Can it happen?  We sure hope so, but this article gives me the jitters. 

The NPA’s 2008 Presidential Candidate Health Plan report card grades the candidates on their health care plans according to the IOM Principles stated here.  One of the two most important distinguishing grades was in regards to the principle of “Affordable for Families”, where Obama scores a “Pass” and McCain a “Fail”.  There are growing questions regarding whether Obama’s estimates for savings on “Main Street” (is anyone else sick of this term?) are accurate.

One other concern is that health care has fallen off the map on the CBS/NYTimes Poll as an answer to the question: “What do you think is the most important problem facing the country today?”.  One year ago, 9% of respondants said health care, second only to war (21%).  The most recent poll had health care at a dismal 3%, behind economy (38%), war (10%), Heating Oil/Gas Crisis (7%), and Iraq (4%).  Granted, it is likely that significant health care reform will improve the economy, but can we get people to listen to the debate regarding health care reform at this time?

 What is needed is the political will.  What is needed is a unified voice.

You’ll be hearing more in the coming months about NPA’s specific approach to this problem, but for more reading about this issue check out this one. 

The NPA Board is meeting for 2 days on intense work at headquarters in Reston, VA.

Apart from the regular Board business, focus was on the campaigns for Unbranded Doctor, Rx Vote and equitable affordable health care. Among other things, we celebrated Board Member Judy Zerzan’s birthday.

Happy Birthday!

America’s Children are too fat. You cannot deny it (just look outside). They develop diabetes at an alarming rate. There is no doubt that many of them will develop into unhealthy adults and suffer of the  consequences: premature coronary artery disease, chronic pain, disability etc.

16 months ago, the American Academy of Pediatrics endorsed a guideline developed with the AHA in 2006 on how to treat children with disorders that have been shown to put them at risk for prematrue coronary artery disease. The highest risk catergory, which would receive medicines early in the course of treatment, featured conditions fairly rare in childhood (including Diabetes Type I). As recently as July 2007, the US Preventive Services Taskforce concluded that

Several key issues about screening and treatment of dyslipidemia in children and adolescents could not be addressed because of lack of studies, including effectiveness of screening on adult coronary heart disease or lipid outcomes, optimal ages and intervals for screening children, or effects of treatment of childhood lipid levels on adult coronary heart disease outcomes (emphasis added)

Now we are reading that children as young as 8 may be candidates for medications if they have a LDL concentration (“bad cholesterol”) above 160 mg/dl. These risk factors include:

obesity, hypertension, or cigarette smoking or a positive family history of premature CVD (cardiovascular disease)

So maybe the above Task Force – and I  – have missed a recent large outcomes trial that shows that treating an overweight child with a Statin (presumably that, because as the article points out most other medicines are poorly tolerated) will prevent adult heart disease. Furthermore, this articles hopefully compared it with the standard of care… if you find it, let me know. What is the standard of care? Here are a few suggestions by the American Heart Association:

Cholesterol and Atherosclerosis in Children

AHA Scientific Position

There is compelling evidence that the atherosclerosis (…) begins in childhood and progresses slowly into adulthood. Then it often leads to coronary heart disease (…)

Elevated cholesterol levels early in life may play a role in the development of atherosclerosis in adults.

Eating patterns and genetics affect blood cholesterol levels and coronary heart disease risk.

Lowering levels in children and adolescents may be beneficial.

(…)

To reduce fatty buildups in arteries in children (and adults):

Cigarette smoking should be discouraged.

Regular aerobic exercise that lasts at least 30–60 minutes on most days of the week should be encouraged.

High blood pressure should be identified and treated.

Obesity should be avoided or reduced.

Diabetes mellitus should be diagnosed and treated.

Children age 2 years and older should be encouraged to eat at least five servings of fruits and vegetables daily as well as a wide variety of other foods low in saturated fat and cholesterol. Doing this will help them maintain normal blood cholesterol levels and promote cardiovascular health.

No mention of drugs…..

I do not doubt that some children, particulary those with extremely elevated LDL (above 500 or so), may benefit from Statin drugs. But every obese child with a LDL above 160? That may be hundreds of thousands if not millions of young people swallowing expensive pills, with rare but serious side effects, and no proven benefit. It may help (prove it!), but the problem of obesity among children is not one of pill deficiency. How about spending the billions of health care dollars that such a treatment program will presumably cost, and getting more education, physical ed and better nutrition to our kids!

 And then when you read that the lead author Stephen Daniels has a conflict of interest (undisclosed by the journal), you may get nauseated… hey, there is a pill for that, too!

Read more in the New York Times, or LA Times.

We Americans know little of how other countries’ health care systems operate. Not because we’re stupid or ignorant, I’d like to think, but because we are not allowed opportunities through our mainstream media to learn about other countries, so myths perpetuate easily. Many of us turn to alternative sources of media or the internet (or both), but still, there’s generally so much policy jargon to sift through. THIS is partly why Michael Moore’s documentary Sicko left so many in the American public stunned regarding the various types of health access and services that citizens of other nations receive.

NPR did a piece on Germany’s health care system, a system which by the way has existed for over 125 years. For some jaw-dropping action, read the whole article, it’s not that long. What really stuck out for me was a fundamental difference in the set of values we hold above all else, in both countries. What we tolerate or praise here would not be tolerated there. What we struggle with here in regards to access to healthcare, bankruptcy from medical bills, huge deductibles, time to see docs, are a non-issue there. Obviously there are problems in every system. Here’s a glimpse, though, of some of the virtues of the German system we’re not exposed to in most of our media sources. Some quotable quotes:

Germany on access to doctors at times of need:

On one particular night, Juergen was the doctor on call for the region. Any German who needs after-hours care can call a central number and get connected to a doctor.

On access to humane and intuitive support services after an operation, as told by a woman who had thyroid surgery:

“Then I came home to my little daughter, who I couldn’t really lift up because of my neck having been cut open,” Sabina says. “So I asked my doctor, ‘What can I do?’ And she said, ‘Well, your health insurance will pay for someone to come help you in the house.’”

They also pay for support services and money to families who want to keep their elderly parents at home and out of nursing homes. Again, a fundamentally different set of values.

On coverage for everyone:

The health care system… is not funded by government taxes. But it is compulsory. All German workers pay about 8 percent of their gross income to a nonprofit insurance company called a sickness fund.

On SOLIDARITY:

Basing premiums on a percentage-of-salary means that the less people make, the less they have to pay. The more money they make, the more they pay. This principle is at the heart of the system. Germans call it “solidarity.” The idea is that everybody’s in it together, and nobody should be without health insurance.

This one really got me. I dream of the day (it is possible!) when Americans routinely use the word solidarity. More after the jump — click here –> (Read more…)

I think I am a decent doctor – I guess that what most doctors think of themselves. But sometimes I wonder if I am just not born for the job, due to lack of business sense. Here is why, it is situations like this:

A 76 year old demented patient is referred to me for a transesophegal echocardiogram (TEE, that is when they take an ultrasound picture of your heart from within your food pipe – although pretty low risk, it’s not the most comfortable experience). He was found to have a moderately leaky valve and a large fluid collection around his heart – 2 months ago! Another cardiologist has referred him, but when speaking to that person, he does not know the patient well, having seen him once. This cardiologist states that the primary care doctor wanted the TEE. That primary care provider also claimed that “he is new to me”.

Now if I do the TEE, although it may not be a great indication, I make ~ $400 for my practice (most from the technical fee), and eventually, some for myself. If I do not, I have spent 30 min reviewing the chart and speaking with the patient and his family, for basically nothing (I cannot charge for a consult as the patient has just been seen by one of my partners). A pericardial effusion may require a follow up ‘surface’ echo, for ~ $50. But if I want to do that, I need to spend another 15 to 20 minutes tracking the referring doctor down, changing the order, explaining the whole thing to the patient….. probably as much time as it would take me to do the study.
There is an apparent conflict of interest – patient health (put at risk by the TEE) and his wallet versus my convenience and bank account. It seems to me that this conflict is resolved often in favor of doctors’ income, if you read about the proliferation of heart CT scans for but the most inappropriate indications.

But what else could be going through your mind? Would you do the TEE? Would you be afraid that the referring primary doctor, maybe used to get what he wants, will refer the patient elsewhere? What about if the patient has worsening symptoms? What if the patient’s family wants to have the test because they want to know “what is wrong with him?” Are you afraid the patient is seriously ill and that you will be sued if harm comes to him and you did not do the test? Would he even be a candidate for surgery of the leaking of the valve was found to be severe?

There certainly is not a lot of black and white here. Is defensive medicine justifiable in the current system? Probably, and unfortunately, yes. However we must always consider the patient first. If more harm than good is done, think back to “Primum Non Nocere”. Whoever came up with it (and it seems not to have been Galen, nor Hippocrates, they spoke greek!) had – and made – a point.

And if I may offer some more of my bad Latin: Cura Te Ipsum (de studium percuniae) – Physician, heal thyself first of the striving for money….

According to the New York Times, Avandia, know for recent revelations about its heart risks, is still one of the dominating medicines for diabetes. This from an article that reports on an FDA panel urging more safety testing for these drugs. Just the other day, Pharma complained that the FDA’s safety review is slowing drug development (see Wall Street Journal, and read on Pharmalot for some interesting comment). The same paper reported that part of Pharmas problem was that

“the industry’s science engine has stalled. The century-old approach of finding chemicals to treat diseases is producing fewer and fewer drugs. Especially lacking are new blockbusters to replace old ones like Lipitor, Plavix and Zyprexa.”

According to the FDA’s Janet Woodock, applications for new drugs are down by 1/3. So let’s stop whining, be thankful that we have a lot of generics that work extremely well, and that there are dedicated researchers and companies that bring us truly novel drugs, such as Gleevac.

By the way, one of the recent drugs that was turned down by a 20 to 1 vote, was Arcoxia (etoricoxib) by Merck, Vioxx 2.0 so to speak. The trial meant to approve it, MEDAL, used an old recipe to make drugs look nice and compared etoricoxib to Diclofenac, which is  – as far as I know – one of the NSAIDs with more GI side effects. Do we really need such ‘new’ drugs?

 Writing this is giving me a headache. I’ll just pick up some 5 cent ibuprofen….

If you happen to get sick this summer in Southern California and you wind up at my hospital, you can expect to find a gaggle of eager, intelligent, competent and caring new, young doctors (we like to call them ‘interns’) ready to listen intently to your story, as well as your heart and lungs of course. They may be ‘green’ but they certainly aren’t dangerous so long as they’re armed with 2 important tools: supervision & sleep.

The former seems blatantly lacking in the story quoted below.

Every neophyte is owed the opportunity to be taught so long as the teacher recognizes her imperative to teach. Especially in a hospital in July.

New Docs on the Block

According to medical lore, July is the worst time to be hospitalized because that’s when inexperienced med students start clinical training. But is summer really riskier for patients?

A month into Sandeep Jauhar’s medical internship at a prominent teaching hospital in New York City, he was asked to drain fluid from the belly of a patient who was HIV-positive. “I was trying to get out of the hospital to keep a dinner appointment,” he recalls. “I was sort of rushing. I heard a snap and there was all this fluid leaking all over the floor.” Jauher’s gloves were too small, he hadn’t assembled the tubes for the blood correctly, he was new, he was inexperienced and nobody was watching. “[The patient] was totally oblivious to the disaster, but it was a mess,” he says. “These are the mistakes that new, green interns can make.”

According to conventional wisdom, a patient’s chances of encountering a mistake-prone rookie like Jauhar go way up in the summer. That’s because July 1 is the start of the academic year for medical schools: In teaching hospitals around the country, medical students will replace interns, interns will replace residents and residents will move on to fellowships or to become full doctors.

This crucial and sometimes perilous training period can be incredibly difficult for medical students. As Jauhar writes in his recent book, “Intern, A Doctor’s Initiation,” incoming doctors are not only practicing on patients for the first time, they’re also learning the often Byzantine workings of their respective hospitals, new technical language, new procedures and the tedious, yet critical, ways to fill out paperwork. All this learning is packed into 80-hour workweeks and overnight shifts in a busy hospital environment—a far cry from the academic environment they might be coming from. But is it really riskier to go into a teaching hospital during those first few weeks of intern training? Or is the “July phenomenon” a medical myth?

Finish reading at

New Docs on the Block

~casey

(cross-posted at Cure This)