Category Archives: Health Care

Texas’ medical licensing logjam

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texas_doctors_comp.jpgThe 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.

Proof that Texas legislators don’t have enough to do

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phys%20ed.jpgThe 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 ìmoderate 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 didnít 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 ìobeseî 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.

Dubious Chronicle advertising

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chiropractic.jpgDavid 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.

More on the futility of dieting

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

Changing history

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Debakey050307.jpgThe 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.

The Hurwitz conviction

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Hurwitz050207.jpgYou 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 didnít intentionally prescribe drugs to be resold or abused. They said he didnít appear to benefit financially from his patientsí drug dealing and that he wasnít what they considered a conventional drug trafficker.
So why did find him guilty of ìknowingly and intentionallyî distributing drugs ìoutside the bounds of medical practiceî and engaging in drug trafficking ìas conventionally understoodî? 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 ìOliver Twistî).
I canít blame the jurors for being confused, because thatís 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 ñ 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 as a result of America’s draconian drug prohibition policy. The doctor-patient relationship has just become much more complicated. And not for the better.

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

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junkfoodjunky.jpgMichael Pollan, the Knight professor of journalism at the Cal-Berkeley and the author of ìThe Omnivoreís Dilemmaî (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 ó indeed, to a considerable extent, for the worldís 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 ó 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 ó indeed, for about as long as the American waistline has been ballooning ó U.S. agricultural policy has been designed in such a way as to promote the overproduction of these five commodities, especially corn and soy.
Thatís 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.

What was Dr. Hurwitz’s motive?

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Hurwitz042707.jpgThe 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 — i.e., violating America’s drug prohibition policy:

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 itís 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. Hurwitzís assets. (Thatís standard procedure in drug cases like this, and one more reason why doctors have such a hard time mounting a defense.) There wasnít much to seize. They took all his retirement savings ó which amounted to less than $250,000. He was at that point 58 years old and had been practicing medicine for decades. . . .
ìItís so ridiculous to hear the prosecutor talk about this rich doctor,î Mrs. [Nilse] Quercia [Dr. Hurwitz’s former wife] told me. ìExcept for that Keough account they seized, he had nothing but debts and a 1990 Subaru.î 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.

Speedy treatment of heart attacks

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heart.jpegThis 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 ó 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.
ìWe deal with it as if it is a gunshot wound to the heart,î Dr. [Elliott] Antman [director of the coronary care unit at Brigham and Womenís 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 ó often hoping it is not a heart attack, wondering if their symptoms will fade, not wanting to be alarmist ó hesitate far too long before calling for help.
ìThe single biggest delay is from the onset of symptoms and calling 911,î said Dr. Bernard Gersh, a cardiologist at the Mayo Clinic. ìThe average time is 111 minutes, and it hasnít changed in 10 years.î

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.

The sad case of Dr. William Hurwitz

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HurwitzTakesTheStand04.jpgFor 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 a sacrificial lamb for America’s voracious drug prohibition policy. Dr. Hurwitz 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 ó part of a drug-trafficking conspiracy, in fact ó because he prescribed large quantities of OxyContin and other pills while ignoring clear ìred flagsî that his patients were misusing and reselling the pills. The prosecutor said that Dr. Hurwitizís prescribing was ìwithout a legitimate medical purposeî and ìin its wake it left destruction, devastation and death.î [. . .]
[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 ìpassionate advocate for patients who had been unfairly treated,î Mr. Sauber talked about Dr. Hurwitzís 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 didnít 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 ìwas no different from a cocaine or heroin dealer peddling poison on the street corner.î
Sound familiar?