The diabetes police concept moves to Texas

Thanks to Sandy Szwarc of the blog Junk Food Science for this alert.

The Metro Health District in San Antonio is creating a "surveillance program" to identify diabetics. Earlier I had written about a similar program in New York. Hemoglobin A1C levels will have to be reported by the clinical labs to the public health folks.

The project is described as a pilot program which came into being by actions of the Texas Legislature.If successful(those sorts of program are very likely to be judged successful by the folks who administer it)it will be transplanted into other metro areas in Texas.

The notion that medical care ( health care) is too important to be left to individual physician and the individual patient gains more traction as the nanny state move on, privacy being a quaint concern of an earlier era.

Safe drinking water and mosquito control are considered to be legitimate concerns of public health authorities, my blood sugar level, hemoglobin A 1C and blood pressure level are not.

Peri-operative beta blockers-quality measure or risk factor for stroke and death

The now published results of the POISE trial raises the question that the rush to make peri-operative beta blockers a quasi-mandatory quality measure may have lead to a number of deaths from stroke . Could that possibly be right?

In the words of at least one of the trial investigators the answer is yes.Dr. P.J. Devereaux's comments can be found here in Medscape news report describing the trial and various commentators' reactions to the results.

POISE was a large ( 8000 plus subjects) randomized trial designed to determine the effect of the peri-operative use of Metoprolol-XL. 100 mg was given 2-4 hours preop and again 0-6 hours post op and then 200mg daily for thirty days.

Total mortality was increased in the treatment arm (3.1% versus 2.3%,Hazard ratio 1.33,p=03) while myocardial infarctions were decreased but strokes were increased.Strokes occurred in 1% of the treatment arm patients versus 0.5 5,Hazard ratio 2.17. Hypotension was also significantly increased in the treatment arm while the incidence of atrial fibrillation was decreased.

Critics of the trial might argue that the dose of Metoprolol was simply too high and too much of this putative good thing might well cause more hypotension. They might argue that POISE only demonstrated that if you give an inappropriate dose of a beta blocker you cause harm. But I do not believe that the results of the trial will be dismissed based on different experts differing on dosing details of the trial.More likely major changes in guidelines will be made.(I will have to admit that if I took 200 mg of metoprolol a day, I would move like a turtle and have a heart of 12.)

If there is a lesson here it is not just that a large randomized clinical trial gives results opposite to earlier smaller trials-that is a story we have heard more than once before. The lesson is not that expert committees sometimes have to revise their recommendations as new information becomes available.The lesson I think that should be emphasized is that overzealous quality rule writers and enforcers can be a hazard to your health ( and I have said that before). Read Dr. Devereaux's comments regarding how many patients may have been harmed by taking peri operative beta blockers and then wonder how many patients received them simply because premature quality guidelines were in place and physicians were caught up in the rush to treat even though it seems clear now that the evidence for such zealous efforts was inadequate.

Dr. DB (AKA Dr. Robert Centor) nailed it when he recently spoke about in this regard " the performance and quality movement which has a 'ready,fire, aim' philosophy".

Still more on Medical Home AKA medical utopia

Yesterday, I signed up for a new, free newsletter, The Medical Home Monitor. This is apparently aimed at those who are interested in this latest version of managed care and its new packaging and how this bogus concept can be sold to the public.

Its advocates promote the Medical Home as a revolutionary sea change in medical care for which the term Utopian fails to properly denote both its purported magnificence and its absurdity.

The Medical Home Monitor uses 7 (count them,seven) back to back adjectives to describe the Home. They are: accessible,continuous,comprehensive,family centered (alternatively the term patient centered is used),coordinated,compassionate, and culturally effective. Not only that but there will be improved clinical outcomes and patient satisfaction and it will not increase health care costs. Think of it, provide many more services that the typical patient now receives and it will not cost more.

Sandy Szwarc in her consistently insightful blog, Junkfoodscience, explains clearly the difference between the hype of the Medical Home and the reality of what it is as envisioned the single payer called CMS. This CMS version of Medical Home as contrasted the warm fuzzy words imployed to hype it gives a new dimension of hubris to the concept of bait and switch.

The Happy Hospitalist explains in agonizing, mind boggling detail the particulars of how the Medical Home will be constructed in the regulation driven world of Medicare.Any doc or any patient who might be conned into taking part in this scheme should read these two blogs.Anyone who believes that Medicare should serve as the paradigm for a universal single payer just might be disabused of that belief by digesting these two essays.

Nurses and doctors, of course, will play a key role in this Medical Care Utopia but patients will be interested to learn that in the Medicare version as structured by the AMA's RUC committee the nurse will be allocated 3.5 minutes for a patient with one condition and 9.4 minutes if 4 or more conditions are present to provide the comprehensive,compassionate, culturally effective care it purports to deliver. Similar micro managed time allocations are given for physician's time. I am not kidding, the RUC wonks describe activities in term of tenths of minutes. Doctors will be allowed 12.5 minutes for those patient classified as "very sick". If anyone on the RUC task force actually took care of complicated, complex medical cases , he/she must have slept through most of the sessions.12.5 minutes should be more than enough to evaluate a elderly person with heart failure,COPD, diabetes and new onset severe back pain who is living alone and taking nine different medications, leaving time to ask about dental flossing and seat belt use and immunization status and to make a few well chosen culturally sensitive comments and hand out three health care educational booklets and allow time for the patient to proudly show the latest photos of her grandchildren.

Dr. Roy Poses takes on this issue in his latest posting on Health Care Renewal as has Kevin in his May 8, 2008 entry blog (see here) and Dr. Vijay Goel in his blog,Consumer-focused Health Care, as he heartedly seconds the analysis of the Happy Hospitalist. If you think-well this is just the government bureaucratic mind set at work and private entities will show everyone how the "Home" should be built- read this earlier entry by DrRich in his blog, Covert Rationing Blog, as he explains how United Health Group plans to do it. I made some comments about that also.

I have been critical of the American College of Physicians' position and role in the Home concept and I await their justification of the RUC 's plans and how they can possibly support what would be a disaster for primary care.Rather than their typical sound bites (quality evidence based, patient centered care,electronic medical records, medical home, blah, blah, blah), they should be saying to the RUC and CMS "Gentlemen , we have read your proposal and as internists we know more than a little about caring for complex medical patients and we know that you cannot attend a complicated patient in 12.4 minutes and if you think it can be done you have no business writing guidelines or rules."

Look who is going to write the compensation rules for the "Medical Home"

The American College of Physicians and others have been touting their solution to most (if not all) of the problems destroying primary care medicine under the banner of "Medical Home". One major obstacle to providing the accessible,continuous and coordinated care has been and is that physicians are not compensated to provide that type service.For example, how would Mediare compensate docs for those activities?

Now we learn that AMA's friend of the primary care doc,the RUC (relative value scale update committee) will play a major role in setting up the rules and ultimately the fee structure for the Medicare version of the Medical Home. The Tax relief and Health Care Act of 2006 mandated a demonstration project .

Here is a link to the AMA site with a description and from there a further link to the full set of recommendations from RUC. Anyone who thinks the Medicare funded Medical Home will be anything different from the morass of rules and tricks and traps of the fee structure and coding mysteries that typifies dealing with CMS should take a few minutes and read what RUC has authored. If you think the current coding games doctors have to play are onerous and irrational
(go to the latest from the Happy Hospitalist to get a flavor of that) wait until you see what the RUC thinks need be done to deliver the "coordinated continuous care" envisioned by the pie-in-sky Medical Home concept.

"Free" pizzza may be gone for students and house staff but speaker's bureaus may be another matter

Go here to read the NYT article on the recent statement made by the Association of Medical Colleges.

The Association seems adamant when it states ""drug and medical device companies should be banned from offering free food, gifts, travel and ghost-writing services to doctors, staff and students."

However, in regard to the sometimes lucrative and sometimes very lucrative speaker's bureaus a somewhat weaker statement emerges;

...medical schools should 'strongly discourage participation by their faculty in industry-sponsored speakers’ bureaus,' in which doctors are paid to promote the benefits of drugs and devices."

On the one hand, banning on the other discouragement.

Dr. Robert Alpern, Yale's Medical School dean, is quoted by the NYT as saying :

“I don’t have a problem with doctors making $3,000 or $5,000 a year on the side, but it’s a totally different thing when it’s $80,000,” he said. Even more distasteful, Dr. Alpern said, is that the slides used in many of these presentations are created by drug makers, not the speakers."

Is he really saying it is ok to be a "ghost speaker" (Alpern's term) if you don't get paid too much?
(We have already determined what you are, Madam, we are just negotiating the price now.)

Dr.Carlat believes we are entering a new era which he labels "post deceptive" Dr. Wes is less impressed.

Dr. Howard Brody who has had much to say about this general issue makes these comments.

My non-insider take is that there will be a flurry of high profile (within the institutions at least) announcements of "no more free lunches" and much self congratulation and talk of professionalism but somehow I doubt the faculty will give up the lucrative lecture gigs although a veneer of word smithed propriety and oversight will be grafted onto it.

The FDA and "Regulatory Capture"

Dr. Howard Brody in his bog, Hooked: Ethics,Medicine and Pharma, hits another home run.

As explained in HOOKED, this shows the ambivalent relationship that is set up by the phenomenon of "regulatory capture" of a Federal agency by the industry it is supposed to regulate. The drug companies are walking a very fine line. They want the FDA to be rendered sufficiently toothless as to be unable to take any actions that cause any inconvenience or lowered profits for them. But at the same time they want the FDA to appear powerful and threatening enough so that they can turn around and blame the FDA oversight process whenever a scandal arises like tainted Chinese-made heparin. Ditto for the present efforts of the industry to support FDA rules changes that would allow companies to market drugs off-label by circulating reprints from medical journals (based on the assumption that the FDA stringently regulates this process so that no false information could ever get through), and to convince the U.S. Supreme Court that they should be shielded from any legal liability in relation to any drug that has been FDA approved (again assuming that the FDA approval process is so stringent that the public needs no additional safeguards).

The term "regulatory capture" refers to the phenomenon in which a governmental agency ostensibly tasked with acting in the public interest to regulate an industry becomes controlled or dominated by the interests of that industry.This is not so much like authorizing the fox to oversee hen house safety but more like the game warden helping the poachers poach while posturing that they are doing just the opposite. Note- finding a different fox believed to be more concerned with the hen's interests is not likely to change the situation in any meaningful way nor will a more dedicated game warden.

Nobel laureate and Chicago School economist George Stigler is credited with this concept in his Economic Theory of Regulation.

Regulatory capture is one of the mechanisms by which interest groups will use government power and coercion to benefit themselves.


I might quibble with Dr. Brody's characterization stating there is an ambivalent relationship between the drug companies and the FDA. Pharma will act in its interest and will control- to the extent it can manage to do so- the FDA's actions, nothing very ambivalent about that as that is the tendency for all such "regulated" industries.

There have been suggestions as to ways to "strengthen" the FDA and at least move to escape from this capture but I am pessimistic.

Thomas Sowell has suggested when you try and understand why a government agency acts the way it does, do not bother with their mission statement but rather consider the incentives and constraints within which it operatives and the feedback it receives. Combine that with the "follow the money rule" and you will likely come up with some useful insights.

Who will sing for me?

The WSJ 's medical health blog talks about general surgeon being the primary care docs for surgery and echoes the thoughts of several bloggers ( see here ) for one who inform us that the ranks of the general surgeon is decreasing much as the primary care docs are seeing refuge elsewhere and for much the same reasons.

Back in day when I was an internist in training we thought about the general surgeon as the other group of "real docs",we internists were the really real docs, all jokes about surgeons notwithstanding.OK, we should have included peds but I think we meant that when someone was "really sick" you would need an internist or a surgeon or both. They would take care of the horrible surgical abdomen patients regardless of what the cause.Perforated bowel, leaking aneurysm,gall bladder, ruptured appendix-all were within their area of expertise. In the strange now forgotten "system" under which we trained the first year medical resident was called to evaluate patients in the area of the hospital that was sort of an ER and sort of a triage out patient area. From time to time there would be a dispute as to whether the patients was "surgical" or "medical". In some of that encounters I would find myself completely out manned facing off with a senior surgery resident who had by that time endured some 4 or 5 years of post MD degree rigorous surgical training. I still admire the skill , confidence and medical expertise of those folks and what they went through to obtain that experience and expertise as I did in practice when I called a general surgeon at 2:00 am .

Fewer freshly minted internists go on to do primary care as more and more become sub-specialists or hospitalists and fewer rookie surgeons go on to do general surgery as more and more do sub-specialty fellowships. Money,control of one's practice and "life style" concerns appear to be the major culprit drivers in this shift as third party payers continue to squeeze the purses and tighten the controls and drain the joy out of being a physician.

I think back attending sick patients and calling in a general surgeon to help sort it out (and sometimes fix it and often follow the patient with me though an often complicated and challenging course in the hospital) and wonder who will be available to play those roles should I be on the other end of the stethoscope and knife. Emmylou Harris's song comes to mind.