Thinking about Ted Kennedy’s health care

ted.kennedy 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?

Marathon madness

chevronmarathon 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.

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:

placebo ad

Following up on my concierge health care experience

DrWilliamLentMDThis 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?

Say what, Doc?

redcross_flag 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.

Dr. Ralph Feigen, R.I.P.

Dr. Feigin 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):

Continue reading

Dr. Michael DeBakey, R.I.P.

Debakey071208 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.

Neuroscience and the Law

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.

Getting to 120/80

hypertension 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.

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

Tiger Woods 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:

master's cool stat