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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Friday, September 30, 2011

More worrisome news about hazards of long term marathoning

I have written before about the troubling reports of certain test results following endurance events.

There is evidence that in the early hours after a marathon or an Ironman type triathlon there sometimes are elevations of troponin in the range seen in myocardial infarctions.There are also reports of echocardiographic changes that could be described as cardiac "fatigue". The changes are those of altered relaxation characteristics and a decreased contractility all of which, along with the elevated troponins returned to normal in 48 hours.There is the hope that all of this is just analogous to the sore leg muscles and raised total CK values that remit in a few days and is of as little consequence but there may be more to it that that.There is at least one report of some of the more subtle echo changes persist at least for one month after a race.

One post marathon study suggested that the above mentioned abnormalities were less marked in the better conditioned runners and another paper found the alterations more likely in first time runners versus more seasoned veteran marathoners. See here for my earlier blog entry discussing some of the issues involved in assessing the harm or absence thereof in marathoners.It should be noted that not all runners show the echo changes and there is a suggestion that the type of ACE gene pattern may play a role in that.

Well,all of the above really address the issue of over use damage that certainly is at least acute and some worry may lead to long lasting permanent cardiac damage, i.e. myocardial fibrosis or an endurance exercise induced cardiomyopathy.

Now for something completely different. There is a report suggesting that many years of marathon running may increase (not a typo) the risk of coronary artery disease at least as possibly indicated by increased coronary artery calcification.This seems counter intuitive as conventional wisdom tells us that exercise may decrease the risk of coronary disease but could this be an instance of " too much of a good thing".See here for that study.

Drs Robert and Jonathan Schwartz reported on a CTA (Coronary Computed Angiogram) study that involved 25 runners who had been running in the 26.2 mile races for 25 years or more and had completed 25 or more marathons.They found a statistically significant increase in calcified coronary plaques and an increase in non-calcified plaques that did not reach the level of statistical significance as compared with 25 controls.

Thursday, September 22, 2011

If Health care planning is like green energy planning, hold on to your seats

In this article in Investor Business Daily we see how well government planning is working out in the Green area.

Here is in in a nutshell. The government gives a 527 million dollar loan guarantee to a solar panel manufacturing company whose business plan worked out badly and the company went broke.Now the employees have applied for a government funded jobs retraining program to cost another 14 million dollars.

On the one hand we have the government tossing away half a billion dollars on a company who was not viable in the market and on the other we have the government raiding and closing down ( hopefully only temporarily) a company on the basis on vague foreign laws.See here for DrRick's take on the Gibson Guitar Company raid by the Fish and Wildlife police and how that exemplifies the principle of Regulatory Speed Trap.

And speaking of regulations,it makes one feel warm and fuzzy and very secure to know that hundreds ( thousands ?) of government technocrats are working on the details that will give ambiguous and flexible operational meaning to the hundreds of pages of Obamacare. Yes, the very same government that gave us Solargate and raids a viable US company for using the wrong kind of wood is busy at work finishing the details that will shape health care for the country.What could go wrong with that??

Monday, September 19, 2011

Medical decision making moves to Washington

Every time I re-read a section of Thomas Sowell's Knowledge and Decisions I am more impressed with how brilliant it is,how filled with insights and how well written .

A central theme of the second half of the book is described by Sowell in this way: (my bolding)

Even within democratic nations,the locus of decision making has drifted way from the individual,the family and voluntary associations of various thoughts and toward government.And within government, it has moved away from elected officials subject to voter feedback,and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.

The ACA (Obamacare) represents a major shift in the locus of decision making regarding medical care. One could consider Obamacare the poster child for that concept. Of course, the locus has already been shifted to a major decree away from the the individual physician and individual patient ( the "dyad" in Don Berwick's quirky terminology ) by the hegemony of third party payers and the virtual single-payer status of government finance health care administered through CMS (Medicare and Medicaid).

A major theme of the first half of his book is the following. One should analyze the decision making processes of institutions in terms of the incentives faced,the constraints in place and the likely outcomes and  whether the decision makers are immune from  or influenced  by  feedback mechanisms .Do not look at the "hoped for results" or the mission statements but rather at the mechanics of the decision making process.

Consider those mechanics in the context of ACA and how the myriad details which will make the lofty goals operational will be determined. Various governmental agencies and panels will deliberate and churn out the pages of rules and regulations that physicians and patients will have to live with. For the most part these rules makers will be immune from meaningful feedback but they will will not be immune to lobbying efforts by various special interest groups during the rule making process.

Consider the mechanics of the Independent Payment Advisory Board ( IPAB) and how decisions will be made by its fifteen member presidential appointed panel and how lobbyists for various special interests will target this group and likely their efforts will be proportional to the power that IPAB has been given.

Addendum: Minor stylistic changes made 9/25/14