Oropharyngeal cancer is increasing at a "dramatic" rate, particularly in the male population http://goo.gl/JAko Related: Michael Douglas Has Stage IV Throat Cancer; Experts Weigh In. WebMD. Catherine Zeta-Jones's fury at the doctors who missed her husband Michael Douglas's throat cancer. Daily Mail. Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.

The assay can be considered as an alternative to the tuberculin skin test. In many patients it's either/or. In some cases the new assay may be advantageous, as in patients at risk not to return to have the skin test read at the proper time.Via MMWR. Medscape report here.

Nicholas J. Gross, MD, PhD comments on a recent Archives of Internal Medicine study and several others that preceded it:This study follows a few other recent observational studies that have come to the same conclusion,[2,3] and a similar study limited to patients aged 65 years and older had the same outcome.[4] Although all of these studies have been observational, their unanimity makes it hard

I've cited papers on this before, dealing with a variety of conditions. This paper deals specifically with STEMI, in which AVT ST elevation is indicative of a poor outcome.

by WhiteCoat, MD

After seeing Mrs. WhiteCoat argue on the phone with Medco representatives for 20 minutes about why one of her 80+ year old patients hadn’t received her medicine despite three lost faxes to Medco, I had to write this post to let the public know what is going on with some mail order pharmacies.

If you’re like most Americans, you want to try to save some money. One of the ways that patients can save money is by cutting prescription costs.

Enter Medco.

Medco is a mail-order pharmacy that receives prescriptions by mail or by facsimile and then sends patients their prescriptions by mail. Often, the prescriptions are for a three month supply of medications. By having warehouses instead of multiple “brick and mortar” retail buildings, Medco can save costs and presumably undercut the competition. An analogy might be that Medco is the “Netflix” of the pharmaceutical industry.

With the cheap prices come problems, though.

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No comment | Tags: Drugs, Health reform, Patient, Primary care | Category: Drugs and pharma

by Douglas Perednia, MD

Thinking is hard work.  This is why so few people bother.  At least voluntarily.  So whenever it seems like the threat of brainwork looms in modern American medicine, we can thank our lucky stars for the geniuses behind healthcare reform and guidelines of care.

This comes up as a result of a conversation that I had with a patient the other day.  A pleasant, obese gentleman.  He had been struggling with his weight and type 2 diabetes for some time, and there were now some early indications of some potentially serious long-term complications.  He mentioned to me that he was working hard to prepare for gastric bypass surgery.   I asked him how he was doing that.

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2 comments | Tags: Health reform, Patient, Surgery | Category: Diagnosis and treatment

According to Forbes.com:

The two regimens were equivalent in terms of treatment failure in this retrospective cohort study. Quinolones were associated with more diarrhea. Mortality was not evaluated.

On the high side, probably. It decreases encephalopathy. Explanation at Renal Fellow Network.

An update with links at Nephron Power.

I have spent my career in academic medicine – a career at 30 years and counting.  Fortunately I have had success on my own terms.

My original reason for taking a job in academic medicine involved teaching.  Readers know that I love teaching internal medicine – to students and residents.  When the light goes on in the learner's eyes, we teachers have ultimate joy.  When former learners seek you out to thank out, our hearts flutter.

Academic medicine, like our sister disciplines, has focused excessively on grant funded research.  Academic medicine has let money define it.

I wish we could return to an ideal academe.  An academe in which knowledge ruled the day.  As I understand academe, we should create knowledge and impart knowledge. 

We should champion those who impart knowledge.  The great educators do much for their learners and thus they do much for society.  We should champion those who truly create knowledge, judging them not on the dollars they attract, but rather the impact of their knowledge creation.

We should champion those who create an atmosphere that stimulates thinking and learning.  The great teachers do this, but too few very good teachers last in the arena.  We need great teachers, but we need very good teachers also, because there are not enough great teachers to do all the work.

We need creative research, and unfortunately much creative research cannot get funded.  We need smart people who can and will think outside the box – people who approach every problem with intellectual skepticism.

As I observe academe at many institutions, I worry.  I worry that we are not building an academy based on ideals, but rather based on dollars.  I have no solutions, but this morning I have uncomfortable questions.

“It's a reflex that's built into the brain circuits,” she said in an interview. “At its core biological basis, it's unfair to criticize men for that initial unconscious circuitry.”In light of this, male ogling must henceforth be considered genetic destiny rather than anti-social creepiness.I guess it's how you process it in your neocortex afterwards that counts.Via Instapundit.

Leapfrog has released a study based on a simulation tool (fake patients, simulated inappropriate order entry) showing that, across many hospitals and many EMR brands, CPOE does a poor job of intercepting errors. For anyone who uses CPOE in the real world that's a no brainer---you don't need a study.Margalit Gur-Arie, guest blogging at Kevin MD, explains the report and notes that the more complex

A new cohort study from a large administrative database published in Archives of Internal Medicine found:Results Of 269 866 patients in the cohort, 38.8% (n = 104 695) underwent consultation. Within the matched cohort (n = 191 852), consultationwas associated with increased 30-day mortality (relative risk [RR], 1.16; 95% confidence interval [CI], 1.07-1.25; number needed to harm, 516), 1-year

Water, it seems. H/T to Instapundit.Maybe homeopathy really does work!

Impedance cardiography (ICG) guided treatment was superior in getting patients to blood pressure goals in this meta-analysis:Results: Significant benefit was found in both RCTs for ICG-guided BP treatment. The combined odds ratio for the two trials was 2.41 (95% CI = 1.44-4.05, p = 0.0008), in favor of ICG treatment, meaning that it was more than twice as likely to achieve BP success when using

---says DB as he talks about the primary care revolution.

When I was a resident in Internal Medicine in the late 70s the work of John Laragh was hot stuff. Renin profiling, although not practical in the real clinical world, was in vogue and frequently performed at the academic medical center where I trained and at other tertiary centers where it was available “in house.” It was based on the idea that pathophysiologic rationale should be used to guide

From Pacific Research.

Here's a publication from NCPA you should read. Forget the sound bite. Forget the government spin. This is the best source I've seen to find out what Obamacare will look like “on the ground” to the extent it's possible to say right now. I add that last qualifier because there's a lot we still don't know. Many provisions of the law are under the discretion of a handful of czars who could

Maybe so.

As I wrote last Friday, I believe primary care docs are rebelling against the system.  The system has made primary care physicians suffer emotionally and financially.  The system has taken the greatest form of medical care – that consisting of continuity, comprehensiveness, complexity and completeness – and denigrated it.

Now I talk about "the system" in an anthropomorphic sense, but "the system" is virtual.  "The system" has no conscious, it is not deliberate, rather it represents the constellation of ignorance that the insurance companies, CMS and policy works have wrought. 

The system has constrained primary care fees while systematically increasing overhead.  The system has listened to well meaning researchers and -ologists to declare primary care physicians in need for quality improvement.  The system has undervalued the value of a good primary care physician.  The system has, without consciously meaning to, held primary care in contempt.

So what do primary care physicians do?  They do what any sensible economic citizen would do, they alter the rules to their benefit.

So decreasing numbers of primary care physicians are taking medicare or medicaid.  So primary care physicians are leaving their jobs to do hospital medicine.  So many primary care physicians are leaving the CMS/insurance company grid and retreating to retainer practices or cash only practices.

The rebellion is a quiet one.  No one has declared this rebellion.  This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera.  This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable.

Some believe that NPs and PAs can fill the void, but those who believe it do not understand the complexity of primary care.  Retreating from physician led primary care will increase costs by increasing subspecialty referrals.  The problem is that too many see primary care as simple, when in fact it is complex.

So I believe the rebellion will continue.  Every anecdotal sign that I see tells me that the rebellion is gaining speed and power.  Now if Congress is dumb enough to once again fail to fix the SGR, they will encourage more rebellion.

One day the wonks on Capitol Hill will realize the problem.  AAFP and ACP (amongst others) have tried explaining the problem to the politicians.  Until they understand that their constituents are angry because they cannot find a physician, they will not focus on the problem.  The quiet rebellion will eventually stimulate a response.  Unfortunately, the fix will cost so much more then than it would have 5 or 10 years ago.  Our health care system will be changed, and likely in a very negative way.

And the quiet rebels will not be the ones suffering.

I remember seeing this ad many times on LMT. Like many doctors during those years who were reeling from the MRFIT data I was reluctant to prescribe thiazides, even combined with potassium sparing diuretics.The ad was kind of silly because it mainly dissed Dyazide but in a way it was prescient.

In addition to the recent deli meat recall and continued egg recall, parents should be aware that Cargill Meat Solutions Corp. has recalled 8,500 pounds of ground beef that may be contaminated with E. coli, another bacteria that can cause food poisoning.

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Visitors are greeted with Welcome to the internet's busiest one-person medical site. Dunno if that's true but there's a lot of good stuff here including all his pathology lecture handouts, lots of images and links, as well as ruminations on science, religion, culture and the humanities.When I'm researching a disease the Internet trail often leads me back to his second year pathology lectures

Walmart is in my back yard. I live about 5 miles from the corporate headquarters. As the company has grown it has transformed my community. Here's a Flowing Data map which shows the growth of the chain since the first store opened here in 1962.

Here are a couple of videos from Mayo.This is research information to change practice now. The effectiveness, however, may be limited by turnaround time. How is it important for hospitalists? Suppose you're planning an early discharge of a patient with DVT or low risk PE. Genotyping, if turnaround time is reasonable, could greatly simplify discharge planning and the transition to ambulatory

A medical resident guest blogging at Kevin MD notes:According to an article published in the Journal of General Internal Medicine, counties with teaching medical hospitals experienced a 10% increase in fatal medication errors as compared to counties without teaching medical hospitals.Of course we've long suspected this. Apparently having better supervision, better hours, CPOE and UpToDate

Your tax dollars paid for this.FactCheck.org explains the use of the weasel words.Why Andy Griffith? Maybe Obama saw A Face in the Crowd.

Before passage, the conversation on health care reform lacked a dimension of reality. Some important issues were discussed, to be sure, but all in all it was pretty nebulous. Since passage, though, the debate has taken on substance as the negative consequences become apparent. That's well illustrated in the video below.As a corollary to what Nancy Pelosi said, we had to pass the bill so we

Who was that masked man?

Here he is at the Restoring Honor rally.Via Gateway Pundit.

Go here to read a publication from the folks at the NCPA telling the readers much they need to know about PPACA.

It is a welcome counterpoint to the rosy and in parts misleading picture painted in this publication from CMS.

For example, CMS talks about the changes in Medicare Advantage in the following way in a section astoundingly labeled as "Improvement to Medicare Advantage". ..." The new law levels the playing field by gradually eliminating Medicare Overpayments to insurance companies." Contrast that characterization with the following from the NCPA booklet:

Loss of Medicare Advantage Coverage. About half of the enrollees in Medicare Advantage (MA) plans (7½ million people) are likely to lose their coverage and will be forced to return to conventional Medicare. If you are able to keep your MA plan, expect higher premiums and fewer benefits. ...Of the 15 million people expected to enroll in Medicare Advantage programs, 7½ million will lose their plans entirely, according to Medicare’s chief actuary, and the remainder will face higher premiums and lower benefits.

The playing field seems to be leveled by forcing several million elderly folks out the MA plans many of whom may have to sign up for a Medicare supplemental insurance which is conveniently offered by AARP who just happened to have championed the health deconstruction-reconstruction bill. The follow-the-money rule has such great explanatory power.The CMS publication's section on MA would be more appropriately titled
"Throwing Medicare Advantage patients under the bus".

The entire NCPA publication is important reading but here is one interesting aspect of the bill that I was not aware of:

The government will require you to give your employer your most recent income tax return. Both at work and in the newly created health insurance exchanges, out-of-pocket premiums will be limited to a percent of your income. In order to enforce that requirement, however, your employer or the operator of the exchange will have to know what your income is. Note: Under the new law, the income-based premium limits are not based on the wages your employer pays you. They are based on your family income — including nonwage income (dividends, interest, trust income, etc.), your spouse’s income (from all sources) and, if your children are dependents, their incomes as well.

Wow, what if you might not want your boss to know how much your spouse makes or how much you made on investments? Too bad. It all just gets better and better. (Well, I won't give Fred a raise, looks how much his wife makes.)

The NCPA booklet is great source for important details of the PPACA. For an insightful,succinct summary statement it is hard to beat this slightly paraphrased comment from the blog "Nostrums by Doc D".
The plan is to take 500 billion from Medicare, spend it on something else and then call it a savings and a quality improvement to Medicare. Compared to that game plan, the business model of the Underwear Gnomes appears brilliant.

Melissa Phillip | ChronicleJasmine Ellison, 9, left, watches her sister, 3-year-old Alecea Coffer, during a July lunch at Oakwood Gardens Apartments' free summer food program. Fewer children accessed free summer meals from the Houston Parks and Recreation Department's feeding...

In addition to the egg recall, parents should be on alert for a meat recall, as the U.S. Department of Agriculture has announced that Zemco Industries, a division of Tyson Foods, has recalled about 380,000 pounds of deli meat.

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DB of "DB's Medical Rants" takes another opportunity to direct some of his typical well thought out criticism against the dangerous concept of pay for performance for physicians. See here.

The thoughts he expresses fall into the category of still-another-reason why P4P is a bad idea.

He refers to the concepts popularized by Daniel Pink in his book "Drive" which include intrinsic motivation and the notion that contingent rewards lead to a loss of autonomy and loss of motivation.As noted by a commentary to DB's entry, Pink seems to rely heavily on the work of Alfie Kohn which can be found in his book,"Punished by Rewards".

The basic idea as it applies to physicians is the following. To offer rewards to someone for tasks that they already find interesting and enjoyable and who are to a large degree driven by their intrinsic motivation to perform at a high level a job that they believe to be important will tend to destroy motivation and eats away at the autonomy which is a major element in that job satisfaction.

Fundamentally P4P ,while touted as a means of improving some nebulous "quality" is a method of control of physicians' activities and succeeds in that control if and only if physicians comply which because of the hegemony of third party payer has become, outside of retainer practices, a fait accompli.

The percentage of adult organ donors in Texas lagged behind every other state at the end of 2009, but Texans have been quickly catching up. This month, the Glenda Dawson Donate Life Texas Registry — the state's official list of...

You may not know this, but I have a hidden talent. I can predict the future. No, this doesn’t involve a crystal ball, Ouija board, or looking at the entrails of a freshly slaughtered surgical intern. I can see the future that is written out, plain as day, in medical journals. While this will not allow me to get rich in the stock market, predict the next presidential election result, or find out exactly when Monica Bellucci is planning to leave what’s-his-name and realize that she was meant for me, my limited skill gives me a little insight into how general surgeons will be treated --- and, more importantly, how they will respond to such treatment --- in the next few years.

A good example is the ongoing, relatively one-sided discussion regarding who should be doing certain procedures. Sounds relatively simple --- look at a variety of measurable outcomes for certain surgical procedures, and compare the results between “high volume” and “low volume” facilities and surgeons. This data is then often used to argue that across the board, we should as a matter of public policy push to shepherd certain types of patients to “high volume” facilities to achieve the best possible results. I have written about this a bit before, and certainly the freight train pushing certain types of procedures (pancreatectomy, esophagectomy, cardiac surgery, etc.) towards higher volume centers has been rolling down the track for so long that it is essentially unstoppable.

But what about procedures that are considered to be less complex? Should the same type of spotlight be placed upon cholecystectomy? Colectomy? Appendectomy? Hernia repair? And what if the data from such an evaluation reveals a contradictory result; should that instigate a reevaluation of prior “low versus high volume” studies? That’s good question, and one that is partially addressed by a study published in the July edition of the Journal of the American College of Surgeons --- Predictors of Major Complications after Laparoscopic Cholecystectomy: Surgeon, Hospital, or Patient?

From the abstract:

• Using the Nationwide Inpatient Sample for patients undergoing laparoscopic cholecystectomy, major complications including acute myocardial infarction, pulmonary compromise, postoperative infection, deep vein thrombosis, pulmonary embolism, hemorrhage, and reoperation were assessed.
• A total of 1,102,071 patients' records were available for this retrospective 1998-2006 study, with a complication rate of 6.8%.
• Univariate analyses showed that advanced age, male gender, and higher Charlson Comorbidity Score were associated with higher complication rates
• Higher surgeon volume and higher hospital volume were associated with fewer complications (6.7% versus 7.0%, 6.4% versus 7.0%, respectively)
• Multivariable analysis showed that advanced age (65 years or older versus younger than 65 years), male gender, and comorbidities (Charlson Comorbidity Score 2 versus 0) were associated with complications
• Neither surgeon nor hospital volume was independently associated with increased risk of complications.

Conclusions -- Major in-hospital complications after LC are associated with individual patient characteristics rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures might be unnecessary. Rather, careful patient selection and preoperative preparation can diminish overall complication rates.

Uh, what did they just say? Let me repeat it --- “Major in-hospital complications after laparoscopic cholecystectomy are associated with individual patient characteristics rather than surgeon or hospital operative volumes.” In other words, we are not a bunch of rubes out here away from the miracle centers. On average, the general surgeons of this country are competent and well trained. “Rather, careful patient selection and preoperative preparation can diminish overall complication rates.”

Time for a little futurama. I have no doubt whatsoever that the push for regionalization of a whole swath of surgical procedures will continue unabated, especially in the current political environment. To an extent, I will benefit from such a push --- I am a high volume general surgeon working in a tertiary referral center, albeit not in the largest city in my state --- and would anticipate an increase in surgical volume over time if such proposals come to fruition. It would be very reasonable to also expect that the types of patients sent up the road will be sicker to a pretty substantial degree, with simpler, elective procedures being done on healthy patients being retained in lower volume facilities.

Look at it this way. Let’s say you are a well-trained and salty seasoned surgeon in a small-to-medium sized city. An hour away is a miracle center, and they have actively pushed to make sure that, for example, colon resections should only be done in high volume centers by high volume surgeons. And let’s say that at 1AM you get a call to the ED to see a 62 year old, 280# diabetic man with hypertension and coronary artery disease who has perforated diverticulitis. Peering into the future, I predict the response of most physicians put into that difficult position will be “Gee, if I am not considered good enough to do elective colon surgery during daylight hours, I certainly am not good enough to do something more complex and emergent on a someone who has had no careful patient selection and preoperative preparation in the middle of the night. Call the miracle center and arrange transport.”

Patient wants to stay in town? Too bad.
Patient is pretty darn sick? Give him antibiotics, load and go.
Patient has given googobs of cash to the hospital? Cue Lindsey Buckingham. Call the hospital CEO to hold his hand during transport.
ED really, really wants you to take care of the patient? Wouldn't be prudent. I can hear the attorney's question when I get sued for a complication: "Doctor, when was the last time you performed one of these operations electively?"

This sort of begs the question, is this a good thing for the patient, or a bad thing? I'm sure you can tell that I come down a bit on the side of "bad thing," but some might argue the opposite. The difficulty is that all hospitals cannot be staffed with high volume surgeons for every possible procedure. It's a Pollyannish idea, sort of like how the schoolkids in Lake Wobegon are all above average.

Please understand, I am not arguing that we should be avoiding progress; obviously, I don't think it's ethical to turn away a patient in need. But progress in medical care has generally come from striving for excellence in training and disseminating information about how to best care for patients. If there is a concern that surgeons performing a lower volume of certain common procedures need a little buffing up, first prove it.....and then I would humbly suggest that the way we have been going about steadily improving care in this country has worked extremely well over the past century. I have yet to see strong evidence that radically changing this system will be beneficial to patients in the long run.

An additional four brands and 24,300 dozen eggs have been added to the egg recall list.

The latest egg recall is from eggs produced by Hillandale Farms of Iowa and packaged by Moark, LLC and sold in Southern California and Las Vegas, Nevada. In addition to unbranded eggs that were sold to food service customers, the recalled eggs were then repackaged under several brand names, including:

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All kids need vitamins and minerals to be healthy and grow normally.

They need vitamin D, iron, calcium, and fluoride, etc., or they will eventually develop signs and symptoms of vitamin and mineral deficiencies.

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As many people expected, the egg recall continues to expand. In addition to more egg brands from the initial 380 million egg recall from Wright County Eggs, experts have found that Hillandale Farms in Iowa may be an additional source of contaminated eggs. This puts the total number of eggs that may be contaminated with Salmonella at 550 million eggs.

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Take one part highly inflammable surgeon. Add a dash of chronic worry, a well-rounded tablespoon of sleep deprivation on call, and stir vigorously with an enormous slab of hospital inefficiency. The cherry on top? That would be ongoing concerns about government regulation compliance, increased taxes on my small business, Medicare payment games, and the Kabuki theater known as Obamacare. That would be my recipe for one, well, aggravated surgeon. To make this situation really cook, however, increase the on call load by having one physician leave the group (and act like a total rectal-discharge-head on the way out). Voila! Aggvavated DocSurg flambé ! C’est magnifique!

What was not so magnifique was my blood pressure, weight, and stress. Think of Ox in Stripes.

"Well, my name's Dewey Oxburger. My friends call me Ox. I dont know if you've noticed, but I got a slight weight problem.....When I was younger, I swallowed a lot of aggression...along with a lot of pizzas!!"

A few changes were in order if I was going to avoid sharing John Candy’s fate. Trying to put one’s time in order when working in a field where a predictable day is a false hope has always been one of my biggest challenges, but I was able to make a few adjustments over the past few months. Activities that helped decrease stress were put on the front burner, and those that simply added consternation with no discernible benefit were dropped faster than you can say “Frankly, my dear, I don’t give a damn.” Or something like that.

What went out with the screaming baby and the bath water?

• Any hospital committee that I wasn’t absolutely required to be a member of.
• Any meeting with hospital administrators that was unscheduled or open-ended. No agenda and no clear reason to be asking for my time? Then sayonara, baby.
• Any time wasted in my office waiting for patients who cost me money, i.e. Medicaid patients, who fail to show up on time. I cannot afford the expense or aggravation involved in trying to work in someone who shows up a half hour late for a scheduled appointment, but whose insurance coverage pays so little that I lose money seeing them to begin with.
• Any time sitting in the surgeon’s lounge bitching about Obumblecare, politics, hospital administration, and healthcare in general. Wasted words, as Mr. Allman would say.
• Potato chips. Worse than crack cocaine for me.
• Orchestrating OR schedule contortions worthy of a pretzel maker in order to accommodate every patient’s request. I try to make things work as well as possible, but it made no sense for me to go to three different places to operate in one day, doing a single case at each location, and racing across town to be on time.
• Any time blogging. Not really a conscious choice, but I needed to quit bitching here too.

What went into the mixing bowl?

• My mountain bike. Specifically, I have tried over the past 5 months to get outside and ride at least 4 times per week. This means lunchtime rides on office days whenever possible, and using any other available time on OR days. I had to carve an extra hour out at lunch and run my office later, but it has been worth it (especially when it was snowing).
• Travel. SWIMBO and I took the Surglings on a long-awaited trip to Rome & Paris. Simply fabulous.
  
• My books. I love to read, but have felt that the time I had available to dip into a good book had evaporated. Made time, read some good books, and then the Surglings bought me a Kindle --- I now have a new version of crack cocaine. I have enjoyed Vanished Smile, The Gardner Heist, The Man Who Loved Books Too Much, the "Dragon Tattoo" trilogy, and Fire among others this summer.
  
• Music. My younger self spent waaaaay too much money on vinyl and concert tickets, but I enjoyed every bit of it. So I have spent time spinning old records and seeing a few concerts --- there is nothing that can compare to an evening at Red Rocks.

But.

But.

But....I haven’t received the miracle cure. I remain, after all, aggravated at my core. Which means that while I haven’t necessarily posted anything, I have been keeping notes. Taking down names. Reading BS journal articles that whose authors don't seem to understand the difference between good medical care and mumbo-jumbo. You know the drill. And while the exercise has been good, to the tune of ~30#, it has also provided me time to consider things I want to write about --- I gotta concentrate on something other than my heavy breathing while climbing a hill.

I guess that means that posting here will have to be added back into the mixing bowl. Sorry. And if I get too worked up --- too aggravated --- let me know.

In addition to the previously announced egg recall brands, Country Eggs, Inc. has announced that some of their eggs were produced by Wright County Egg of Galt, Iowa where many other eggs may have become contaminated with Salmonella.

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A very readable piece from Gina Kolata of the New York Times:

Doubt on Tactic in Alzheimer’s Battle
By GINA KOLATA
The New York Times
Published: August 18, 2010

"The failure of a promising Alzheimer’s drug highlights the gap between diagnosis and treatment."

Read the full article

Many parents are confused about the current egg recall, especially since the recalled eggs from Wright County Eggs were sold under so many different brand names across the country. Remember that these eggs may be contaminated with Salmonella and could cause diarrhea and other salmonella symptoms if eaten.

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An ongoing, nationwide outbreak of salmonella has been linked to eggs from a farm in Galt, Iowa. The CDC reports an increase of salmonella cases since May that has now been linked to these eggs.

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Should medical student applicants be chosen less for their demonstrated ability to master large amounts of knowledge and solve problems and more for their social consciousness and desire to push forward with social justice?

That appears to be the suggestion of a panel of experts from the AMA in a project called the Initiative to Transform Medicine (ITM) who believe an altruism deficiency underlies the migration to certain more lucrative medical specializations at the expense of forsaking primary care causing a shortage of primary care doctors.See here for the AMA page regarding that initiative and from there a link to the recommendations of that panel.Yes, I realize this is not breaking news but I only now heard about it.

See here for a good summary and exposition of reasons more convincing than a sudden attack of selfishness, greed and hypertrophied self interest as to why fewer medical students choose primary care .Yes, it does depend to a significant degree on income, but there is more to it.

(h/t) to John Goodman's blog entry authored by Linda Goodman.

The suggestion made by the panel that social awareness or social consciousness should be weighed more heavily than ability to master a formidable load of knowledge and problem solving ability in selecting students for primary care residency training reflects a lack of awareness of what is required in primary care and a demeaning characterization of primary care medicine. Often more problem solving skill is demonstrated in sorting out a patients diagnoses from a myriad of often non-specific complaints that is evident in the specialists subsequent handling of the case which arrive in his office with the label already properly applied. Internists were once thought of as being at the top of the problem solving food chain but now those limit their practice to outpatients seem to be considered merely as members of the category of primary care provider.

I believe the shift of medical students from primary care to specialties is due less to some alleged "altruism gap" than to the combination of three other gaps; 1) an income differential gap, 2) a life style differential gap, and 3) a practice hassle gap.

The above referenced link contains a useful, succinct summary how the income gap came about. This is a story often told in the medical blogs of the Resource Based Relative Value Scale and the now infamous RUC and the role that once obscure group played in protecting the income of procedure oriented physicians versus those who do not do procedures.

In addition to the altruism deficiency the panel "determined" another weakness of physicians as they are trained today.

Physicians are generally not prepared to be advocates for patients on issues related to social justice (for example, elimination of health care disparities, access to care) and to be citizen leaders inside and outside of the medical profession. This also includes engaging in advocacy on public health issues.

Apparently in the view of this group of self designated experts, one of the many requirements of physician training is to prepare them to work for social justice, which must involve redistribution of wealth. Perhaps lessons in community organizing could be added to the curriculum. I suppose libertarians need not apply. Neither should anyone who thinks Thomas Jefferson had it right when he said;

"To take from one because it is thought that his own industry and that of his father's has acquired too much, in order to spare to others, who, or whose fathers have not exercised equal industry and skill, is to violate arbitrarily the first principle of association -- the guarantee to every one of a free exercise of his industry and the fruits acquired by it."

(h/t to Wealth is not the Problem blog)

The general philosophical basis of the ITM is the same as that underlying to the creation of The New Medical Professionalism,which seriously weakens the fiduciary duty of the physician and inserts a nebulous duty to society to the physician 's obligations .See here.

Audio available from The BBC:

Listen

From the show's webpage:

"Neurobiologist Professor Colin Blakemore was a war baby brought up in devastated Coventry. His two-up two-down home had the first TV in the street on which he lived next door to relatives and a family of ten. As an only child, his parents were able to cash in an insurance policy of £16 which enabled him to go to the local grammar school where he proved himself to be more of an artist and actor than a scientist. Producer: Smita Patel."

It has been a record year for heat across much of the country this year. Unfortunately, it looks like we will hit another record this year - the number of kids who will have died in hot cars.

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From FierceBiotech

FDA panel backs new epilepsy drug from GSK, Valeant
August 12, 2010 — 7:41am ET
By John Carroll

"GlaxoSmithKline and Valeant got a solid endorsement for their new epilepsy drug Potiga (ezogabine) from the FDA's panel of experts, putting them on track to a likely approval. The experts unanimously agreed that the drug would benefit epilepsy patients whose meds couldn't stop seizures. And they agreed that careful monitoring would flag patients who experience an inability to urinate while taking the drug."

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From The New York Times

Patricia Neal, an Oscar Winner Who Endured Tragedy, Dies at 84
By ALJEAN HARMETZ
Published: August 9, 2010

Patricia Neal

Two recently released projections of what Obama Care (PPACA aka ACA) will do paint different pictures.
The paper by the Medicare Trustees take the provisions as written,assume that the provisions will be met and conclude that Medicare will remain fiscally viable for a longer period time than would obtain that if the bill were not passed.

The Chief Medicare actuary, however,claims that it is highly improbable that the cuts to Medicare providers, that are necessary to make Medicare more solvent, will ever happen. Congress , so far, repeatedly postponed the looming SGR formula cut so that now to belatedly enact them would bring about a 30% cut in Medicare fees for physicians. This would cause an even greater exodus from Medicare on the part of physicians, particularly primary care docs-internists and family physicians, at a time when some 31 millions folks will have recently obtained health insurance and will be seeking primary care.At least some of these will have plans that will pay more than Medicare.Further with the cuts to Medicare Advantage more senior will be looking for primary care docs in the traditional Medicare program.

So, if Congress would re-grow a spine and invoke the cuts to Medicare it may well be the case that Medicare patients will struggle to find primary care and lines will form. If they don't, the allegedly effect of making Medicare more solvent will not occur.In any event lines will form. Shortages are one foreseeable consequence of price controls and University of Chicago Law School professor, Richard Epstein, has characterized the health care bill as a giant mishmash ( my paraphrasing ) of price controls.

If the cuts do occur it is projected (by the Medicare Trustees) that Medicare reimbursements will fall below those of Medicaid by 2019. How many internists will participate in Medicare with that level of reimbursement? How many internists accept Medicaid patients now? The leadership at AMA and ACP should have second thoughts for sponsoring a plan that would so seriously reduce access to care by the Medicare population.See here for John Goodman's comments about Medicare projections.

President Obama in a recent radio address and Paul Krugman in a recent column ( see here) and a spokesman for the American College of Physicians in a recent blog all heralded the projected increased soundness of Medicare.We were not told much if anything specifically about the report of the Medicare's chief actuary regarding the implausibility of the cuts to Medicare actually happening and thereby the savings evaporating.The wink-wink-nudge-nudge dance and the attempts try to find the right shade of pig lipstick continue.

Available for viewing and downloading from the NIH:

It Takes Tau to Tangle : Plaques, Tangles and Neurodegenerative Disease
by Karen Duff

23 June 2010

link

Several incidents this week reinforce the idea that accidents and tragedies don't just happen to toddlers and preschoolers and we can't make our kids safe by simply childproofing the house and putting the kids in a car seat.

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I suspect we will be hearing more and more about paying for "quality" since the recess appointment of Dr. Donald Berwick to be the head of CMS. His views on central planning of medical care are the subject of much discussion. The following is a lightly re-edited version of a commentary I wrote several years ago on "measuring" quality and value.

Dr. RobertWachter, Professor of Medicine at UCSF , tells us that "value=quality/cost" and we have a moral obligation to "solve" equations for various clinical services. I reference his comments in the ACP observer as he replies to a letter to the editor commenting on the interview he gave discussing the overseas out-sourcing of medical services.(ACP Observer,July/August/2006 pg4) Dr. Wachter says in part:

Health care will be judged by its value: i.e.quality/cost...It is immoral not to seek ways to provide high quality care at more affordable costs"

It seems to me that this "equation" presupposes an intrinsic theory of value in which value is considered to be something that can be objectively measured and is an intrinsic property of a good or service much like the specific gravity of a liquid or the density of a compound.

Since the Austrian School of economics popularized the subjective theory of value most mainstream economists reject the intrinsic value theory.

The same service may be more or less valued by a given person as her circumstances and desires change. No two individuals need value the same thing to the same degree though they may.Value to most economists is not an intrinsic measurable number but rather value is subjective and is in "the eye of the beholder". Thomas Sowell ( pg 51,Knowledge and Decisions,Basic Books, 1966) puts it this way:

"Value being ultimately subjective, it varies not only from person to person but from time to time with the same person, and varies according to how much of the given good he already has."

Advocates of the subjective value theory would argue that to define value with the above equation is to erroneously claim that value (or in this case "quality" which along with "cost" determines "value") is an objectively measured entity. Are the medical quality experts( as best I can tell this is a self proclaimed designation) who are able to or claim to be able devise means to measure quality merely substituting their preferences-dressed up as objective measurements-for the value judgments of others?

Wachter continues saying:

"Patients, payers and policy makers now expect us to tap into actual clinical data to assess a physician's quality of care.I suspect once we truly figure out how to do that..."

I take this to mean that exactly how to measure the quality of care has not yet been "figured out". Somehow, I think that compliance with guidelines and adherence to protocols will play a big role in this-it has so far- and I doubt if patients will be asked what it is they value. I agree that payers and policy makers want quality data to use as a cost containment tool, the gatekeeper concept now largely abandoned, but patients want a physician who will spend time with them,care about their problem and be more interested in doing what the doc and patients agree on as the right course for that person and not adherence to some guideline that the patient has probably never heard of and does not take the particulars of his situation into account.

I believe "quality" which is now the main rhetorical tool of the cost-containment movement has become a classic bait-and-switch term. Everyone, docs and patients alike,would naturally say we want to give/receive good care or "quality" care. But the quality guidelines so often turn out to be what some self-appointed quality guru, committee or task force says is an quality indicator and are often no more than simplistic, easy-to-count, check-off list items, some of which may have counterproductive or harmful effects.

I have no doubt there are many well-intentioned physicians working hard to improve medical care- if you will improve quality- but much of the quality movement and arguably its major motive force is to contain costs.


The movement to contain costs derives from so much of medical care being paid for with other people's money. We are not instructed about the moral imperative of providing high quality legal services, or haircuts or home repairs at more affordable costs because the people who use these services pay for them themselves.

Some may rejoice in the passage of Obama care as a golden opportunity to improve the quality of medical care while the more cynical think of the legislation with unparalleled power placed in the hands of various governmental agencies as the mother of all opportunities for what economists call rent seeking in which various interested parties ( now known a stake holders) seek special privilege.

While Dr. Don Berwick, Obama's recess appointee to head CMS, speaks of Britain's NHS in glowing if not poetic and outlandishly laudatory terms,Britain's Prime Minister who has actually studied a report about NHS failings presents a different portrait . See here for the white paper on the NHS.

Here is one except from that report:

... the NHS has achieved relatively poor outcomes in some areas. For example, rates of mortality amenable to healthcare, rates of mortality from some respiratory diseases and some cancers, and some measures of stroke have been amongst the worst in the developed world.


"Worst in the developed world" Berwick began his remarks celebrating the 60th anniversary of the NHS with this:

"I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country."

His expressed infatuation for the single payer,centrally planned health system of Great Britain is obvious.What is less obvious is how he (or anyone) could reconcile those views with his self admitted radical views of patients primacy.

Dr.RW takes on this daunting task in his recent blog posting (see here) and using in part material from a 2007 IHI publication (see here) he provides insight into Berwick's thinking about reconciling conflicting aims.

Everyone ,physicians,patients,anyone who might become a patient should read about the "goals" that Berwick's organization advocates for a health care system.Then consider on what planet or in what alternative reality those aims could be actually accomplished by governmental central planning.It makes Will Roger's quote " Boil the oceans" ( to get rid of German U-boats ) seem practical.

Dr RW says this about their formulation:

'Grandiose, nebulous and intrusive are adjectives that come to mind." I think he is too kind.

Go here to see the labyrinth of provisions, regulations, deadlines,subsides and cross subsidies from the hundreds of thousands of words from PPACA that will transform American medicine. Read through it and try and see who gains and who loses. I suggest the countless details defy a comprehensive analysis. It will be years before the the unintended consequences can begin to be sorted out.Did the advocates for Obama care from AMA and ACP and other medical organizations who claim a victory for "social justice" have a clue about what the bill really contained? I suggest they understood even less that some of legislators who admitted they had not even read the bill.Further, many of the operational particulars have not yet been defined.That is a work in progress by the numerous governmental agencies who are now beset upon by the various lobbying interests(known euphemistically as stakeholders ).

Perusing the chart makes me wonder why there is so so much detail,why so many elements and provisions are there ,why laws are crafted to be so long and so opaque and why are so many agencies and governmental entities are necessary to carry out any stated goal.

Angelo Codevilla's essay on the ruling class provides one answer:

"[O]ur ruling class’s standard approach to any and all matters, its solution to any and all problems, is to increase the power of the government – meaning of those who run it, meaning themselves, to profit those who pay with political support for privileged jobs, contracts, etc."

Simply put, it has to be long and detailed and governmental agencies have to empowered to make many discriminatory decisions so that the folks in power can ensure who is that profits and who it is that picks up the tab. A statute's mind-boggling length and opacity serves to obscure what is happening.

Senator Baucus apparently really knew what the health care bill was all about even though he likely could not detail exactly what all the provisions were when he said in his exuberant candor after the bill was passed:

"Too often, much of late, the last couple three years, the mal-distribution of income in America is gone up way too much, the wealthy are getting way, way too wealthy and the middle income class is left behind," he said. "Wages have not kept up with increased income of the highest income in America. This legislation will have the effect of addressing that mal-distribution of income in America."

Right, it was all about redistribution of wealth which it just so happens is Dr. Don Berwick's desire as well as regards health care in America expressed in this quote from Berwick:

"...and that any health care funding plan that is just, equitable, civilized, and humane must – must – redistribute wealth from the richer among us to the poorer and less fortunate.


H/T to the Blog We Stand Firm

An essay that is receiving much attention as it should is available here .The author is Angelo M. Codevilla, a professor emeritus from Boston University. His characterizations of the" Ruling Class" and the "Country Class" is in the least thought provoking. I quote from the section labeled " Dependence Economics" with my bolding added:

"By taxing and parceling out more than a third of what Americans produce, through regulations that reach deep into American life, our ruling class is making itself the arbiter of wealth and poverty. While the economic value of anything depends on sellers and buyers agreeing on that value as civil equals in the absence of force, modern government is about nothing if not tampering with civil equality. By endowing some in society with power to force others to sell cheaper than they would, and forcing others yet to buy at higher prices -- even to buy in the first place -- modern government makes valuable some things that are not, and devalues others that are. Thus if you are not among the favored guests at the table where officials make detailed lists of who is to receive what at whose expense, you are on the menu.
Eventually, pretending forcibly that valueless things have value dilutes the currency's value for all. Laws and regulations nowadays are longer than ever because length is needed to specify how people will be treated unequally. For example, the health care bill of 2010 takes more than 2,700 pages to make sure not just that some states will be treated differently from others because their senators offered key political support, but more importantly to codify bargains between the government and various parts of the health care industry, state governments, and large employers about who would receive what benefits (e.g., public employee unions and auto workers) and who would pass what indirect taxes onto the general public."

Treating people differently seems to be the essence of "social justice" for which supporters of Obamacare claim a victory.

While the leaders of AMA and ACP ( and other medical organizations as well) announced proudly they had a seat at the adults' table with the Obama administration in planning health care reform , for most of the medical profession, I think the designation of "on the menu" is more appropriate as it is for many citizens who were "happy with their doctors and health care plans". Maybe sometimes folks just thought they had a seat at the table or , even worse, maybe they got what they wanted.

From UCLA: Obituary: Paul Satz

Obituary: Paul Satz, 77, psychiatry professor, founder of UCLA neuropsychology program
By Mark Wheeler
June 25, 2010
UCLA

Paul Satz, a UCLA professor emeritus of psychiatry and biobehavioral sciences and the founder of the neuropsychology program at UCLA's Semel Institute for Neuroscience and Human Behavior and Resnick Neuropsychiatric Hospital, died June 20, in Lihue, Hawaii, after a long battle with cancer. He was 77.

One of the founders of the discipline of neuropsychology, Satz was widely recognized for his groundbreaking research on brain–behavior relations. During his tenure at UCLA (1981–2002), he established the UCLA Neuropsychology Program and helped turn it into one of the world's largest and most successful training programs for clinical neuropsychologists.

The author of more than 300 publications, Satz's scientific contributions to the understanding of normal and abnormal brain development had — and continue to have — a major impact on diverse disciplines. His seminal contributions include landmark works that laid the foundation for the understanding of healthy and pathological asymmetries of brain structure and function; innovative theories of developmental disorders, including autism, dyslexia, attention deficit disorders and schizophrenia; and trailblazing research on the cognitive and affective consequences of head injuries and HIV/AIDS.

In recent years, Satz made additional high-impact contributions to the understanding of how individual differences in brain structure and function may protect people from the declines usually associated with aging, dementia and head injuries. He was widely acknowledged as a scientist uniquely capable of deep and creative insights into both the clinical and basic scientific foundations of the topics he investigated.

"It is impossible to summarize the accomplishments of a man who forged an entirely new discipline and transformed every area of inquiry that he encountered," said Robert Bilder, a colleague of Satz and a professor-in-residence of psychiatry and biobehavioral sciences at UCLA. "Neuropsychology has lost one of it's most innovative and critical thinkers. I believe, however, that Paul was proudest of the lasting impact he had on such a large number of students. Fortunately, we can still hear echoes of Paul's voice in their continued teaching and research, passion for discovery of truth, and love for their own trainees, colleagues and patients."

Always deeply dedicated to teaching and mentorship, Satz directed, sponsored or co-directed some 31 training awards at UCLA and served in mentorship roles for more than 200 trainees. Even after his retirement, he personally sponsored fellows at UCLA and continued to supervise students and develop collaborative relationships, including the UCLA–Help Group Fellowship in Neuropsychology, which is named in his honor.

His legacy is evident in the large number of his students who have gone on to make major contributions to the field. Many of Satz's trainees also continue to serve actively in the medical psychology and neuropsychology programs at the Semel Institute and the David Geffen School of Medicine at UCLA.

Satz studied music at Boston University in the early 1950s and received his bachelor's degree in 1957 and a master's in clinical psychology in 1959 from the University of Miami. After earning his doctorate from the University of Kentucky College of Medicine in 1963, he served as a postdoctoral fellow and, in 1964, established the sub-specialty of clinical neuropsychology in the department of clinical and health psychology at the University of Florida.

Satz continued to direct the University of Florida's neuropsychology program through 1979. He then served as a visiting professor at the University of Victoria in British Columbia before coming to UCLA in 1981.

Satz was president of the International Neuropsychology Society from 1973 to 1974, and in 1981, he became a founding member of the American Board of Clinical Neuropsychology. He was one of the board's inaugural diplomates in clinical neuropsychology, complementing his diplomate status in clinical psychology.

The recipient of numerous accolades, Satz was honored with the Albert J. Harris Award from the International Reading Association (1977), the Meritorious Service Award from the American Board of Professional Psychology (1988) and the American Psychological Association Award for Distinguished Professional Contributions to Knowledge (1997). He held leadership roles in more than 26 organizations spanning many disciplines in psychology, neuropsychology and learning disorders, including the President's Commission on Mental Health.

Satz's many scientific, clinical and training contributions were matched by an irrepressible sense of humor, a love of life, and a joy in the company of others. In a recent tribute, Satz was described as a champion of "serious fun," acknowledging his rare combination of scientific rigor and joie de vivre.

An accomplished pianist, Satz fondly recalled a newspaper that once published his picture, mistakenly identifying him as Frank Sinatra, to whom he bore an uncanny resemblance.

Satz is survived by his son Mark, with whom he lived in Hawaii; daughter Julie Satz, of Kona, Hawaii; son Scott, of Hibbing, Minn.; brother George; sisters Ada Casperino and Ruth (Henry) Best; and grandchildren Ryan and Jade Satz, Alexia Satz, and Drake and Dustin Satz.

A memorial fund has been established in honor of Dr. Satz to support education in neuropsychology. To contribute by check, please make checks payable to The UCLA Foundation and write "Paul Satz Memorial Fund" in the memo section. Checks should be mailed to Alan Han, Director of Development for Neuroscience, UCLA Medical Sciences Development, at 10945 Le Conte Ave., Suite 3132, Los Angeles, CA 90095-1784.

A tribute to Satz will be held on Friday, Aug. 6, at UCLA. For further details, please contact Robert Bilder at 310-825-9474 or rbilder@mednet.ucla.edu.

For a while it seemed only a few medical blogs were expressing concern about Dr. Donald Berwick's suitability to be the head of CMS. See here for one of Dr. RW Donnell's posting on that topic and here for one by Dr. Doug Perednia of the new blog Road to Hellth. Now others are joining it.

The prolific and widely read Dr. David Gorski has submitted a detailed discussion about Dr. Berwick expressing in part concern about Berwick's apparent support for unscientific alternative medicine .See here for the commentary. Additionally, Gorski makes the case, based on quotes from Berwick, that in some regards his views appear to be naive and out of touch with real world physician-patient encounters and relationships. Quoting Gorski:

Berwick strikes me as a very well-meaning person with some good ideas about how to make our health care system less rigid and more responsive to patients’ needs, both medical and nonmedical. Unfortunately, he also appears to be naive to the point of my wondering whether he has any clue what it’s like to practice medicine in the real world or even in the idealized world of academics.

I agree.A number of Berwick's comments appear very naive,unrealistic, and something more expected from someone not actually caring for patients than a physician with any recent background in patient care.As best I can tell he had not been practices medicine for a while.

There is a major disconnect between Berwick's expressed adulation of the NHS and his statement that rationing must be done with his views of patient centerness which he self describes as radical.

Dr. Kimball Atwood,a tireless opponent of non-scientific alternative medicine expressed similar views to Gorski in his essay on the blog Health Care Renewal. See here. Quoting Atwood:

"In February of 2009, Dr. Berwick gave a 'keynote' address at the IOM and Bravewell Collaborative-sponsored Summit on Integrative Medicine and the Health of the Public. He shared the podium with Mehmet Oz, Dean Ornish, Senator Tom Harkin, and other advocates of pseudoscientific health claims. I wrote about the conference at the time, mainly to call attention to its misleading use of the term "integrative medicine": literature emanating from the Summit characterized it as "preventive" and "patient-centered," whereas the only characteristic that distinguishes it from modern medicine is an inclusion of various forms of pseudomedicine. I noticed that Dr. Berwick was on the speaker roster, which I found disappointing: I imagined that he had either gone over to the Dark Side or, perhaps, was sufficiently naive about the topic to have been duped; or, more likely, that he had cynically accepted the offer to further his ambitions."