By JOE FLOWER

According to a new poll, half of all Americans say they are “confused” about healthcare reform. And boy howdy, are they right!

Take a look at this new Kaiser Family Fund poll: http://www.kff.org/kaiserpolls/upload/8156-C.pdf

Scan down to Slide 9: Almost a quarter of all Americans think that ObamaCare has been already been repealed. More than a quarter aren’t sure. Barely half are paying attention enough to realize that it’s still law.

What about the idea that the reform law is wildly unpopular, and most people want it repealed? Slide 4 shows that 39% want it repealed, and 50% want it kept or expanded. But take a look at slides 7 and 8. The only major provision of the law that a majority of Americans want repealed is the individual mandateâ€"the part that says you have to buy healthcare insurance or be fined. Even those who want the law repealed agree, except that a majority also think it’s unfair to make the wealthy pay a heftier Medicare tax.

Think about that: Even those who will tell pollsters that they want the law repealed say that, well, yes, they think it’s a good idea to give tax credits to small business to help them give health insurance to their employees. And to close the Medicare “doughnut hole.” And to subsidize low and moderate income Americans to buy health insurance. Or to provide voluntary long-term care insurance (the CLASS Act). And to tell insurance companies that they have to take all comers (“guaranteed issue”).

So 39% want health care reform repealed, but 30% want it expanded. And a majority across the spectrum want insurance companies to be forced to sign up all comers, but they don’t want to be forced to sign up if they don’t feel like it.

What are we to make of this?

1. What most Americans think about healthcare reform is somehow not exactly what you would hear on Fox News or on the red side of the House of Representatives.
2. Most Americans aren’t exactly paying attention anyway.
3. If Americans have a strong suit, it’s not arithmetic.

Filed Under: Front Page

Feb 25, 2011

Contact Lens

If you are a user of contact lenses you may be using disposable contact lenses or you may be using hard and reusable contact lenses. If you are using disposable contact lenses, you may need to buy frequently and if you need to buy frequently it is wise to think to buy online from comfort of your home and with a click of your mouse. If you are buying contact lenses online you should remember and follow certain aspects for buying quality contact lenses at right and affordable price.

Follow some important guidelines while buying contact lenses online and you will never regret later. The most important and first criteria for online purchase is trustworthiness of the site offering contact lenses (or any other goods or services for that matter). The site you will buy should be reputed site and it is much better if you or any of your friend or known people have purchased from that site online. If you have already purchased from a site and satisfied with the service and quality of goods (contact lenses) you should buy again from the same site.

• Before you buy contact lenses decide what brand you want to buy and if possible buy online from their authorized online dealers only, if the company has authorized somebody to sell their products online. If you find this, you can expect quality product and service.
• Find out if the online store is giving refund if you are not satisfied with the contact lenses you received.
• Compare prices of different contact lens brands and different prices of same brand with different online stores. Find out if the online store is giving information about the manufacturer of contact lenses. A trusted site (online store) will always give details information about the manufacturer. Compare the online price of contact lens you are going to buy with your local store for the same brand and specification.
• Do not settle for substitutes for your contact lenses and always buy what you need. Always buy what is prescribed by your ophthalmologist.
• After receiving the contact lenses, do not forget to double check with your prescription and your order. The brand, the diameter and power of the contact lenses should be exact as your doctor prescribed.

If you follow the guideline given here, you can make sure that you receive the exact contact lenses you need and at right price.

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Lululemon Athletica/Flickr

A recent poll asked Americans a seemingly simple question: Has the national health care law been repealed? Our hosts, April Fulton and Rebecca Davis, were surprised to find out how almost half of people answered.

On this week's show, we discuss this unlikely statistic, plus health care woes from Tennessee and Pennsylvania. And we bring you two stories of exercise improving the health of seniors - their muscles and their minds.

Later, blog host Scott Hensley drops by with news about an exciting (and potentially expensive) experimental cystic fibrosis drug, as well as thoughts from Robert Beall, head of the Cystic Fibrosis Foundation, which has helped with its development.

Plus, we hear a conversation with author Claire Dederer about her search for perfection â€" through yoga.

If your search for perfection involves our podcast, you can listen here or download to listen on the go. To subscribe to the Your Health podcast click here.

Secondary amenorrhea is much more common in compare to primary amenorrhea and there are several causes of secondary amenorrhea. The following are the causes of secondary amenorrhea.

Pregnancy:

This is the most common cause of secondary amenorrhea, especially if the women are normal and sexually active and in reproductive age group.

Use of contraceptive:

Some women (although very few of them) may not menstruate if they are taking oral contraceptive pills. Menstruation may not start after stopping pills, as it may take three months or more for ovulation to start after stopping contraceptive pills, especially with progesterone containing pills.

Breast feeding & secondary amenorrhea:

Mothers who breast feed their babies may experience amenorrhea for few months after delivery. During breast feeding it is possible to have ovulation in absence of menstruation and as a result pregnancy can occur without menstruation.

Medications & secondary amenorrhea:

Certain medications may affect menstruation and cause amenorrhea. Some examples of medications that can cause secondary amenorrhea are some anti cancer drugs, oral corticosteroids, antidepressants and antipsychotic drugs.

Hormonal imbalance:

PCOS or polycystic ovarian syndrome, a hormonal disorder is a common cause of amenorrhea. There is high and sustained level of estrogen and androgen (normally there is fluctuating level) in PCOS and result in amenorrhea.

Low body weight & secondary amenorrhea:

Excessively low body weight can cause menstruation to stop, as seen in eating disorder anorexia nervosa. Extremely low body weight cause hormonal imbalance and amenorrhea may result.

Stress:

Mental stress, especially if present for long duration may result in amenorrhea due to abnormal functioning of hypothalamus. Menstruation usually resume if stress is removed or reduced.

Excessive physical exercise & secondary amenorrhea:

Excessive exercise as done by athletes such as long distance runners may have disturbed menstrual periods due to low body fat, excess energy expenditure, stress etc.

Thyroid problems:

Thyroid problems such as under active thyroid which cause hypothyroidism may cause amenorrhea. In hypothyroidism prolactin level is reduced which affect hypothalamus and cause amenorrhea.

Pituitary problems:

Some pituitary problems such as tumor in pituitary such as prolactinoma (which cause increase production of prolactin) can cause amenorrhea.

Scar in uterus:

There may be scar formation in uterus after surgical procedures in uterus such as caesarean section, removal of fibroid, dilatation and curettage (D & C) etc. Scar in uterus cause interruption in normal build up and shedding of the uterine lining, which may cause scanty menstrual bleeding or no bleeding at all.

Primary Ovarian insufficiency:

Normally menopause occurs in between 45 and 55 years of age. But in some cases there may be primary ovarian insufficiency and menopause may occur at the age of 40 years or before, due to lack of ovarian function. Primary ovarian insufficiency, also called as premature menopause may be due to genetic factors or autoimmune disease, but in most cases a cause can not be found.

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Cancer control (Secondary prevention)

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Chronic fatigue syndrome has been controversial ever since 1984, when a cluster of cases in an upscale Nevada resort town attracted national attention.

Now a British study in The Lancet is likely to open another chapter in the medical saga.

Comparing four different treatments for CFS, researchers find that psychotherapy and gradual increases in exercise were clearly better than specialist care or an approach favored by many CFS advocates called "adaptive pacing," which helps patients live within their limits.

 

The results were quite clear," Dr. Michael Sharpe of the University of Edinburgh told Shots. "When a therapist worked with the patient to help them do better over time, it produced better function and less fatigue." Sharpe is the paper's senior author.

The two therapies that proved superior in the study are:

• Twice-a-week cognitive behavior therapy to change the way CFS patients think about their devastating fatigue, or to reduce their fear of exertion; or
• Similarly frequent sessions that gradually increase a patient's activity level, within the patient's ability.

The 641 patients in the study â€" the largest ever in the treatment of chronic fatigue â€" were randomly assigned to different treatments, got six months of therapy, and then were evaluated for fatigue and level of function six months after that.

In a surprise to the researchers, adaptive pacing â€" teaching CFS patients to live within their energy limits â€" didn't reduce fatigue or improve patients' ability to walk longer distances, climb stairs, or engage in daily activities of life, such as grocery shopping.

"It achieved nothing more than just seeing a doctor," Sharpe says. And just seeing a doctor â€" a specialist in CFS â€" wasn't very effective. For what it's worth, all the patients in the study got specialist care, but only one-quarter of them had no other therapy.

All patients rated their own symptoms and how well they were functioning, which were translated into scientifically validated scores. The researchers say they were careful to screen out candidates who didn't meet accepted definitions of CFS, sometimes called myalgic encephalomyelitis.

Study authors point out that psychotherapy and graded exercise came out on top even though patients were less confident in them at the outset.

"I hope the results of this trial will go some way to reassuring some of those people that if this treatment is done by skilled people in an appropriate way, it actually is safe and can stand a very good chance of benefiting them," Sharpe says. But he acknowledges the findings are sure to be controversial.

"There will be some who will be straightforwardly pleased," Sharpe says. "But I think there will be those who are more concerned and suspicious about it."

It might seem strange that people suffering from a lingering, devastating disease like CFS, whose cause remains unknown, would be upset by results that show some treatments actually work better. But people with CFS have learned from bitter experience that any suggestion their symptoms have a psychological component leads many to leap to the conclusion that it's all in their head.

"If you have a condition that people decry and criticize you for, saying it's not really real, it's just psychological, then someone tells you, 'You need a psychological treatment,' it seems like rubbing it in, that people don't believe they're ill," says Sharpe, a professor of psychological medicine.

And indeed, CFS advocates on this side of the Atlantic immediately raised that concern. "The issue with cognitive behavior therapy and graded exercise therapy...have to do with the impression that if these things are effective then it must mean that the condition is all in my head," Kim McCleary, president of the Chronic Fatigue and Immunodeficiency Syndrome Association of America, told Shots. "If you can make it better by changing my illness beliefs, what you're saying to me that I don't have a real illness or a physical illness."

People with CFS and their advocates are also very wary of "graded exercise therapy" â€" partly, it seems, because it may suggest that people with the disorder could get out of bed and push themselves. But a bigger concern is that CFS patients are afraid the approach can backfire, sending them to bed exhausted by post-exertional malaise.

"Far and away the bigger danger is overdoing," says Bruce Campbell, a CFS sufferer who counsels others with the disease. "The number of patients that I've known who were afraid of activity and did too little, I could count them on the fingers of my hands, and I've known several thousand patients."

The British researchers say the rate of serious adverse reactions, such as worsening of fatigue, was no higher among patients in the study who got graded exercise than in those who were counseled to stay within their limits. And no more people in the exercise group dropped out of the study than those in the adaptive pacing group.

The study was funded by Britain's Medical Research Council, a government agency. The U.K.'s National Health Service favors the use of cognitive behavior therapy and graded exercise for CFS.

Chronic fatigue syndrome has been controversial ever since 1984, when a cluster of cases in an upscale Nevada resort town attracted national attention.

Now a British study in The Lancet is likely to open another chapter in the medical saga.

Comparing four different treatments for CFS, researchers find that psychotherapy and gradual increases in exercise were clearly better than specialist care or an approach favored by many CFS advocates called "adaptive pacing," which helps patients live within their limits.

 

The results were quite clear," Dr. Michael Sharpe of the University of Edinburgh told Shots. "When a therapist worked with the patient to help them do better over time, it produced better function and less fatigue." Sharpe is the paper's senior author.

The two therapies that proved superior in the study are:

• Twice-a-week cognitive behavior therapy to change the way CFS patients think about their devastating fatigue, or to reduce their fear of exertion; or
• Similarly frequent sessions that gradually increase a patient's activity level, within the patient's ability.

The 641 patients in the study â€" the largest ever in the treatment of chronic fatigue â€" were randomly assigned to different treatments, got six months of therapy, and then were evaluated for fatigue and level of function six months after that.

In a surprise to the researchers, adaptive pacing â€" teaching CFS patients to live within their energy limits â€" didn't reduce fatigue or improve patients' ability to walk longer distances, climb stairs, or engage in daily activities of life, such as grocery shopping.

"It achieved nothing more than just seeing a doctor," Sharpe says. And just seeing a doctor â€" a specialist in CFS â€" wasn't very effective. For what it's worth, all the patients in the study got specialist care, but only one-quarter of them had no other therapy.

All patients rated their own symptoms and how well they were functioning, which were translated into scientifically validated scores. The researchers say they were careful to screen out candidates who didn't meet accepted definitions of CFS, sometimes called myalgic encephalomyelitis.

Study authors point out that psychotherapy and graded exercise came out on top even though patients were less confident in them at the outset.

"I hope the results of this trial will go some way to reassuring some of those people that if this treatment is done by skilled people in an appropriate way, it actually is safe and can stand a very good chance of benefiting them," Sharpe says. But he acknowledges the findings are sure to be controversial.

"There will be some who will be straightforwardly pleased," Sharpe says. "But I think there will be those who are more concerned and suspicious about it."

It might seem strange that people suffering from a lingering, devastating disease like CFS, whose cause remains unknown, would be upset by results that show some treatments actually work better. But people with CFS have learned from bitter experience that any suggestion their symptoms have a psychological component leads many to leap to the conclusion that it's all in their head.

"If you have a condition that people decry and criticize you for, saying it's not really real, it's just psychological, then someone tells you, 'You need a psychological treatment,' it seems like rubbing it in, that people don't believe they're ill," says Sharpe, a professor of psychological medicine.

And indeed, CFS advocates on this side of the Atlantic immediately raised that concern. "The issue with cognitive behavior therapy and graded exercise therapy...have to do with the impression that if these things are effective then it must mean that the condition is all in my head," Kim McCleary, president of the Chronic Fatigue and Immunodeficiency Syndrome Association of America, told Shots. "If you can make it better by changing my illness beliefs, what you're saying to me that I don't have a real illness or a physical illness."

People with CFS and their advocates are also very wary of "graded exercise therapy" â€" partly, it seems, because it may suggest that people with the disorder could get out of bed and push themselves. But a bigger concern is that CFS patients are afraid the approach can backfire, sending them to bed exhausted by post-exertional malaise.

"Far and away the bigger danger is overdoing," says Bruce Campbell, a CFS sufferer who counsels others with the disease. "The number of patients that I've known who were afraid of activity and did too little, I could count them on the fingers of my hands, and I've known several thousand patients."

The British researchers say the rate of serious adverse reactions, such as worsening of fatigue, was no higher among patients in the study who got graded exercise than in those who were counseled to stay within their limits. And no more people in the exercise group dropped out of the study than those in the adaptive pacing group.

The study was funded by Britain's Medical Research Council, a government agency. The U.K.'s National Health Service favors the use of cognitive behavior therapy and graded exercise for CFS.

Kidney stones (medical term nephrolithiasis for kidney stone is derived from Greek nephros meaning kidney and lithos meaning stone) occur from dissolved urinary minerals such as calcium, magnesium, ammonium etc. and other chemicals (such as uric acid). The size of kidney stones vary from a few millimeter to several millimeters and treatment of kidney stones depends (at least to some extent) on the size of the stone, numbers of stones and symptoms it may cause. Kidney stones if small (generally up to 6 mm) can be managed appropriately by conservative methods. But bigger stones may require some intervention, such as surgery or lithotripsy.

Conservative management of kidney stones:

Most (approximately 85%) of the kidney stones can be treated by conservative methods, which involve passing of small kidney stones in urine. Kidney stones smaller than 5-6 mm are treated by conservative methods, as bigger stones may be difficult to pass in urine. Conservative treatment is generally done within three days of starting of symptoms.

Stones bigger than 5-6 mm need some intervention for removal. There are several methods of removal of kidney stones such as drinking lots of water after taking a diuretic (e.g. furosemide), straining while urinating. If the stones can not be removed conservatively, some intervention such as lithotripsy or surgery may be required. Surgery is also must be done promptly if the individual have urinary tract infection, stones obstructing both kidneys or if an individual have only one functioning kidney.

Use of alpha-adrenergic blockers:

Alpha adrenergic blocking drugs such as tamsulosin (brand name Flomax) can be used for helping removal of kidney stones conservatively. Some studies claim tamsulosin can increase spontaneous removal of kidney stones by up to 30%, but other studies question the claim.

Analgesics in treatment of kidney stone:

NSAIDs (non steroidal anti inflammatory drugs) or opioid analgesics are required for management of pain due to kidney stones. Oral analgesics may be sufficient for mild pain but intravenous analgesics are required for more severe pain. Analgesics which are used include ibuprofen, acetamenophene, diclofenac etc. Use of analgesic is only a temporary measure, because unless the stone is removed pain will recur.

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Chronic fatigue syndrome has been controversial ever since 1984, when a cluster of cases in an upscale Nevada resort town attracted national attention.

Now a British study in The Lancet is likely to open another chapter in the medical saga.

Comparing four different treatments for CFS, researchers find that psychotherapy and gradual increases in exercise were clearly better than specialist care or an approach favored by many CFS advocates called "adaptive pacing," which helps patients live within their limits.

 

The results were quite clear," Dr. Michael Sharpe of the University of Edinburgh told Shots. "When a therapist worked with the patient to help them do better over time, it produced better function and less fatigue." Sharpe is the paper's senior author.

The two therapies that proved superior in the study are:

• Twice-a-week cognitive behavior therapy to change the way CFS patients think about their devastating fatigue, or to reduce their fear of exertion; or
• Similarly frequent sessions that gradually increase a patient's activity level, within the patient's ability.

The 641 patients in the study â€" the largest ever in the treatment of chronic fatigue â€" were randomly assigned to different treatments, got six months of therapy, and then were evaluated for fatigue and level of function six months after that.

In a surprise to the researchers, adaptive pacing â€" teaching CFS patients to live within their energy limits â€" didn't reduce fatigue or improve patients' ability to walk longer distances, climb stairs, or engage in daily activities of life, such as grocery shopping.

"It achieved nothing more than just seeing a doctor," Sharpe says. And just seeing a doctor â€" a specialist in CFS â€" wasn't very effective. For what it's worth, all the patients in the study got specialist care, but only one-quarter of them had no other therapy.

All patients rated their own symptoms and how well they were functioning, which were translated into scientifically validated scores. The researchers say they were careful to screen out candidates who didn't meet accepted definitions of CFS, sometimes called myalgic encephalomyelitis.

Study authors point out that psychotherapy and graded exercise came out on top even though patients were less confident in them at the outset.

"I hope the results of this trial will go some way to reassuring some of those people that if this treatment is done by skilled people in an appropriate way, it actually is safe and can stand a very good chance of benefiting them," Sharpe says. But he acknowledges the findings are sure to be controversial.

"There will be some who will be straightforwardly pleased," Sharpe says. "But I think there will be those who are more concerned and suspicious about it."

It might seem strange that people suffering from a lingering, devastating disease like CFS, whose cause remains unknown, would be upset by results that show some treatments actually work better. But people with CFS have learned from bitter experience that any suggestion their symptoms have a psychological component leads many to leap to the conclusion that it's all in their head.

"If you have a condition that people decry and criticize you for, saying it's not really real, it's just psychological, then someone tells you, 'You need a psychological treatment,' it seems like rubbing it in, that people don't believe they're ill," says Sharpe, a professor of psychological medicine.

And indeed, CFS advocates on this side of the Atlantic immediately raised that concern. "The issue with cognitive behavior therapy and graded exercise therapy...have to do with the impression that if these things are effective then it must mean that the condition is all in my head," Kim McCleary, president of the Chronic Fatigue and Immunodeficiency Syndrome Association of America, told Shots. "If you can make it better by changing my illness beliefs, what you're saying to me that I don't have a real illness or a physical illness."

People with CFS and their advocates are also very wary of "graded exercise therapy" â€" partly, it seems, because it may suggest that people with the disorder could get out of bed and push themselves. But a bigger concern is that CFS patients are afraid the approach can backfire, sending them to bed exhausted by post-exertional malaise.

"Far and away the bigger danger is overdoing," says Bruce Campbell, a CFS sufferer who counsels others with the disease. "The number of patients that I've known who were afraid of activity and did too little, I could count them on the fingers of my hands, and I've known several thousand patients."

The British researchers say the rate of serious adverse reactions, such as worsening of fatigue, was no higher among patients in the study who got graded exercise than in those who were counseled to stay within their limits. And no more people in the exercise group dropped out of the study than those in the adaptive pacing group.

The study was funded by Britain's Medical Research Council, a government agency. The U.K.'s National Health Service favors the use of cognitive behavior therapy and graded exercise for CFS.

Primary amenorrhea is absence of menstrual period by the age of 16 years and affects approximately 1 percent of girls. The causes of primary amenorrhea includes chromosomal abnormalities, diseases in hypothalamus, diseases in pituitary, lack of or absence of reproductive organs, anatomical abnormalities in vagina etc.

Chromosomal abnormalities:

Some chromosomal abnormalities can cause depletion of ova and destruction of follicles responsible for menstruation and ovulation (maturation of ova).

Diseases in hypothalamus:

Menstrual cycle is regulated by hypothalamus and any functional abnormality in hypothalamus can result in amenorrhea. Several factors such as eating disorders (anorexia nervosa), excess physical exercise (as sometimes seen among female athletes), physical stress, psychological stress etc. can contribute to abnormal functioning of hypothalamus and result in primary (as well as secondary) amenorrhea. Tumor in hypothalamus can also contribute to abnormal functioning of hypothalamus and result in amenorrhea.

Diseases of Pituitary:

Pituitary gland is also involved in regulation of menstrual cycle in females. Any disease such as a tumor in pituitary gland can be responsible for disruption of control of menstrual cycle by pituitary and result in amenorrhea.

Lack of or absence of reproductive organs:

In absence of reproductive organs there will be no menstrual period. Some girls are born without some important organs (including reproductive organs) such as cervix, vagina, uterus etc. and in absence of reproductive organs menstruation does not begin.

Anatomical abnormality in vagina:

In case of anatomical abnormality in vagina such as obstruction of vagina by a membrane may not allow the menstrual blood to be seen as the membrane blocks the outflow of menstrual blood from uterus and cervix. Surgical removal of the membrane will establish normal menstruation in this case.

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Don't ask why, but I was rummaging through photos from the National Museum of Health & Medicine on Flickr this morning.

This poster urging moderation on the chow line jumped out at me. In 1944, the U.S. Navy was worried about sailors wasting food. But, it seemed to me, the message resonates today for a completely different reason.

Mediterranean food is one of the most popular recipes we have in this world. The Mediterranean diet is not only mouth watering in its taste, but also has several health benefits; one of the most notable benefits is the benefits for the heart. The heart health benefits of the Mediterranean recipes are particularly important at present context, due to increasing health hazards (especially cardiovascular health hazards) of many Western diets (high calorie fast foods and many more).

Important features of the Mediterranean Diet, if you understand, the health benefits of the Mediterranean food can be easily understood. A traditional Mediterranean Diet is rich in vegetables, fresh fruits, olive oil (which is most consumed raw or uncooked), nuts, pasta, rice etc. and most of these are rich in antioxidants. Mediterranean diet is also beneficial for patients with hypertension (high blood pressure), obesity (especially abdominal obesity individuals are at high risk of heart problems), high cholesterol and diabetic patients.

In many studies it was confirmed that metabolic syndrome is less common among people eating Mediterranean diet. Metabolic syndrome is the condition which increases the risk of high blood pressure (stroke, heart ischemia and other cardiovascular problems as a result), diabetes, atherosclerosis etc. Eating Mediterranean diet can help in management of metabolic syndrome even without weight loss or doing regular aerobic exercise as advised by most doctors to reduce cardiovascular diseases such as stroke, angina, ischemia, heart attacks etc.

Nuts are commonly used in the Mediterranean recipes and nuts contain healthy fats (unsaturated fats such as omega-3 fats which are important for healthy heart), minerals (potassium, calcium, magnesium etc.) and fibers. All the ingredients present in nuts can help in reducing cholesterol level, reduce blood pressure, and improve insulin sensitivity in diabetes patients (patients of type-2 diabetes have reduced sensitivity to insulin and as a result need more insulin for same work than normal individuals).

Want to know more about Mediterranean diet and recipes?

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Sorry, Readability was unable to parse this page for content.

AFP/AFP/Getty Images

Do kids and energy drinks such as Red Bull mix? Some pediatricians say no.

In a conclusion that sounds downright Rumsfeldian, researchers at the University of Miami write in the medical journal Pediatrics that "the known and unknown pharmacology" of ingredients in energy drinks are a cause for concern about potential side effects.

Anywhere from about a third to half of teens and young adults drink the beverages, boosted with such things as caffeine, guarana, taurine and L-carnitine, the paper says. And, citing previous work, the researchers say a single can or bottle of the stuff may be enough to put a youngster, already consuming some caffeine over the daily limit for side effects.

 

Teens and younger kids shouldn't consume more than about 100 milligrams of caffeine in a day. That's about two cans of Mountain Dew or 1 1/2 cans of Red Bull.

Kids with certain heart conditions or ADHD may be particularly sensitive to the drinks effects.

So the paper, a compendium of published scientific papers and publicly availble info, argues that because the drinks have no "therapeutic benefit" and some risks, they ought to be consumed sparingly by kids and scrutinized a little more carefully by everyone else.

Makers of the drinks objected to the characterization of their products. "This literature review does nothing more than perpetuate misinformation about energy drinks, their ingredients and the regulatory process," said a statement from the American Beverage Association's Dr. Maureen Storey.

Pediatricians, the paper says, should make themselves aware of patients' use of energy drinks and be diligent in asking athletes and children sensitive to caffeine about their consumption.

"We would discourage the routine use" by children and teens, Dr. Steven Lipshultz, head of pediatrics at the University of Miami's medical school, told the Associated Press.

The paper concludes that over the long haul, restrictions may be in order:

Unless research established energy-drink safety in children and adolescents, regulation, as with tobacco, alcohol and prescription medications is prudent.

Already, drinks that contain alcohol and stimulants, such as FourLoko, have come under fire for causing health problems. The scrutiny and increased regulation have led to changes in their formulas and availability.

By BOB WACHTER

Although the medical profession has been harming unlucky patients for centuries, the patient safety movement didn’t take flight until 1999, when the Institute of Medicine published its seminal report, To Err is Human. And that report would have ended up as just another doorstop if not for its estimate that 44,000-98,000 Americans each year die from medical mistakes, the equivalent of a jumbo jet crashing each day.

Come to think of it, the quality movement also gelled after the publication of Beth McGlynn’s 2003 NEJM study, which produced its own statistical blockbuster: American medical care comports with evidence-based practice 54% of the time, a number close enough to a coin flip to be unforgettably disturbing.

These two examples demonstrate the unique power of a memorable statistic to catalyze a movement.

Last month, my colleague Rebecca Smith-Bindman, professor of radiology, epidemiology, and ob/gyn at UCSF and one of the nation’s experts in the risks of radiographs, gave Medical Grand Rounds at UCSF. Her talk was brimming with amazing statistics, but this is the one that took my breath away:

A 20-year old woman who gets an abdominal-pelvic CT scan (i.e., just about any young woman coming to the ED with belly pain) has a 1 in 250 chance of getting cancer from that single scan.

Did that fully register? One CAT scan, which until recently most of us ordered with no more restraint than we exhibit when asking the Starbucks barista for a tall latte, will cause cancer in one out of every 250 patients. Two-hundred fifty: that’s the number of students in my college Bio 101 class. Wow. Continue reading “A Game-Changing Statistic: 1 in 250″

Filed Under: Bob Wachter, Patient Safety

Feb 11, 2011

By JOHN GOODMAN, PhD

Pop quiz. How many doctors are at the top of Mt. Everest? None, actually. Yet, think about how many people get sick up there. Think about how many die? Do you think extra bonus payments could coax a few doctors to relocate up there? What if we waived their student loan debt? If you find these questions interesting, there’s clearly something wrong with you. But cheer up. As the map below shows, there is a lot of variation in the number of people per doctors across Texas counties. [Thanks to Jason Roberson and his colleagues at The Dallas Morning News for making the data available.] At one extreme, Bandera County in the Texas Hill Country has 21,266 people and only one doctor. At the other extreme, Baylor County, near the Oklahoma border, has 666 patients per doctor.

Should we care about any of this? If so, why?

Before getting into specifics, let me address a cultural issue that I believe greatly prejudices all discussions of doctor location.

Bandera County bills itself as “The Cowboy Capital of the World.” It clearly promotes tourism. But the online reviews of its eight area restaurants don’t make me want to visit any time soon. Ditto for the online reviews of its 10 hotels, motels and dude ranches. Still, a lot of people visit there and it has a growing population.

Continue reading “Where Doctors Locate”

Filed Under: Superhealthanomics

Feb 8, 2011

By PAUL LEVY

We are about to witness the clash of two tectonic plates in health care. The creation of Accountable Care Organizations, combined with a movement towards capitated and other types of bundled payments, will be forces towards integration of care across the continuum. From primary care to tertiary care to skilled nursing and rehabilitation, principles of care management will combine with financial incentives to create ever more concentration in the health care market. Proprietary electronic medical records systems and "captive" doctor organizations will work towards reducing consumer choice in this new environment.

You already see health care companies engaged in this and advertising it as an attribute. Here, for example, one company notes: [Q]uality care is not just about the care in one institution

Filed Under: Uncategorized

Feb 2, 2011

Many individuals know acne by different names (synonyms) such as pimples, zits, blemishes etc. But by whatever name you may know acne, if you are suffering from acne or if you have suffered from acne (majority of individuals suffer from acne during adolescence and teenage life), you must be aware of the symptoms acne produce and the difficulty you might have faced while treating acne. Acne is in fact one of the few medical conditions (diseases) diagnosis of which do not need (in most cases) opinion of a doctor, as most of us know what acne is, with few exceptions, when it may not be easy to diagnose acne even by trained dermatologists.

Most of us are aware of the symptoms of acne; still here I have discussed the symptoms of acne, common and usual symptoms as well as some uncommon symptoms of acne. The acne may cause psychological distress (although generally do not cause physical distress) and persistent (resist treatment), that is annoying. The symptoms of acne include papules, pustules, nodules, cysts and comedones.

Papules in acne:

Papules are important symptom of acne. Papules are (in dermatological term) skin lesions that are small and raised. If papules are infected or inflamed they become red and tender (painful).

Pustules in acne:

Pustules are also symptom of acne. Pustules are infected papules that are filled with pus. Due to infection they are red and tender.

Nodules:

Nodules are large (larger than papules), solid and painful lumps beneath the skin surface. Nodules develop due to clogging of hair follicles by secretions (mostly sebaceous secretions) and in some cases infection may occur.

Cysts:

They are puss filled lumps under the skin surface. If cysts burst by itself or manually they can leave scar mark.

Comedones:

They are also known as blackheads or whiteheads. Comedones develop when hair follicle opening is clogged and blocked by secretions (sebaceous and oily secretions), dead cells or sometimes by bacteria. If comedones have opening to the surface, they look black and called blackheads. If comedones do not have opening, they look skin colored and little raised and called whiteheads.

Need to know more about acne?

Related posts:

Baby Acne and Juvenile Acne

Acne: Severe Forms

Acne Vulgaris: an Understanding

Acne: Severe Forms (The Other Four)

Acne: Treatment & Management

2nd Cause of Acne (out of 4 main causes)

Treatment of acne & Acne Scar

Body Acne

Symptoms of Cold Sores

Occupational Acne

Courtesy of Tara and Jake Hallman

Brett Hallman had a surgery â€" as a 25-week fetus â€" to treat his spina bifida. Now, he's an active first grader who enjoys swimming and other sports.

Health news can be kind of a downer sometimes. Seems like every day we learn about something else that is contributing to cancer or obesity. But this week's podcast starts out with some good news from NPR health correspondent Richard Knox.

Richard flew in from Boston just so he could join us on the podcast (well, maybe that wasn't the only reason) and fill us in on two new studies: one with good news for some breast cancer patients, and another with good news for the 1,500 babies born every year in the U.S. with a spinal defect called spina bifida.

Also on the show: Michelle Obama's anti-obesity campaign turns one, why some of us get sick and some dodge the virus, and a closer look at the sneeze.

Plus, we'll hear a skeptic of homeopathic medicine try to overdose on a sleeping spray â€" all the way down in Antarctica.

You can find the podcast at the bottom of the page under the podcast heading. To subscribe to the Your Health podcast click here.

February 10, 2011 The Real Cost of Early Elective Deliveries

By VANESSA HURLEY

What if I told you that across the country there’s a procedure being performed on pregnant women that makes their newborns more likely to end up sick and in a $3,000-a-day Neonatal Intensive Care Unit (NICU)?

Too outrageous to believe?

It’s true.

Early elective delivery â€" when labor is induced 3 to 4 weeks early without medical necessity â€" is on the rise in the U.S. According to a report released in January 2011 by the Leapfrog Group, between 1992 and 2003 the number of these births increased from 19% to 29%. Seven hospitals across the country perform these deliveries on 100% of women without medical necessity, and over thirty others perform them 50% of the time or more.

The American College of Obstetricians and Gynecologists (ACOG) has long recognized the risks associated with inducing labor when it’s not medically needed. One retrospective study found that infants born at 37 weeks are nearly 23 times more likely to suffer severe respiratory distress than those born between 39 and 41 weeks. ACOG thinks this is unacceptable.

So why do hospitals do it? Experts see a few possible explanations:

Obstetricians deliver but don’t care for newborns. They move quickly from birth to birth, and lack a complete understanding of the complications associated with early deliveries.

Natural deliveries are difficult to anticipate. Nature can be fickle and tends to ignore the schedules of busy physicians. Patients may simply agree because they see little harm in early deliveries. 

There’s yet another incentive worth pondering. It’s prefaced by a big green $, and followed by plenty of zeros. NICUs - where many pre-term babies end up - are highly profitable for hospitals. John Lantos, a former Chief of General Pediatrics at the University of Chicago, recently wrote in Health Affairs:

 “…the NICU - which represented nearly 4 percent of total admissions [for the hospital] â€" had generated 11 percent of the net revenue. Since most of the academic medical center’s divisions either barely broke even or lost money, that meant that a staggering 69 percent of the net profits of the entire hospital system came from the 4 percent of hospital admissions to the NICU.”

In other words, healthy, full-term babies are not nearly as profitable as preemies. The average cost of caring for a premature baby is $41,610 versus just $2,830 for a full term baby. A clear line can be drawn between more early term births and more days spent (and dollars generated) in the NICU. Increasing the numbers of preterm births creates a perceived need for additional NICU beds, thereby increasing the need to fill those beds. A self perpetuating cycle quickly emerges.

Such a cycle can be broken, as illustrated by Intermountain Healthcare. This Utah and Idaho-based health system reported a 30% rate of early induced labor in 2001 before introducing a protocol that explicitly urged doctors to avoid performing early inductions unless medically necessary. At first, some obstetricians didn’t see a problem. Convincing them required bridging the “information gap” between what doctors thought they knew and the evidence-based reality. When presented with data from their own patient base â€" which showed a lot of babies in distress â€" obstetricians fundamentally changed their practice patterns.

By 2004, Intermountain’s rate of early elective deliveries had plummeted to 5%. They have since brought this rate even lower to 2%. A New York Times article on Dr. Brent James, the chief quality officer at Intermountain, noted that Intermountain’s protocol had reduced the number of babies who ended up in the NICU.

Maybe it’s time to start thinking about babies first and changing the way we pay for births. Simply put, as hospitals reduce their early elective deliveries, they’ll see reduced NICU profits. Intermountain is a capitated health system, so there is little incentive to provide unnecessary care. The fee-for-service model of most American medicine still encourages doing more, even when more medicine doesn’t translate to better health. Bundling payments for birth might be one way to discourage hospitals from performing early elective deliveries when they’re not medically necessary. Although bundled payments require risk adjusting to account for the mother’s health, they would serve as a check against doing more than what’s really needed. Early elective deliveries involve more care at a very great cost â€" a baby’s health.

Vanessa Hurley is an analyst for New America’s Health Policy Program. She earned her bachelor’s degree in English from Dartmouth College. Ms. Hurley also holds a Master of Public Health degree from The Dartmouth Institute for Health Policy and Clinical Practice.

February 10, 2011 | Permalink

With the House expected to vote to defund last year's health overhaul law and frequent battles in the Senate over repealing the law all together, things have been pretty ugly here in Washington.

But this week brought a small win for moms. A group of lawmakers are celebrating a decision by the Internal Revenue Service to allow women to deduct the cost of breast pumps and other breastfeeding supplies.

The policy change means that from now on, taxpayers will be able to get back the money shelled out for breastfeeding supplies, which can cost hundreds of dollars.

 

It's not super easy (is anything dealing with the IRS easy?) But women in the know can now get reimbursed if they use money from their Health Savings Accounts or Flexible Spending Accounts. Or, they can deduct the costs from their income taxes â€" if they have other medical expenses that make up more than 7.5 percent of their income.

"This is good news for nursing moms, and a welcome recognition of scientific fact by the IRS: breastfeeding has significant health benefits," said Rep. Carolyn Maloney (D-NY), who has led the charge for over a decade. Previously, breastfeeding supplies weren't deductible because the IRS considered them a nutritional expense, rather than a medical one.

The change was also lauded by the American Academy of Pediatrics. "For years, the AAP has been urging the IRS to recognize that breast milk is not just the best and most natural food for infants; it confers well-documented health benefits on both baby and mother that cannot be obtained any other way," AAP President Dr. O. Marion Burton said in a statement.

Rep. Maloney was the lead sponsor of a 1999 law that expressly permits breastfeeding on federal property.

But apparently not everyone got the message. The Washington Post reported earlier this week that a woman attempting to breast-feed her baby on a bench at the Hirshhorn Art Museum (part of the federal Smithsonian complex) was asked by a security guard to do it in the ladies' restroom instead. When she said there was no place to sit in the restroom, the guard "told her to try sitting on the toilet."

In response, a number of breast-feeding mothers are planning a "nurse-in" at the museum this weekend. And it's now tax-deductible.

Enlarge David McNew/Getty Images

Marijuana buds tumble out of a jar.

David McNew/Getty Images

Marijuana buds tumble out of a jar.

Can marijuana use lead to mental health problems popping up sooner?

The question weighs on the minds of parents and doctors. Now there's more evidence, culled from more than 80 different studies, that marijuana can speed up development of serious psychotic illness.

Australian researchers found that marijuana users who developed psychosis were 2.7 years younger than nonusers who became psychotic. Other sorts of substance abuse sped up psychosis by 2 years, but alcohol alone showed no effect. The result were published online by the Archives of General Psychiatry.

What's going on?

 

The researcher say the results point toward a strong effect for marijuana in vulnerable people:

This study lends weight to the view that cannabis use precipitates schizophrenia and other psychotic disorders....

Alternative explanations could be that people prone to psychosis are medicating themselves with marijuana or that the drug worsens subtler symptoms.

"It is a wonderful meta-analysis," Dr. William Eaton, chairman of the mental health department at the Johns Hopkins Bloomberg School of Public Health, told Shots after reviewing the paper. The work is both "timely and well done," he says, and adds to the evidence that "there is an association between using cannabis and psychosis."

Proving causation is a high bar, and Eaton says this paper can't be said to go that far. "I think it could be true, but there's no real compelling evidence of that."

Still, he says, the researcher's consolidation of the literature is valuable and important. And the finding that marijuana is associated with earlier onset of severe mental illness is troubling, Eaton says. Even a few years can make a big difference in how a young person's life unfolds. Someone who becomes mentally ill at 22 has a better prognosis than someone struck at 18.

What should parents do? If there's a history of schizophrenia in a family, Eaton says, or the "kids were a little strange," say loners or prone to flight of fancy, "I'd be real worried about them using marijuana." He says we should "protect people" from marijuana who might be on the road to developing psychosis.

February 08, 2011 Where Doctors Locate

By JOHN GOODMAN, PhD 

Pop quiz. How many doctors are at the top of Mt. Everest? None, actually. Yet, think about how many people get sick up there. Think about how many die.

Do you think extra bonus payments could coax a few doctors to relocate up there? What if we waived their student loan debt?

If you find these questions interesting, there's clearly something wrong with you. But cheer up. Today's Health Alert is written especially for your benefit.

As the map below shows, there is a lot of variation in the number of people per doctors across Texas counties. [Thanks to Jason Roberson and his colleagues at The Dallas Morning News for making the data available.] At one extreme, Bandera County in the Texas Hill Country has 21,266 people and only one doctor. At the other extreme, Baylor County, near the Oklahoma border, has 666 patients per doctor.

 

Should we care about any of this? If so, why?

Before getting into specifics, let me address a cultural issue that I believe greatly prejudices all discussions of doctor location.

Bandera County bills itself as "The Cowboy Capital of the World." It clearly promotes tourism. But the online reviews of its eight area restaurants don't make me want to visit any time soon. Ditto for the online reviews of its 10 hotels, motels and dude ranches. Still, a lot of people visit there and it has a growing population.

Now (here's the glitch) if you're a health policy wonk living, say, in Princeton or New Haven you cannot in your wildest dreams imagine why anyone would ever voluntarily choose to live in Bandera County. Think how far away it is from the Met, from Broadway, from Avery Fisher Hall. Think how far away it is from decent Chinese or Italian cuisine. Think how far away it is from… from… well, from civilization.

So to a great many of my colleagues, underdoctored areas are natural and inevitable. What graduate of Harvard Medical School is going to want to move to Bandera? It's hard to even imagine being able to bribe them enough with hard currency. It may require handcuffs and cattle prods, whips and chains â€" or whatever our 21st century courts rule is constitutionally permissible.

The problem with this kind of thinking is that it should apply to the other professions as well, if it were correct. After all, there's nothing particularly special about medical students. So I did a quick check and found seven area listings under "lawyer," seven under "accountant," and seven under "engineer." If Bandera attracted doctors at the same rate that it attracted other professionals, it would have a respectable 3,000 patient/doctor ratio!

So what makes health care different? To begin with, one-third of the U.S. population is in Medicare or Medicaid â€" government health insurance programs that impose price controls at a much different level than would occur in a free marketplace. A private health insurance system dominated by only a few large sellers, such as we have, then piggybacks on top of the reimbursement formulas used by those programs. Bottom line: in health care, when government dictates prices, the supply of health care cannot be properly allocated.

Another problem is that these discussions almost always ignore transportation. Surely the access issue is: how long does it take a patient to get to a doctor; not how many patients or doctors reside in any geographical area. Although this may come as a surprise to some, in most rural areas people no longer rely on horse and buggy. They almost all have… you guessed it… fossil fuel-burning vehicles. [I know. They pollute and cause global warming. A rational society would have rural free light rail. But what can you do?]

The Bandera County Chamber of Commerce, for example, lists seven Hill Country hospitals nearby, not counting San Antonio (about 70 miles from Bandera) and Austin (about 115 miles).  There are a dozen or so clinics as well.

Nationwide, most people in most "underdoctored" areas are not really that far from a doctor. A somewhat dated study in The New England Journal of Medicine found that 80 percent of rural residents lived within 10 miles' driving distance of some physician and 98 per cent lived within 25 miles.

Then, of course, there is the whole issue of medical practice laws that keep Physicians Assistants who treated our soldiers in the field in Iraq and Afghanistan from performing the same services for people who live stateside.

I'll sign off with a possibility not considered. Instead of patients traveling to see the doctor, why not reverse the travel pattern and let the doctor to come to you. Consider this:

Family practitioner Ken Jackson is known around Kingman, Ariz., as the "Cowboy Baby Doctor," though he says the nickname is a bit misleading â€" he doesn't always ride a horse or wear his cowboy hat, and he prefers alternative rock to country music.

But for the past three years, Jackson has traveled by horseback once a month deep into the Grand Canyon to provide prenatal care for Supai, a remote Native American village of about 400 that is inaccessible by automobile. It is the last place in the USA to which the U.S. Postal Service makes deliveries by mule.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.

February 8, 2011 | Permalink

Comments

Besides some largely random points and pot-shots, was exactly was the point of this post again? There are shortages of a number of professionals (not just physicians) in a number of rural areas around this country. Part of the larger overall trend that has been ongoing where you are seeing massive depopulation in many parts of rural America for several reasons especially in the upper Midwest.

Posted by: MG | Feb 8, 2011 8:37:54 PM

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Posted by: Fayyaz | Feb 9, 2011 2:49:19 AM

Doctors locate where their wives want to locate.

Posted by: Peter | Feb 9, 2011 3:53:24 AM

This has been a problem for a long time in heathcare, and it predates Medicare and Medicaid. In fact, when Ronald Reagan recorded his record warning doctors' wives that Medicare was a socialist plot they should fiercely oppose, one of the dangers he cited was that Medicare would create a socialist government that would force doctors to practice where the government told them to, not where they chose. (Like all the other hysterical right-wing warnings, this did not come to pass).

In the 1960's, doctors' wives were well aware there wasn't anybody practicing in Appalachia or the Hill Country (where, incidentally, LBJ grew up), and most of them did not want to move from their very nice homes in Westchester or Beverly Hills to live there, so it was a VERY good scare tactic to get them to oppose Medicare.

Still, nice try to blame a market problem on the government. You get twenty conservative bonus points: 10 for slamming the government, and 10 for standing up against reality-based policy positions in favor of ideological bias.

Posted by: anon | Feb 9, 2011 5:10:53 AM

"So what makes health care different? To begin with, one-third of the U.S. population is in Medicare or Medicaid â€" government health insurance programs that impose price controls at a much different level than would occur in a free marketplace."

Then we shouldnt want to practice in NYC or Boston. You get the same patients and the cost of living is higher. Also, I was not aware that Harvard is the only medical school in the country. My wife went to med school at UTMB at Galveston, just so you know that other states have medical schools. (I know, this just an opportunity t take a shot at elites.)

As anon points out, this is a longstanding problem that precedes Medicare. Being old, and having grown up in the rural Midwest, I have firsthand experience with lack of access to medical care. When you have close family die because fairly routine emergency care was too far away, you tend to remember how things really were.

Lastly, after noting that Bandera has no docs, you claim that the surrounding area is full of them. That people do have access to care. Other than getting to take a shot at elites and AGW, what then was the point of this post? I think we can award you another 20 conservative points, 10 each for the elites and the AGW, to give you a grand total of 40.

Steve

Posted by: steve | Feb 9, 2011 5:47:56 AM

Even if Medicare and Medicaid paid the same rates as commercial insurers, doctors were paid twice what they could make in NYC, Boston or SF, and housing were free, most doctors would not want to live in rural areas. It’s a quality of life issue pure and simple. Even if they were willing to give it a shot, their spouses would probably object. With the possible exception of people who grew up in the area and like it enough to want to return and make it their home, it’s just not an attractive environment for doctors and many others as well, especially highly educated professional types. As MG notes, rural areas are likely to continue to depopulate. As farming and ranching continue to consolidate into fewer but larger entities, there will be fewer job opportunities that pay enough to support a family.

Posted by: Barry Carol | Feb 9, 2011 6:26:57 AM

Bandera County, being in the beautiful Texas Hill Country (and within driving distance of Austin and San Antonio) is arguably in a far better position that most rural counties. Doctors probably don't mind settling (or semi-retiring) in the area. Physicians are readily available in the larger towns. But, as other comments have said, rural communities are depopulating all across the country.

Physicians (and everybody else) increasingly do not want to live in small towns, remote areas or communities that lack the amenities commonly found in large cities. The rural county where I grew up subsidizes medical personnel who practice in the county. The county provides lavish income guarantees not just because of inadequate revenue (from too few residents), but presumably to encourage doctors to live (or commute) to the town, when physicians would otherwise would prefer to practice in larger towns.

I have fond memories growing up in a small, rural community but I sure don’t want to repeat the experience anytime soon. I like living in Big D â€" and the associated ability to try new restaurants, buy imported wines, shop at gourmet grocers (and visit friends) without having to drive 35 to 85 miles for mediocre products.

Posted by: Devon Herrick, National Center for Policy Analysis | Feb 9, 2011 8:41:52 AM

I would imagine the first question a physician considering locating to a rural area asks himself or herself is, "who is going to share my night and weekend coverage?"

As someone who was, for a number of years, the sole practitioner of a particular, emergency prone subspecialty in a rural county, I am familiar with the demands of this situation.

Lawyers and accountants don't have to consider this issue, and it profoundly affects one's quality of life.

Posted by: lurker | Feb 9, 2011 9:46:49 AM

Barry - You nailed the issues largely. Rural depopulation issues are almost exclusively tied to agricultural policies/trends in this country. They go hand-in-hand. Average farm has continued to get larger and larger for several reasons and independent ranchers have largely been run of the game due to the trends in the meat processing industry in the US.

Part of it is that younger people don't necessarily want the economic uncertainty/hardship of running the family farm but it is more simple economics. Just not enough job and higher-paying wages to support it. Not to mention the days of $1-$2/gallon gas are never coming back either.

Posted by: MG | Feb 9, 2011 10:08:07 AM

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February 04, 2011 Shaw Got It Right

By PAUL LEVY

George Bernard Shaw wrote The Doctor's Dilemma, Preface on Doctors in 1909. It is fun to read some excerpts:

It is not the fault of our doctors that the medical service of the community, as at present provided for, is a murderous absurdity. That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.

Scandalized voices murmur that these operations are necessary. They may be. It may also be necessary to hang a man or pull down a house. But we take good care not to make the hangman and the housebreaker the judges of that. If we did, no man's neck would be safe and no man's house stable. But we do make the doctor the judge... I cannot knock my shins severely without forcing on some surgeon the difficult question, "Could I not make a better use of a pocketful of guineas than this man is making of his leg? Could he not write as wellâ€"or even betterâ€"on one leg than on two?"

Why doctors do not differ

The truth is, there would never be any public agreement among doctors if they did not agree to agree on the main point of the doctor being always in the right. Yet the two guinea man never thinks that the five shilling man is right: if he did, he would be understood as confessing to an overcharge of one pound seventeen shillings; and on the same ground the five shilling man cannot encourage the notion that the owner of the sixpenny surgery round the corner is quite up to his mark. Thus even the layman has to be taught that infallibility is not quite infallible, because there are two qualities of it to be had at two prices.

But there is no agreement even in the same rank at the same price. During the first great epidemic of influenza towards the end of the nineteenth century a London evening paper sent round a journalist-patient to all the great consultants of that day, and published their advice and prescriptions; a proceeding passionately denounced by the medical papers as a breach of confidence of these eminent physicians. The case was the same; but the prescriptions were different, and so was the advice.

Now a doctor cannot think his own treatment right and at the same time think his colleague right in prescribing a different treatment when the patient is the same. Anyone who has ever known doctors well enough to hear medical shop talked without reserve knows that they are full of stories about each other's blunders and errors, and that the theory of their omniscience and omnipotence no more holds good among themselves than it did with Moliere and Napoleon.

But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor's livelihood or reputation would be worth a year's purchase. I do not blame him: I would do the same myself.

But the effect of this state of things is to make the medical profession a conspiracy to hide its own shortcomings. No doubt the same may be said of all professions. They are all conspiracies against the laity; and I do not suggest that the medical conspiracy is either better or worse than the military conspiracy, the legal conspiracy, the sacerdotal conspiracy, the pedagogic conspiracy, the royal and aristocratic conspiracy, the literary and artistic conspiracy, and the innumerable industrial, commercial, and financial conspiracies, from the trade unions to the great exchanges, which make up the huge conflict which we call society. But it is less suspected.

Statistical Illusions

Public ignorance of the laws of evidence and of statistics can hardly be exaggerated. There may be a doctor here and there who in dealing with the statistics of disease has taken at least the first step towards sanity by grasping the fact that as an attack of even the commonest disease is an exceptional event, apparently over-whelming statistical evidence in favor of any prophylactic can be produced by persuading the public that everybody caught the disease formerly.

Thus if a disease is one which normally attacks fifteen per cent of the population, and if the effect of a prophylactic is actually to increase the proportion to twenty per cent, the publication of this figure of twenty per cent will convince the public that the prophylactic has reduced the percentage by eighty per cent instead of increasing it by five, because the public, left to itself and to the old gentlemen who are always ready to remember, on every possible subject, that things used to be much worse than they are now ... will assume that the former percentage was about 100.

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past three years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

February 4, 2011 | Permalink

Comments

Great find. It's a bit exaggerated in parts to sharpen the point, but Shaw as a satirist can be easily forgiven. I wonder how much further back the understanding of perverse incentives actually goes.

Posted by: Jonathan | Feb 4, 2011 6:43:58 AM

Back to the Future

Paul - Did you know that Dr. Malcolm T. MacEachern, Director of Hospital Activities for the American College of Surgeons once presciently observed:

... "Our hospitals are now involved in the worst financial crisis they have ever experienced. It is absolutely necessary to all of us to put our heads together and try to find some solution. If we are to have effective results we must have concerted and coordinated immediate action. Repeated adjustments of expenses to income have been made. Never before has there been such a careful analysis of a hospital accounting and study of financial policies. It is entirely possible for us to inaugurate improvements in business methods which will lead to greater ways and means of financing hospitals in the future. It is true that all hospitals have already trimmed their sales to better meet the financial conditions of their respective communities. This has been chiefly through economies of administration. There has been more or less universal reduction in personnel and salaries; many economies have been affected. Everything possible has been done to reduce expenditures but this has not been sufficient to bring about immediate relief in the majority of instances The continuance of the present economic conditions will force hospitals generally to further action. The time has come when this problem must be given even greater thought, both from its community and from its national aspect" ….

No doubt many CEOs, CFOs, physicians, comptrollers, healthcare organization administrators and policy-makers would agree that Dr. MacEachern accurately described today’s healthcare environment … back in 1932!.

Dr. David Edward Marcinko MBA
www.HealthcareFinancials.com
[Editor-in-Chief]

Posted by: Dr. David E. Marcinko MBA | Feb 4, 2011 7:36:02 AM

Paul, Thanks for giving a sampling of this relevant piece by Shaw, about which I'd forgotten. Now I want to read the whole thing -

Posted by: Elaine Schattner, MD | Feb 4, 2011 7:39:32 AM

Without seeming overly critical of this post, I'd like to offer several observations. This critique of physician motivation absents many features of why physicians start their own venture outside the hospital environment. As a CEO and hospital administrator you fail to mention that inherent bias, without mentioning the 'hospital conspiracy' Hospitals are subject to similar external forces to maintain profitabilityand ensure 'survival' in an increasingly hostile environ,environment. Not mentioned is the historical poor efficiency of hospitals in providing outpatient services, both financially and operationally. In the 1980s and early 1990s physicians required efficient operations in terms of cost, and the mechanics of seeing a higher volume of cases, not so much to make more money, but to offset decreases in environment. As a developer in a joint venture of an ASC our hospital was at a loss as to how to implement those changes, and the physician group was allocated the design and operation of such a facility. By actual comparison our ASC was able to perform surgeries on the average at twice the rate of the hospital for several reasons. Turnover time was drastically reduced, Rescheduling of routine cases virtually disappeared without the need for inseting emergency cases in the schedule. The presence of one or more dedicated anesthesiologist prevented cancelling or rescheduling cases.

I know from experience, that I and my fellow physicians were trained in a different era, however all the things you mention regarding 'the conspiracy' were dealt with in my training, we all took the Hippocratic Oath, which is very meaningful to all of us. Our proudest moment is at the time when we graduate, stand on the stage and all take the oath in unison. There were few who did not feel the chill that went down our spines.

Each time a surgeon (which you seem to focus upon) lifts his scalpel he knows the risks, to the patient, and his own responsibility to determine a safe uncomplicated outcome.

Each surgery takes a toll on the surgeon, mentally, emotionally and physically. We may love our work, but we are also taught “primum no nocere”. Physicians are supposed to detach financial gain from their objectivity and decisions in their daily patient care. Not only is the work on patients part of being a physician, but the administrative, paperwork burden, dictation part of the load, so too is the malpractice liability, and the real threat of financial survival by health reform.

I agree that statistic are an illusion. One can prove almost anything statistically, or conclude a result such as you describe. The delivery of the results are not the 'conspiracy of physicians who do have solid grounding in basic statistics, but the inane descriptions and delivery of them by statisticiants the writers of the papers, and the lack of use of simple English. That is why and how patients ( the public) are misinformed.

Hospitals and physicians do not (as you well know) operate in tandem or unison.

I did enjoy your blog post, it was stimulating, although I disagree with most of your conclusions.

Posted by: Gary Levin | Feb 4, 2011 8:13:41 AM

Someone once told me that there are only two types of a doctor: the ones that care and that ones that don't. It always pains me to encounter those doctors who do not even pretend to show some compassion and have the face to bill their patients too much. It's so inhumane.

Posted by: Shiela Marvel | Feb 4, 2011 9:02:57 AM

Money is what talks in this world. With so-called lost revenue for the Urologists, Gastroenterologists, and Dermatologists, they are now setting up their own laboratories within their group and hiring a Pathologist to do the Anatomic Work so these Subspecialty Groups can make up for lost income. Then, some Pathologists cry foul because they lose their income. Reading the debate for In-Office Pathology Labs is mind-boggling. Hospitals and Commercial Laboratories are in it for the business, too. Nurses and Ancillary Services are trying to survive. And what is the difference between a For-Profit Hospital and a Non-Profit Hospital? I can only shake my head at the whole wide world and just do the best I can to help people in my own little world.

Posted by: Marilyn | Feb 4, 2011 9:34:17 AM

Gary and Shiela,

This was satire. Written over 100 years ago. It was meant to be humorous then, and I think it still is.

BTW, Gary, I am not a hospital administrator (any more.) Also, I did not reach any conclusions other than in the title, which was also meant to be humorous.

Posted by: Paul Levy | Feb 4, 2011 10:44:33 AM

Perhaps satire, but, your comment "But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor's livelihood or reputation would be worth a year's purchase. I do not blame him: I would do the same myself" hit home for me. Having once had to take a colleague to task after basically letting a patient take one's life and then later totally disrupting the treatment interventions of another patient's care I had intiated that led to the patient being horrendously back in serious symptoms following said doctor's care plan, guess how it ended?

The state invested my complaints, took 4 years to finish the review and then, only after I commented at a newspaper letters to the editor about the dearth of action by the state board of physician quality review on complaints about doctors to this board by physicians and patients, did they find against this doctor and admonish him just with a letter of poor care behaviors.

Me, on the other hand, was ostracized by the community I tried to protect, attacked by colleagues for intiating the complaint, and realized first hand that legitimate whistleblowing is not only a waste of time, but can ruin the career of the concerned party(s).

So, hope your satire effort was humorous for you and the readers who gleemed the comedic input. Not for me!

Posted by: DeterminedMD | Feb 4, 2011 3:49:47 PM

I like the Shaw piece...I used the same one to summarize the key issue in my blog entry "Prescribing Profits" back in November (http://mcolblog.squarespace.com/kcblog/2010/11/10/prescribing-profits.html)

I'm sure many others have also cited Shaw's piece...amazing how applicable it still is.

Posted by: Kim | Feb 4, 2011 6:02:45 PM

DMD, a couple of very basic points: Those weren't Paul Levy's words you quoted; they were George Bernard Shaw's. Also, the point of satire is to laugh at something or someone in a critical fashion. Yes, it is meant to amuse but also to inform and criticize. Shaw is not describing this behavior with approval. In fact, the point for Shaw was to motivate reform. Easily verified by Google or Wikipedia.

Posted by: Jonathan | Feb 4, 2011 9:51:02 PM

having 4 Doctors in my family and i don't like it ):

Posted by: Asif Zardari | Feb 4, 2011 10:22:39 PM

Satire works because it has an element of truth. Would you docs who dislike Shaw's "Doctor's Dilemma" agree with his comments on religion?

http://www.positiveatheism.org/hist/quotes/gbs.htm

Posted by: Peter | Feb 5, 2011 1:51:47 AM

Satire, cynicism, and criticism are easy. Leadership is more difficult. Suffice it to say there will never be a system which is not constructed with incentives. The challenge is to balance the forces so the desired outcome serves the patient population. Taking Shaw's simple example of leg amputation, perhaps the best system is one in which the surgeon is paid the same for operating or for treating the case medically.

Posted by: imdoc | Feb 5, 2011 6:34:36 AM

I am not sure how much still applies.
"But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor's livelihood or reputation would be worth a year's purchase. I do not blame him: I would do the same myself."

That physicians stick together and cover for each other is, for the US, largely an obsolete observation. Sure, there may be inactive state- and specialty boards (as DMD experienced), and local doctors may occasionally obstruct fact finding (but even that may be limited because in today's environment, the 1st reflex to stay out of trouble yourself and shift responsibility). However, it is no trouble to find a medical expert to testify anything ... outsiders for the crackpot stuff and academics for partisan exploration of fact.

And the fact that procedures are highly incentivized: could be fixed by just adjusting fee schedules. Unfortunately, public awareness/pressure is lacking.

Posted by: rbar | Feb 5, 2011 7:01:52 AM

This Dilemma is present in many different industries. My auto mechanic doesn't make any money telling me my car is in tip top shape, and that darn air filter is always dirty and in need of replacement.

Posted by: Andy | Feb 5, 2011 9:56:13 AM

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Asbestosis is a chronic inflammatory disease which affects the parenchymal tissues of the lungs. Asbestosis is caused due to inhalation and retention of asbestos fibers. Asbestosis usually occurs after high intensity exposure to asbestos and/or exposure to asbestos for prolonged period. As the disease occurs among workers of factories manufacturing products with asbestos (involve in mining, manufacturing, handling or removal of asbestos) or the users of the asbestos containing products, Asbestosis is considered an occupational lung disease. Individuals suffering from asbestosis are at high risk of developing lung disease such as lung cancers (including mesothelioma). The most important and common symptom of asbestosis is severe breathlessness.

Treatment:

There is no specific treatment (no curative treatment) of asbestosis. Treatment of asbestosis is symptomatic in nature and meant to alleviate symptoms. Administration of oxygen (at home or at hospital) is usually required for relieving symptom of breathlessness. Prolonged breathlessness may lead to hypoxia (lack of oxygen supply to the tissues) and be problematic.

Other supportive (symptomatic) treatment for asbestosis includes removal of respiratory secretions from lungs by respiratory physiotherapy (by postural drainage, chest percussion, and vibration).

Medications may have to be administered in nebulized form for treating obstructions in the airways. Vaccination for pneumococcal pneumonia and influenza (annual) are recommended. If the patient is smoker it is highly advisable to stop smoking as they are at high risk of respiratory malignancies.

Periodic health check up is recommended. Patient should undergo periodic PFTs (pulmonary function tests), chest x-ray and cancer screening.

In many countries asbestosis is a reportable to concerned health authorities and can claim legal compensation.

Want to know more about Asbestosis?

Enlarge Mario Tama/Getty Images

A premature baby, born at 28 weeks, lies in the neonatal intensive care unit of a New York hospital. The CDC says the large number of premature births is one factor behind the high infant mortality rate in the U.S.

Mario Tama/Getty Images

A premature baby, born at 28 weeks, lies in the neonatal intensive care unit of a New York hospital. The CDC says the large number of premature births is one factor behind the high infant mortality rate in the U.S.

The biggest reason why the United States has higher infant mortality than other developed countries is that American women are more likely to deliver prematurely â€" before 37 weeks. And, for unknown reasons, the US rate of preterm delivery has been going up in recent years.

That's why it's a pretty big deal that the Food and Drug Administration has okayed a drug, called 17-HP, that experts say could make a dent in the preemie problem.

Not a huge dent, but a significant one. The March of Dimes calculates that if all the women eligible to get the newly approved drug actually did, there would be 10,000 fewer preemies a year â€" out of more than half-a-million born that way.

 

"Although that may seem like a small percent, it's really a very extraordinary ability to impact on what is really a major public health problem," Dr. Alan Fleischman, the March of Dimes medical director, told Shots.

According to the best research, the drug reduces the risk of premature birth by one-third among women who are at high risk because they had a previous preterm birth.

The drug is not for women whose prior premature births were of twins or other multiple births, or who are carrying more than one fetus in their current pregnancy. Nor is it for women who have other conditions that raise their risk of preterm birth, such as high blood pressure or infection.

And even for the 30,000 or so women who are eligible, 17-HP, which will be marketed as Makena, isn't a magic bullet. The study showed that 37 percent of women who got weekly injections of it delivered prematurely, compared to 55 percent of women who got injections of a placebo.

Interestingly, the drug is not new â€" it's just taken a long and circuitous route to approval.

In 1956, the FDA approved 17-HP for the treatment of certain cancers and other hormonal disorders, under the brand name Delalutin. But its manufacturer withdrew it from the market in 2000 "for reasons unrelated to safety," as the FDA puts it.

In fact, as a Federal Register posting last year chronicled, there have been questions raised about whether 17-HP caused birth defects of various kinds. In the 1970s, the FDA required warnings on drugs containing progesterone, as 17-HP does, because of an increased risk of birth defects. They later revoked them.

The FDA is apparently satisfied that 17-HP is safe, but it's requiring its sponsors KV Pharmaceuticals and TherRx to conduct further studies of women who have taken it and children exposed during pregnancy.

Everyone in this field is mindful of the long-running tragedy of vaginal and other cancers and male urinary disorders that resulted from the last drug thought to prevent premature birth â€" a synthetic estrogen called diethylstilbesterol, or DES. In 1971 researchers realized children exposed to DES in utero had a higher incidence of vaginal and breast cancers, and males were subsequently found to have urinary-tract problems.

Fleischman, the March of Dimes official, says there's no such risk from 17-HP, partly because it's not used before the 16th week of pregnancy, when fetal organs have already formed.

"We have been very aggressively tracking all the data," Fleischman says, "and we have no reason to believe that this drug will increase birth defects."

There are several drugs, which are used in treatment (management) of Alzheimer’s disease (AD), some of which are approved and some are not approved by appropriate authorities (such as USFDA) for treatment of Alzheimer’s disease. All of the drugs used in Alzheimer’s disease acts non-specifically and that is the reason so many drugs are available and used in the treatment of AD. Some drugs are shown to have beneficial effects on the disease and used for management.

At present USFDA approves donepezil, rivastigmine, galantamine, memantine, and tacrine for treatment of Alzheimer’s disease. But tacrine is highly hepatotoxic (toxic to liver) and no more used for management of Alzheimer’s disease. Donepezil, rivastigmine and galantamine acts by cholinesterase inhibiting the enzyme cholinesterase (the enzyme is responsible for breakdown or metabolism of acetylcholine), which results increase in acetylcholine in brain. Memantine act by blocking overexcited N-methyl-D-aspartate (NMDA) channels.

Studies (double-blind, placebo-controlled, crossover studies) with memantine and cholinesterase inhibitors (donepezil, rivastigmine, galantamine) has shown to improve cognitive function and the caregiver’s rating for patients functioning. The maintenance of cognitive test score is better for patients using cholinesterase inhibitors, than those using placebo. Use of cholinesterase inhibitors and memantine also slow down the cognitive deterioration in moderate to severe AD, but they are not approved for use in mild AD patients.

The side effects of cholinesterase inhibitors are not severe and include sleep disturbance, lowering of heart rate, muscle cramps, gastrointestinal symptoms such as nausea, diarrhea, and cramps.

How other medications (such as gingko biloba, NSAIDs, antioxidants, lipid lowering agent statins) used in Alzheimer’s disease acts is not clear.

February 03, 2011 Health Care Reform in the U.K. and U.S

By HERBERT MATHEWSON, MD

“England and America are two great nations separated by a common language.”
-attributed to both Winston Churchill and George Bernard Shaw

In 1965 I spent the summer of my third year in medical school at the General Practice Teaching Unit of the Royal Infirmary in Edinburgh, Scotland because I wanted to learn more about the National Health Service (NHS). My impression then was that both the U.K. and U.S. medical care systems were evolving toward the same end result from very different directions. (1) That viewpoint has been reaffirmed by recent events. Both countries have embarked this past year on significant health care reform. Both countries are seeking to reduce costs, improve quality, become more patient-centered, and invest in health information technology (HIT). In both countries the majority of patients are highly satisfied with the NHS or Medicare and are vigilant about not giving up any of its benefits.

Both health care reform acts are being criticized for being too timid, or too bold, or too incremental, or too radical. The U.K. plan is being attacked by some as a disastrous turn toward privatization while the U.S. plan is “another step toward socialism”, i.e. very little change in the tenor since 1965. Vocal U.K. critics on the left decry the proposed move away from regulation (NHS) toward competition and market-place economics while the vocal U.S. critics on the right warn against more regulation and movement away from reliance on competition and market-place forces.

Increased Primary Care Support
The basic foundation of the NHS has always been General Practice physicians (GPs) who have no hospital privileges and refer all patients needing hospitalization to full-time hospital specialists (Consultants). (2) In 1965, and in 1996,  such a separation of outpatient and inpatient medical practice was threatening to community physicians in the U.S. (3) Today it is difficult to recruit primary care physicians (and some specialists) to a community unless the hospital has hospitalists to care for inpatients. The community-based internist in U.S. is now more like the GP in U.K. then ever before, and that is not a bad thing.

Accountable Care Organizations (ACOs)
In the U.K. regional Primary Care Trusts (PCTs) have been responsible since 1948 for “commissioning” (purchasing) care beyond primary care; hospitals, specialists (consultants), ambulance service, maternal health. GPs advised these trusts, but did not run them. By 2013 they will. 141 GP Consortia will commission (purchase by contract) all patient care services for a defined population and will control the allocation of 80% of the NHS budget. Secondary care providers (hospitals and consultants/specialists) will be competing on quality grounds for the contracts. Prices will remain regulated nationwide by the NHS. Sounds like a physician-run Accountable Care Organization (ACO) doesn’t it? (Remember 50% of U.S. medical care services are currently paid for by our government; Medicare, Medicaid, VA, or Federal Employee Health Benefits).

Medical Home
Since most GP practices have been closely connected for years with visiting home care nurses, social workers, and other ancillary social services through the Local Health Authority and every patient needs to “register” with a GP, GP practices closely match the newly-coined U.S. definition of “A Medical Home”; i.e. a multidisciplinary primary care unit that manages, but does not provide, all aspects of the patient’s care. Now the GP referrals will more directly affect the flow of money.

HIT Investment
A multi-million dollar program started in the U.K. in 2003 to develop digital patient records and hospital administrative systems outsourced to two national major vendors its imhas been poorly implemented  . The new plan calls for incentives for more local and regional initiatives from the Trusts/Consortia to move HIT along.
“Improving IT is essential to delivery of a patient-centered NHS”..a modular approach based on”connect all” rather than “replace all”.
The government proposals call for an NHS-wide “information architecture” set around standards, improvements in data accuracy, and the opening up of records to patients online. The NHS looks to saving $32B (billion) by 2015 by implementation of the revised HIT plan. There is a concern about the Trusts/Consortia having enough HIT expertise to do this is. In the U.S. the establishment of 70 Regional Extension Centers and HIT Workforce Development Grants will help implement the “meaningful use” of HIT. Neither the U.K. nor the U.S. plans have established national standards for connectivity; standards that need to be “transparent and centrally mandated” to reduce complexity. This lack of connectivity will be an increasingly vexing problem for both providers and patients in both countries.

Bottom line: Both U.S. and U.K. are evolving toward a similar mixture of public/private health care schemes from their different historical directions. They share common objectives and common problems., and neither country is finding the path to be particularly smooth. Since EVERY country’s health care system is different, and critics of health care reform on both sides of the Atlantic are whipping up fear of the “other system”, it is time to move on and expand our vision by trying to learn more from France and Germany’s experiences.

References:
1. Mathewson, H.O.. “General Thoughts About General Practice: a medical student’s view of the future of general practice in the United Kingdom.”  J Med Educ. 1968, Jan;43(1):36-41.
2. David J. Kerr, M.D., D.Sc., and Mairi Scott, M.B., Ch.B., “British Lessons on Health Care Reform” , September 9, 2009, at NEJM.org
3.Wachter R, Goldman L. “The Emerging Role of ‘Hospitalists’ in the American Health Care System”. N Engl J Med 335 (7): 514â€"7. 1966

Herbert Mathewson, MD, blogs at HUB's LIST, a compilation of medical fun facts gleaned from a variety of medical journals, newspapers, other public and professional sources, and an occasional private communication.

February 3, 2011 | Permalink

Comments

Interesting that you find so much commonality in two very different systems. How does the UK manage to keep people healthier than the US while spending less than half of what the US spends?
I agree that we should look to other countries (i.e. every other developed country) who manage to provide better health to their population than the US... all at less than half the per capita expense of the US.
I have some experience with the Swiss system which is much like the new US design (mandatory private insurance). They have strong regulation of prices and services which keeps costs low and quality high.

Posted by: Mark Spohr | Feb 3, 2011 8:51:11 AM

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