The philosophy supporting the "diabetes police" is more than frightening

I have written before about the movement of at least some of the public health community into areas not traditionally thought to be within their purview such as local public health departments monitoring the hemoglobin A 1 C levels. I was not aware of the degree to which the philosophy animating this movement was developed and being expounded in very explicit terms.

Thanks to Sandy Szwarc of Junkfood Science . Her entire piece should be read but below are some of the comments made by exponents of what you might call "the new public health ethics".

In a nutshell,the basic notion is that an individual's health and health related behaviors are too important to be left to the individual as they poise a threat to society and government must act for the good of society.

Ms. Szwarc quotes from a "thought leader" in this field of public health ethics, Dr. Angus Dawson who is at the Centre for Professional Ethics at the University of Toronto as he discusses his approach to the problem of obesity.

[the educational approach to battle obesity] "will fail as it wrongly assumes..that we ought to respect an individual's existing preferences " and "an ethical obesity policy ought to focus on collective interventions [ in which] the individual will not be able to opt out.

If people will not do what we know to be best for them and society we will make them do it.This seems to be the core of the public health ethics.

Lest you think that we are dealing with the relatively, unheard voice of a fringe philosopher in the wilderness (or at least in Canada),essentially the same theme is expressed by Dr. VJ Guillory who served on the AMA Expert Committee on Obesity when he wrote in the Journal of Public Health , "The mandate to ensure and protect the health of the public is an inherently moral one...and it implies the possession of an element of power to carry out that mandate."

In this age of supposedly evidence based medicine it is interesting to read one of the comments from a report about a meeting of the AMA Expert Committee on Obesity : "The magnitude of the obesity is too great to wait for evidence-based guidelines before increasing efforts focused on prevention and intervention." So it is ready, shoot, aim- all with very generous funding from the Robert Wood Johnson Foundation and it is individual freedom and autonomy the targets.

Will the options for internists be even fewer as time goes by?

Had retirement not worked out to be better than I had hoped for, I had thought that a concierge practice or being a hospitalist would be the way for me to go. The retainer practice might allow me to escape from the clutches of the third party payers whose ever tightening of the control and payments screws sucked much of the joy of patient care and the threat of things getting even worse casting a pale over the future. The hospitalist gig offered the relief of no call and a opportunity to attend the type of complex,often very ill patients which seemed to be what an internist was trained to do.

But now we hear that perhaps the hospitalist role may not be a safe haven for the internist for very long. Dr. RW tells us about that scenario here.

Even as the future for hospitalist might appear less rosy, we should not forget that the safety and quality movement leader guru, Dr. Donald Berwick still has much for them to do as they become the change agents and integrators of a new medical system that will provide quality care, reduce costs and improve public health. I guess it is better that I did not become a hospitalist as all I could do on a good day was to take as good of care of my patients as I could leaving the problems of maximizing public health and obtaining universal medical coverage to someone else.

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.

Latest we-won't-pay proposal from CMS-Silly is too weak a word

The latest proposal from CMS to not pay for treatment of certain conditions appears to demonstrate evidence of such an outstanding ignorance of medicine that it is difficult to find words strong enough to characterize them. These conditions are referred to as " hospital acquired conditions" that are "reasonably preventable through the applications of evidence based guidelines" This are beyond absurd. The actions taken by hospitals to live with this rule (if it is finally approved and becomes a rule) will elevate the concept of unintended consequences to new heights.

Here is press release and here you can find comments by Dr. Roy Poses.

DVT/PE ( deep vein thrombosis/pulmonary embolism) is one such condition. There is no prophylaxis that lowers the attack rate to zero or close to zero. The heparins and warfarin and other non pharmacological preventive measures have not been shown to regularly achieve reductions to less than 10-20%% incidence and in a number of studies studies the treatment arm of a number of randomized trials with various anticoagulants may be as high as 25% to 40%. (for example the 1996 study from several institutions in Canada by J.R. Leclerc reported an incidence of DVT in 36.9% of knee replacement patients receiving fixed dose enoxaparin.See here for details.) If you do hip surgery, knee replacements, spine surgery, or neurosurgery you will have patients with DVTs in spite of the best preventive measure known to man.

Delirium is another event CMS seems to believe that can be totally prevented in hospitalized patients. Dr. Poses discusses the lack of evidence for any really effective preventive measure for this common complication of the elderly who become ill whether or not they are in a hospital.

Ventilator acquired pneumonia is another candidate condition. Again zero incidence is beyond what current knowledge and techniques can achieve.

What is going on when a government agency demands the impossible? What is going on when well meaning professionals attempt to do it? And you know they will. How long was the list of hospitals that refused to play along with the four-hour pneumonia rule?

Is it possible that a government agency charged with payment for medical services for millions of people could be so ignorant of fairly simple medical facts? Are there no folks there who know enough to say "wait, these things cannot be entirely prevented"? At least two medical bloggers suggest what is really going on with this absurd recommendation. Their comments can be found here and here. If it is about quality, we are in trouble with outrageous non-reality based proposals. If it really about saving money and rationing care while pretending to do something else it is another frightening chapter in the play book of covert rationing as explicated by DrRich.

When a measurement becomes a target, it is no longer a valid measurment

The title of this essay is one version of an insightful observation made by various people in a variety of settings .

The first time I became aware of that general thought was when I read about the Westinghouse Effect which is that the observation of an event is influenced by the act of observation.

Two eponymous designations refer to formulations that expand that concept and give it more useful meaning; Goodhart's Law and the Lucas critique. These have important implications in this era of hyperplastic medical guidelines, pay for performance, quality measures which pretend to measure the unmeasurable and the cookbookization of primary care medicine.

Charles Goodhart was an economist in Great Britain who expressed the following thought:

Once a measure is made a target for the purpose of conducting policy, it will loose the information content that would qualify it to play such a role.

A medical example is the four-hour pneumonia rule. There are data indicating that those pneumonia patients who received antibiotics within some several hour time frame did better that those whose antibiotics were delayed. This even conforms with common medical sense-a patient with a serious infection requiring antibiotics should do better getting the medication sooner rather than later. So promptness of delivery antibiotics was considered to be a measure of quality and then became a target. Once a target, ER personnel seemed to have treated towards this target and later we learned that one unintended consequence was some not insignificant number of patients were given antibiotics within the magic time frame but did not have pneumonia at all.

This line of thought was developed further by another economist and Nobel prize laureate, Robert Lucas.

Lucas said it was naive to think one could predict the effect of a policy purely based on aggregated historical data. An example might be the data suggesting promptness of treatment influenced pneumonia outcomes.To predict the outcome of a policy change one has to consider how individuals are likely to behave given the change.

To predict the effect of a policy change (rewarding 4 hr treatment for example) you need to consider the constraints the players operate under and basic human nature.Outcomes may change ( even if those outcomes are not measured) when policy ( or rules of the game) is changed.The effort to meet some deadline that folks are graded on may well take away efforts to provide necessary timely care for other patients not currently covered by some quality rule and target.In the era before the imposition of the four hour rule, promptness of antibiotic administration may have been one of a number of indicators of a good general care. Once it became a target it lost its value as an indicator of quality even though now it was considered to be an official indicator of quality.

This general theme was discussed recently by the Management editor of The Guardian.See here.

He offers this example also from the medical world having introduced a concept analogous to Gresham's Law, bad measurements drive out good ones.

What happens when bad measures drive out good is strikingly described in an article in the current Economic Journal. Investigating the effects of competition in the NHS, Carol Propper and her colleagues made an extraordinary discovery. Under competition, hospitals improved their patient waiting times. At the same time, the death-rate following emergency heart-attack admissions substantially increased. Why? As targets, waiting times were and are measured (and what gets measured gets managed, right?). Emergency heart-attack deaths were not tracked and therefore not managed. Even though no one would argue that the trade-off - shorter waiting times but more deaths - was anything but a travesty of NHS purpose, that's what the choice of measure produced.

At the risk of underlining something too much-the point is that measurements loose their value as measurements once they become targets and that does not depend on the original validity of the measure. It can be a great measure, but it is ruined when it become a target. So the answer is not to get better measures much as the answer to bad government is not to replace the officials with better ones.

Goodhart and others made this observation some time ago but fortunately we in medicine were- for quite a while- spared the pain of seeing it first hand in our practices.

Are hospitalists to be the change agents for universal medical coverage?

Some would argue that various economic forces coalesced to animate and catalyze the hospitalist movement. This report from the national hospitalist meeting would indicate that Dr. Berwick,of safety fame has lofty goals for the nation's hospitalists whatever the "follow-the-money" reasons may have been for their birth.

Delivering the first keynote address at the meeting of the Society of Hospital Medicine (SHM)Dr. Berwick speaks of the need for a financial management system, public health initiative and universal access to medical care. He would have hospitalists as the integrators of this new system focusing their boundless energy on what he call the triple aims which are:

1)the experience of care (safety and quality)
2)the per capita cost of care,
3)population health

I would hope that my hospitalist will provide good care ( o.k., call it high quality and we certainly hope it is safe-remember first do no harm.) And I hope the second aim won't trump the first. I wonder when she will have time to also fix- or at least improve- population health.

I imagine that many internists choose the hospitalist role because it provided an opportunity to spend much of their professional time doing what they were mainly trained to do-take care of complex,complicated, very sick patients-while having regular hours,no call and relative to what internists incomes have become a fairly good income. Dr. Berwick would like to task them to do much more than "simply" take the best care they know how for each individual patient and to act primarily in the interest of the patient; he wants hospitalists working for the common good. Will the number 2 and number 3 goals above conflict with the primary fiduciary duty of the physician to his patient?

Pleas and exhortations to work for the greater good and eschew one's own interests for a greater interests somehow never really change human nature or reality. The reality is that after you put in your shift at the hospital and devote as much time as many do in their off hours to trying to keep up with the medical literature there may be little time or energy left to rebuilt the system in Dr. Berwick's or anyone else's vision.

Survey indicates majority of physicians favor universal coverage-but what kind?

A recent survey claims that more than 50% of physicians (over 80% of psychiatrists for some reason) indicated they favor universal medical coverage. The research is in the April Issue of the Annals of Internal Medicine-subscription required

I believe-with no survey to support the claim-that many would say they would opt for
universal coverage because they believe or hope that almost anything would be better than the morass of increasingly impossible to deal with nonsense with the the third party payers.

However, a key point ignored in the survey is what is meant by universal coverage.
Such programs can vary on a number on dimensions but the most important in may opinion is will the patients be allowed to seek care outside of the system or seek more care than the basic coverage of the system provides. If not, we would have a system much like that in Canada or if such freedom would not be crushed then perhaps a system more like Great Britain or France.

How many physicians would favor a universal coverage system of the Canadian type?

DrRich discusses this important issue here.

He makes the important distinction between equality of access and equality of outcomes-choosing between autonomy and equality of outcomes.

...universal healthcare does not necessarily preclude individuals from supplementing publicly-funded services with their own resources. To achieve equal access to all healthcare services (and not just the services that are publicly-funded), we would have to actively restrict individuals from exercising their rights of individual autonomy.

[With the Canadian type system] we would be denying individuals the right to spend their own money on their own health....

...it is beyond disturbing that we seem ready to abandon our foundational principle, especially since it will be for no good reason. We would be empowering our government to abridge our personal liberties, all in a vain attempt to achieve something that our founders recognized could never be achieved and should not be sought - an equality of outcomes .

Yes,way beyond disturbing.

U.S. Health Care -counterpoint to Krugman and Moore from Cato

If you read Paul Krugman and look at what Michael Moore has to offer concerning the relative merits of various countries health care systems (or in our case "non-system") you might begin pricing air fare offers to Croatia.

Before you pack your bags, take the time to read the analysis offered by the Cato Institutes's Michael Tanner and you might conclude things are relatively not as bad as you may conclude from Krugman's writings and the medical grass in rest of the world may be less green than depicted by Mr. Moore.

The author begins by pointing out the obvious-yes, the U.S.spends more on health care but that is not necessarily bad. If fact, some would say it is good and a sign we are an affluent country and are able to spend more on folk's health care than many less money challenged countries. His discussion on the vagaries and tricks and technical considerations in regard to using life expectancy and infant mortality will show that use of the those indicators has been misleading in some the widely quoted comparison studies in which the U.S. is relegated to implausibly low ordinal rankings. In view of his arguments, the assertion that the U.S. spends more and yet still has lower life expectancy looses credibility. Life expectancy varies significantly between certain states in this country even though both have the same "system". If one takes into account homicides and fatal car crashes ( areas where the U.S. unfortunately does lead the pack) the U.S. life expectancy is close to the top of the list.

If there is one simple message from Tanner's article ( there are actually a number) it is there is no free lunch. The medical utopia of which Moore talks about doesn't exist anywhere. Many countries are finding that some system of co-payments and deductibles need to be in place to mitigate the escalating costs that are occurring everywhere-rising costs are not unique to the U.S. Many are shifting to some degree of market mechanism cost control (aka- another form of rationing) while in this country the major rhetorical thrusts seem to advocate the opposite ( universal mandatory coverage and government boards to determine what is necessary care).

Physicians (or just folks with MD degrees) and product promotion

The Jarvik-Lipitor ads have disappeared from TV but the larger issue of physicians promoting certain products or services has attracted the interest-among others-of two straight-talking medical bloggers.

Dr, Howard Brody,director of the University of Texas Medical Branch (Galveston) Institute for the Medical Humanities makes his views clear and is quoted in an article in the March 24, 2008 issue of American Medical News. His blog is here.

What is a doctor doing putting money in his or her pocket,shilling for a product?..There is no positive reason for doing such a thing.

Dr. Roy Poses of the blog Health Care Renewal is also makes his views very clear when he states:

I wouldn't do it.

He argues that an endorsement could induce bias in in favor of a product when it is not in the best interest of the patient.

Arthur L. Caplan of the University of Pennsylvania Bioethics Center offers a more morally relativistic position: I might urge someone to think twice about it, but I can understand they may choose to do it.


The AMA "ethical guidelines" offers another tepid general statement saying that physicians are free to promote their services in what form they see fit but do not mislead or deceive.

I can remember a quaint era when physicians did not advertise at all and I seem to have a foggy memory of a time when internists also did not offer cosmetic procedures in their offices,sell vitamins or skin care products, actually attended their sick patients in the hospital after attending them as an outpatient, spent more time treating their patients than treating their chart in an effort to squeeze the best payment by performing the most clever coding and placating the latest pseudo-quality, documentation initiative and did not relegate their patient's care to "mid-level" practitioners or their call to triage nurses or a telephone answering machine and the default strategy of sending everyone to the ER.

Dr.Rich has spoken of a decline in the pride and ethics of physicians and I have echoed that notion. There is much to suggest a loss of pride and ethics but with the continuing straight talk that call our attention to matters that are wrong and things about which we should express outrage from physicians such as Dr. Poses and Dr. Brody you have to be hopeful that if you keep fighting the good fight there is at least a chance of winning.

More concern re: oral phosphate solutions and kidney damage

The PEG solutions that have been widely used for colon cleansing for colonoscopy are very effective but are also widely unpopular with patients. The times I have used it I began gagging a bit long before the giant bottle was emptied. The oral phosphate compounds seemed to offer an improvement as the volume burden was less and the taste arguably a little bit better.

However reports surfaced on renal damage for some using the oral phosphates and accordingly the FDA issued a warning with particular concern expressed regarding those patients who were using certain blood pressure pills, namely the ACEi and the ARBs.

Now we have a recent retrospective report from the Scott and White Clinic in Texas which tends to reinforce the concern. The authors conclude:

Oral sodium phosphate solution preparation is associated with decline in GFR in elderly patients with creatinine levels in the normal range. Its routine use for elective and screening procedures should be discouraged in the elderly population.

I agree- the PEG solutions are safer.

Dr. Rob -Health Care is not a system-so how will the medical home work?

The latest entry by Dr. Rob puts forth the notion that various advocates for medical care change ( single payer advocates or let the market have at it) tend to talk about a system and there is no system. There are multiple independent or variably dependent entities typically working in ignorance or purposeful disregard of the other's actions and influences and do their various jobs in often what is a myopic, self contained sphere of activity that sometimes only incidentally benefits either the patient of the health care provider ( forgive me for the designation) and too often does little good for either.He gives us a revealing thumb nail sketch of many of the players ( primary care docs, ERs, specialist, medical insurers, etc) that hits many nails on the heads. Whatever you can say about health care in the this county you cannot say it is coordinated.

All of this seems so obvious that I continue to fail to see how the increasingly hyped ACP version of the "Medical Home" would work wherein somehow the primary care doc (an internist if you go along with the ACP-United Health Care version of this latest dressed up P4P) would somehow accept responsibility for the comprehensive care of the patient. As long as the patient has the freedom to see whomever for whatever ( e.g. a orthopedist for his swollen knee who then sends him off for a MRI and PT outside of the watchful,comprehensive caring eye of the homie) the medical home doc cannot control the situation and therefore cannot reap the benefits of controlling cost, in the absence of which United HealthGroup would not be a player to begin with. It is looking more and more like a HMO-oid situation with a touch of P4P thrown in , significant restrictions on what the patients- and the doc - can do, plus a dollop of electronic records and a giant heaping of guidelines which will be more toothy than guidelines and a lovely icing of "continuous quality improvement" verbiage to suck in the corporate employer clients.

It does seem to be getting some traction as discussed in this latest press release from ACP which brags about recent grants received from Pfizer and others to study and implement the medical home plan.

The UHF and Pfizer grants, in addition to a grant awarded to ACP by the Commonwealth Fund in late 2007, will help ACP continue the design and implementation of practice-based resources for internists and their office teams. ACP Executive Vice President and Chief Executive Officer John Tooker, FACP, said the grants are an indication of how the model of care could be here to stay. “The patient-centered medical home, in coordination with the other components of the health care delivery system, is the future of health care,” he said.

Spiriva and Stroke-FDA's warning may be too much (or too soon) information

As best I could tell, wading through the big-pharma disseminated information and infomercials and what also sounded reasonable, and with a desire to try and make COPD patients breath a little better, Spriva (tiopropium) seemed a worthwhile improvement over the then available other medication in that category for the treatment of COPD. Once a day is better than twice a day if only for the fact that folks are more likely to use the medications as intended. Its anticholinergic ancestor, ipratropium or Atrovent was taken twice a day.

Now we are warned about possible an increase risk of stroke in Spiriva users. Dr. Matthew Mintz in his blog give us a good perspective of this breaking news and gives a good explanation of what sort of data the FDA looked at and what information is likely to come down the pike in a reasonably short length of time that might mitigate the worry generated by what might be described "as too much information" or at least maybe "too soon information". Data from a 4 year study called "Uplift" is said to be available in June.

A pet ranting topic of mine has been the issue of the small relative risk which I talked about here.

Could the FDA have waited until June to sound the alarms if they needed to at all.With their recent history of Avandia and Vioxx they probably can't win and will get flak whatever course they take. Being an expert is not easy anymore and epidemiology is not for sissies.

Health Care Renewal's take on the good life of some academics

The blog Health Care Renewal discusses the good times had by officials of Southwestern Medical School with funds donated to the school presumably for expressed reasons other than providing the good life for the bosses of the school. He points out the large, gaping disconnect between the mission statement of the school and such activities.

Thomas Sowell has provided his readers many insights as to how things work. He has said that when one wants to understand what is going on with a entity ( governmental agency,academic institution,business) do not expect to be informed by their mission or vision statement but rather by considering the incentives and constraints under which it operates and the feedback it receives.

If the leaders of the medical school received grants that consider to be unrestricted one might expect little in the way of constraints. In this instance the major mechanism of control of conduct may well be the feedback. If you get caught with your hand in the cash register and the local TV station lets folks know about it may be the behavior gets toned down a bit. Hats off to channel 11 in Dallas and to Dr. Poses of HCR for what we can only hope to be some behavior changing light shinning.

More on Health Care Vouchers

Definitely worth reading today is the latest entry by DrRich, who graciously took up my invitation to comment on ( and explain to me) exactly what the deal is with the proposal by Dr. Fuchs and Dr. Emanuel to fix the current health care mess with a voucher system.

In his first of a promised two part series DrRich begins to dissect the concepts underlying the Emanuel-Fuchs proposal. As usual insight-filled stuff.

As a physician and occasionally as a patient I have seen both sides of the "there-really is-a free lunch" thought process. There is no end to profligate spending if you are spending or even think you are spending "some one else's money".