative care and end-of-life issues who is a professor of medicine, psychiatry, and medical humanities at the University of Rochester, School of Medicine and Dentistry. In this article, Dr. Quill dispassionately reviews what has occurred in the Schiavo case, and then makes the following observation:

In considering this profound decision, the central issue is not what family members would want for themselves or what they want for their incapacitated loved one, but rather what the patient would want for himself or herself. The New Jersey Supreme Court that decided the case of Karen Ann Quinlan got the question of substituted judgment right:

If the patient could wake up for 15 minutes and understand his or her condition fully, and then had to return to it, what would he or she tell you to do?

If the data about the patient�s wishes are not clear, then in the absence of public policy or family consensus, we should err on the side of continued treatment even in cases of a persistent vegetative state in which there is no hope of recovery. But if the evidence is clear, as the courts have found in the case of Terri Schiavo, then enforcing life-prolonging treatment against what is agreed to be the patient�s will is both unethical and illegal.

In the same issue, George P. Annas, J.D., the Edward R. Utley Professor and Chair Department of Health Law, Bioethics & Human Rights at Boston University School of Public Health, pens this article in which he reviews the legal precedent relating to the Schiavo case and criticizes Congress for ignoring it. In so doing, Professor Annas observes the following:

There is (and should be) no special law regarding the refusal of treatment that is tailored to specific diseases or prognoses, and the persistent vegetative state is no exception. "Erring on the side of life" in this context often results in violating a person�s body and human dignity in a way few would want for themselves. In such situations, erring on the side of liberty � specifically, the patient�s right to decide on treatment � is more consistent with American values and our constitutional traditions.

Hat tip to the HealthLawProf blog for the links to these articles.

Posted by Tom at 8:17 AM | Comments (3) | TrackBack (0)

March 17, 2005

The Texas Children's case

This HealthProfBlog post provides an insightful analysis of the legal issues raised by the decision of Texas Children's Hospital earlier in the week to take Sun Hudson, the nearly 6-month-old who had been diagnosed and slowly dying from a rare form of dwarfism (thanatophoric dysplasia), off the ventilator that was keeping him alive. A Houston state district court had authorized the hospital's action, and Sun died shortly after being removed from life support.

Posted by Tom at 7:42 AM | Comments (0) | TrackBack (0)

March 8, 2005

Dr. DeBakey: Health model

Dr. Michael DeBakey is Houston's most famous physician and one of the most reknowned of the post-World War II generation of doctors who changed the way medicine was practiced in the world. But in