Routine Medical Screenings May Not Deliver as Promised, One Doctor Says
OPINION by NORTIN M. HADLER, M.D.

Sept. 26, 2008-

Most of us believe that when a doctor orders screening tests, that’s a serious step toward keeping illness at bay. The screening test can find factors that place us at risk for diseases we might develop in the future or find hidden diseases. In either case, we will be treated.

Screening tests are considered a triumph of modern public health medicine. I only wish it was that straightforward.

It turns out that many of the commonly recommended screening tests fall far short on this promise. They fall so far short that no one should have them without first discussing them with their doctor.

If you are not convinced you will be advantaged by having the test, why bother?

Let me illustrate this with three of the commonly recommended tests. I will explain why I have never let anyone check my cholesterol or my PSA, and why I have submitted to colonoscopy once, and never again.

Blood Cholesterol
Blood cholesterol level is a risk factor for heart and other blood vessel diseases — but not much of a risk factor. If you have the worst LDL and HDL cholesterol we find occasionally in the population, you have a year or two of life expectancy at risk.

For nearly all who are told they have “high” cholesterol, the amount of time on earth that they are risking is measured in months. I’m not sure we can even measure such a small risk, or that I care.

But if you do, the next question is crucial. Can we do anything to my cholesterol that reduces the risk? That’s not the same question as can you lower the cholesterol? We can do that very well, and we do lower the cholesterol of millions of Americans thereby reducing the risk factor. But does that reduce the risk?

There are scientific studies asking this question. The treatment does not reduce the risk of dying from heart disease. The most optimistic analysis of these scientific studies leads to the following conclusion: 250 people who have not had a heart attack would have to swallow a statin drug every day for five years to spare a heart attack.

Do you believe we can even measure such a tiny effect? Is it worth your while to take these pills for years? Would it be worth it if you had to pay out-of-pocket?

PSA Testing
PSA stands for Prostate Specific Antigen. It’s a normal protein in the prostate. A small amount gets into the bloodstream normally.

Greater amounts get into the bloodstream if the prostate is inflamed by infection. Prostate cancer is another cause of more PSA getting into the bloodstream.

Prostate cancer is a normal part of aging; by age 70, essentially all men have prostate cancer. Furthermore, nearly all men will die with their prostate cancer and not from it.

The challenge for screening is not to find prostate cancer, but to find the prostate cancer that will kill a man before his time. That’s a tall order, and one for which PSA screening is a double-edged sword. After all, if you want to be sure you will not die from prostate cancer before your time, you will have to submit to a procedure, usually a major surgical procedure that offers a 15 percent likelihood of incontinence and more of impotence.

In a clinical trial in Scandinavia, a great number of aging men were divided into two groups. Those who were offered and opted for surgery for their elevated PSA gained very little for the experience compared to those who were not offered surgery. They gained too little for me to opt for the surgery if my PSA was elevated. Therefore, I won’t let anyone check my PSA. You need to have this discussion with your doctor before you opt to have a screening PSA.

Colonoscopy
A few rare families and rare diseases aside, colon cancer is another disease of the sunset years.

Like prostate cancer, it is slow to grow and slow to spread but it is far less common than prostate cancer. The treatment, surgical removal, has far less likelihood of complications than prostate surgery.

The screening is not a blood test; it’s hunting for the cancer directly. More and more, this is done by inserting a tube into the colon and looking inch-by-inch. It’s not a perfect test, requiring patience as much as dexterity.

And it has complications, many of which relate to the removal of polyps which are grape-like growths on a stalk that have very little potential for harm (if they develop into cancer at all, it takes decades).

So we are back to our critical question. The issue is not whether one can find a cancer and remove it, but whether one can find and remove the cancer that is likely to cost me time on this earth.

I don’t care if I develop colon cancer in my 80s; something else is likely to kill me long before it can. I don’t care if I develop colon cancer in my 70s either, for the same reason. Furthermore, screening me in my 40s is largely an exercise in futility; colon cancer is so very, very rare in 40-year-olds that the chances of a complication of colonoscopy far outweighs the chances of finding the rare cancer. It’s in the 50s and 60s that finding and removing the rare colon cancer is likely to be meaningful to that person and worth the risks to all those who don’t have colon cancer.

Hence, I had my one colonoscopy. In fact, I settled for a partial look (flexible sigmoidoscopy) because that was good enough risk assessment for me and the procedure is gentler and safer.

I am not alone in realizing the limitations of these tests and others such as mammography or even the annual physical examination. Many a researcher has been recruited to the task of improving screening tests. However, until we have much better screening tests, no person should be screened unaware of the limitations of the test.

Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of Worried Sick: A Prescription for Health in an Overtreated America and The Last Well Person.

Popularity: 15% [?]

There have been a series of articles that discuss deathrow inmates and their request for clemency due to the fact that they are obese.  The inmates claim an even greater risk of experiencing excruciating pain and suffering than other inmates due to the fact that they are overweight.

Similar lawsuits have been filed in several states which have led to the halting of executions in Texas, Delaware and New Jersey.

The men in these articles have tortured, raped and killed innocent people.  What gives them the right to life? They took a life, if not, several.  What about the rights of the victim’s family to see justice for the loss of a loved one?

What kind of message would we be giving criminals?  By halting executions, are we telling “would be” criminals to fatten up to commit heinous crimes so that they may not face the death penalty?  I don’t think the victims of these men had a choice in the way their lives ended so abruptly!

Here are the articles, if you would like to read them…   

http://www.cnn.com/2008/CRIME/08/25/death.penalty.fat.ap/index.html

http://abcnews.go.com/TheLaw/story?id=3684431

Popularity: 38% [?]

The NHS should not always attempt to save someone’s life if the cost is too much, the medical regulator has ruled

By Robert Winnett, Deputy Political Editor

The National Institute for Health and Clinical Guidelines (Nice) has ruled for the first time that saving a life cannot be justified at any cost, in a review of its ethical guidelines.

The ruling – made by the board of the controversial organisation – contradicts advice it received from its own ‘Citizens Council’ which offers advice from a representative sample of the general public.

Nice is facing growing criticism over the number of drugs it is now rejecting which are available throughout Europe and in America. Last week, it refused to sanction four kidney cancer drugs which can double life expectancy.

It has now rejected the so-called “rule of rescue” which stipulates that people facing death should be treated regardless of the costs. The rule is based on the natural impulse to aid individuals in trouble.

In a report on “social values judgement” the regulator says: “There is a powerful human impulse, known as the ‘rule of rescue’, to attempt to help an identifiable person whose life is in danger, no matter how much it costs. When there are limited resources for healthcare, applying the ‘rule of rescue’ may mean that other people will not be able to have the care or treatment they need.

“Nice recognises that when it is making its decisions it should consider the needs of present and future patients of the NHS who are anonymous and who do not necessarily have people to argue their case on their behalf…The Institute has not therefore adopted an additional ‘rule of rescue’.”

The ruling contradicts the advice of Nice’s Citizens Council, which said that a rule of rescue was an essential mark of a humane society. The report said that where individuals are in “desperate and exceptional circumstances” they should sometimes receive greater help than can be justified by a “purely utilitarian approach”.

Doctors have also criticised the ruling. Tony Calland, chairman of the ethics committee of the British Medical Association, said: “We would be opposed to ignoring a rule of rescue when it introduces a degree of flexibility around extreme cases. So what if you waste a few pounds if you are doing your best for humanity?”

Nice defended its ruling last night saying that the Citizens Council provided useful input to its decisions but that the organisation’s role was to determine how best to allocate the health service’s limited resources.

Nice is facing increasing accusations that it is giving undue weight to financial considerations – rather than medical benefits – when making decisions on whether to allow drugs or other treatments on the NHS. Doctors and patients have alleged that they are treated with contempt by the organisation and that life-saving drugs are being unfairly denied.

The Daily Telegraph disclosed yesterday that Nice is preparing to offer patients advice on the medical benefits of drugs that are not available on the NHS. The disclosure is likely to anger patients who face paying tens of thousands of pounds for expensive drugs which may prolong their lives.

Popularity: 15% [?]

Research Shows Return Trips to Battle Increase Troops’ Alcholism, Suicide Risks

By MARILYN ELIAS
USA TODAY
Aug. 15, 2008—

Multiple combat deployments to Iraq are increasing serious mental health problems among soldiers, triggering drug and alcohol abuse and contributing to record suicide levels, suggest reports out Thursday at the American Psychological Association meeting in Boston.

In a typical unit headed to Iraq, 60 percent are on their second, third or fourth deployment, lasting about a year each, says U.S. Army Col. Carl Castro, who directs a medical research program at Fort Detrick, Md.

More time in Iraq means heavier exposure to violence, which leads more soldiers to develop symptoms of post-traumatic stress disorder (PTSD) and depression, Castro told the psychology meeting. By their third tour to Iraq, more than a quarter of soldiers show signs of mental problems, such as PTSD, and it’s about 1 out of 3 for those exposed to heavy combat, according to a U.S. Army Surgeon General report in March on more than 2,000 soldiers.

In another report at the meeting, deployment correlated with more heavy drinking and illegal drug use, according to anonymous questionnaires given to about 34,000 active duty troops, Reservists and National Guard members. Deployed Reserve troops had the highest traumatic stress symptoms and rates of “seriously considering suicide,” according to the Defense Department-funded study by RTI International, Research Triangle Park, N.C.

National Guard and Reservists sent to Iraq and Afghanistan are disproportionately represented in returning veteran suicides, according to a Departmentof Veterans Affairs analysis. There were 115 Army suicides and 935 reported attempts in 2007, a record high, show Army reports.

“There are concerns about the reserves,” says Lynn Pahland, a health promotion policy director in the Defense Department. But the military is increasing efforts to prevent, identify and treat troubled troops,she adds.

At a crisis hotline for veterans, about 75 percent of the 400 calls a weekcome from Reserve and National Guard troops or their families, says Shad Meshad, president of the National Veterans Foundation (1-888-777-4443), which runs the line. “Many have been sent back three or four times,” he says.

On Wednesday, a Texas Reservist going to Iraq for the fourth time called “in a hysterical state” because his house is being foreclosed on, and his wife is taking the kids and leaving him. Says Meshad: “We’re just trying to help him out with the financial stuff and keep him from hurting himself.”

Copyright © 2008 ABC News Internet Ventures

Popularity: 16% [?]

Terminally Ill Denied Drugs for Life, But Can Opt for Suicide

By SUSAN DONALDSON JAMES
Aug. 6, 2008 —

The news from Barbara Wagner’s doctor was bad, but the rejection letter from her insurance company was crushing.

The 64-year-old Oregon woman, whose lung cancer had been in remission, learned the disease had returned and would likely kill her. Her last hope was a $4,000-a-month drug that her doctor prescribed for her, but the insurance company refused to pay.

What the Oregon Health Plan did agree to cover, however, were drugs for a physician-assisted death. Those drugs would cost about $50.

“It was horrible,” Wagner told ABCNews.com. “I got a letter in the mail that basically said if you want to take the pills, we will help you get that from the doctor and we will stand there and watch you die. But we won’t give you the medication to live.”

Critics of Oregon’s decade-old Death With Dignity Law — the only one of its kind in the nation — have been up in arms over the indignity of her unsigned rejection letter. Even those who support Oregon’s liberal law were upset.

The incident has spilled over the state border into Washington, where advocacy groups are pushing for enactment of Initiative 1000 in November, legalizing a similar assisted-death law.

Opponents say the law presents all involved with an “unacceptable conflict” and the impression that insurance companies see dying as a cost-saving measure. They say it steers those with limited finances toward assisted death.

“News of payment denial is tough enough for a terminally ill person to bear,” said Steve Hopcraft, a spokesman for Compassion and Choices, a group that supports coverage of physician-assisted death.

Letter’s Impact ‘Devastating’
“Imagine if the recipient had pinned his hope for survival on an unproven treatment, or if this were the first time he understood the disease had entered the terminal phase. The impact of such a letter would be devastating,” he told ABCNews.com.

Wagner, who had worked as a home health care worker, a waitress and a school bus driver, is divorced and lives in a low-income apartment. She said she could not afford to pay for the medication herself.

“I’m not too good today,” said Wagner, a Springfield great-grandmother. “But I’m opposed to the [assisted suicide] law. I haven’t considered it, even at my lowest point.”

A lifelong smoker, she was diagnosed with lung cancer in 2005 and quit. The state-run Oregon Health Plan generously paid for thousands of dollars worth of chemotherapy, radiation, a special bed and a wheelchair, according to Wagner.

The cancer went into remission, but in May, Wagner found it had returned. Her oncologist prescribed the drug Tarceva to slow its growth, giving her another four to six months to live.

But under the insurance plan, she can the only receive “palliative” or comfort care, because the drug does not meet the “five-year, 5 percent rule” — that is, a 5 percent survival rate after five years.

A 2005 New England Journal of Medicine study found the drug erlotinib, marketed as Tarceva, does marginally improve survival for patients with advanced non-small cell lung cancer who had completed standard chemotherapy.

The median survival among patients who took erlotinib was 6.7 months compared to 4.7 months for those on placebo. At one year, 31 percent of the patients taking erlotinib were still alive compared to 22 percent of those taking the placebo.

“It’s been tough,” said her daughter, Susie May, who burst into tears while talking to ABCNews.com. “I was the first person my mom called when she got the letter,” said May, 42. “While I was telling her, ‘Mom, it will be ok,’ I was crying, but trying to stay brave for her.”

“I’ve talked to so many people who have gone through the same problems with the Oregon Health Plan,” she said.

Indeed, Randy Stroup, a 53-year-old Dexter resident with terminal prostate cancer, learned recently that his doctor’s request for the drug mitoxantrone had been rejected. The treatment, while not a cure, could ease Stroup’s pain and extend his life by six months.

Playing With ‘My Life’
“What is six months of life worth?” he asked in a report in the Eugene Register-Guard. “To me it’s worth a lot. This is my life they’re playing with.”

The Oregon Health Plan was established in 1994 and the physician-assisted death law was enacted in 1997. The state was recently hailed by a University of Wisconsin study as having one of the nation’s top pain-management policies.

The health plan, for those whose incomes fall under the poverty level, prioritizes coverage — from prevention first, to chronic disease management, treatment of mental health, heart and cancer treatment.

“It’s challenging because health care is very expensive, but that’s not the real essence of our priority list,” said Dr. Jeanene Smith, administrator for the Office of for Oregon’s Health Policy and Research staff.

“We need evidence to say it is a good use of taxpayer’s dollars,” she said. “It may be expensive, but if it does wonders, we cover it.”

The state also regularly evaluates and updates approvals for cancer treatments. “We look as exhaustively as we can with good peer review evidence,” she said.

The health plan takes “no position” on the physician-assisted suicide law, according to spokesman Jim Sellers.

The terminally ill who qualify can receive pain medication, comfort and hospice care, “no matter what the cost,” he said.

But Sellers acknowledged the letter to Wagner was a public relations blunder and something the state is “working on.”

“Now we have to review to ensure sensitivity and clarity,” Sellers told ABCNews.com “Not only is the patient receiving had news, but insensitivity on top of that. This is something that requires the human touch.”

Sellers said that from now on insurance officials will likely “pick up the phone and have a conversation,” he said.

But a 1998 study from Georgetown University’s Center for Clinical Bioethics found a strong link between cost-cutting pressures on physicians and their willingness to prescribe lethal drugs to patients — were it legal to do so.

The study warns that there must be “a sobering degree of caution in legalizing [assisted death] in a medical care environment that is characterized by increasing pressure on physicians to control the cost of care.”

Cancer drugs can cost anywhere from $3,000 to $6,000 a month. The cost of lethal medication, on the other hand, is about $35 to $50.

Advocates for the proposed Washington law say that while offering death benefits but not health care can be perceived as a cost-cutting, “respectable studies” say otherwise.

“The reason is that hospice care, where most patients are at the end of life is relatively inexpensive,” Anne Martens, spokesman for Washington’s Death With Dignity Initiative, told ABCNews.com.

But even those who support liberal death laws say Wagner’s predicament is reflective of insurance attitudes nationwide.

Case Is Not Unique
“Her case is hardly unique,” said Michigan lawyer Geoffrey Fieger, who defended Dr. Jack Kevorkian’s crusade to legalize physician-assisted deaths. “In the rest of the country insurance companies are making these decisions and are not paying for suicide,” Fieger told ABCNews.com. “Involuntary choices are foisted on people all the time by virtue of denials.”

“I am surprised there hasn’t been a revolt in this country,” he said. “It happens every day and people are helpless.”

Indeed, one executive suffering from a rare and potentially fatal form of liver cancer is fighting his insurance company for coverage. Oncologists from a major teaching hospital in New York City have prescribed Sutent — a medication that costs about $4,000 a month and could extend his life expectancy.

“Most of my objections are that some second rate guy on the staff of the insurance company is second-guessing one of the foremost authorities and trumping his judgment,” said the 57-year-old executive, who didn’t want his name used to protect his privacy.

“I am fortunate to have the financial resources and the ability to fight these people who would rather these you die,” he told ABCNews.com.

Dr. Jonathan Groner, clinical professor of surgery at OSU College of Medicine and Public Health in Columbus, Ohio, said some patients may want to prolong their lives for a life-cycle event, like a birth or wedding.

“A course of chemo would not cure, but would subdue the cancer long enough to be meaningful,” he told ABCNEWS.com. “There are many people with slow-growing but nonetheless metastatic cancer for whom death, while inevitable, is many years away.”

“The problem with the Oregon plan is it sounds like administrators, not physicians, are making treatment decisions,” he said. “And if a patient can get assisted death paid for but not cancer treatment, the choice is obvious.”

Derek Humphry, founder of the Hemlock Society and author of “Final Exit,” who helped write the Oregon Death With Dignity Law, said only about 30 people a year choose an assisted death, which must be approved by two doctors.

“It’s purely optional and the patient and doctor can walk away from it,” the 78-year-old told ABCNEWS.com. “It’s not the mad rush our enemies predicted and for our residents it has worked out well.”

His own wife, Jean, was diagnosed with fast-growing breast cancer in 1975 and asked him to help find drugs to help her die. At 42, she chose to take them and ended her life.

Humphry says the Oregon Health Plan’s approach to coverage is sound.

“People cling to life and look for every sort of crazy cure to keep alive and usually they are better off not to have done it,” he said.

Meanwhile Wagner has faith in her medicine, not assisted death. Now, at the request of her doctor, the pharmaceutical company Genentech is giving her Tarceva free of charge for one year.

“The doctor did say it would put a lid on the cancer and I am hopeful,” she said.

Wagner’s daughter Susie May says her mother is a fighter. “I think we all knew that this is her last hope,” she said.

Even Wagner’s ex-husband, Dennis Wagner of Springfield, has weighed in on the ethical dilemma.

“My reaction is pretty typical,” he told ABCNews.com. “I am sick and tired of the dollar being the bottom line of everything. We need to put human life above the dollar.”
Rana Senol of ABC News Research contributed to this report.

Popularity: 18% [?]

Will Giving Doctors More Money to Coordinate Care Pay Off?

By JULIE APPLEBY
July 14, 2008

States, the federal government and private insurers are experimenting with an idea to cut costs and make patients happier: Paying primary-care doctors extra money to oversee and coordinate patients’ care.

The pay boost rewards doctors who reshape their practices to recreate an era when a trusted family physician helped patients through hospitalizations, coordinated specialist care and provided routine screenings. Such efforts may save money by reducing hospitalizations, ER visits and disease.

Dubbed “medical homes,” the concept is a modern twist on an idea first promoted in the 1960s. Under most pilot projects being tested, primary-care doctors who have established medical homes will receive additional fees ranging from just a few dollars a month per patient to more than $35,000 a year per doctor from states, Medicare or other insurers.

Medicare this year will choose eight states to test whether paying primary-care doctors more per month to treat patients with chronic illnesses in medical home settings results in better care and lower costs than traditional practices.

The concept aims to change rushed doctor’s appointments and fragmented specialist care by creating patient care “teams,” which could include nurse practitioners, nutritionists or other medical staff. Medical homes also offer longer office hours, electronic medical records and same-day appointments.

The idea is that patients would turn to a trusted adviser, either the doctor or another team member, for preventive and routine care and rely on that person to help coordinate needed screenings, specialist visits and other care, says Terry McGeeney, head of TransforMED, a subsidiary of the American Academy of Family Physicians that helps doctors create such practices.

While health maintenance organizations and managed care companies aimed for such coordination, many didn’t pay doctors adequately for it, instead rewarding them financially for restricting care, says McGeeney. Under medical homes, he says, doctors won’t prevent patients from seeing specialists or ordering tests.

It’s not clear how well such plans will work. North Carolina saved $231 million in 2002-03 by setting up medical homes in its Medicaid program.

Joseph Antos, an economist at the conservative American Enterprise Institute, says no one argues with the goal, but: “If all we’re doing is rearranging the deck chairs on the medical Titanic, and spending more money, that’s clearly not something we want to do.”

The idea appeals to doctors such as Joseph Mambu, who set up his Pennsylvania practice as a medical home. They recreate “the old-fashioned doctor who has the time to get to know you,” he says. “This is our last, best hope to save primary care.”

Copyright © 2008 ABC News Internet Ventures

Popularity: 18% [?]

Study leads to debates on mandates

By Kay Lazar
Globe Staff / July 8, 2008

A long-awaited report concludes that 12 cents of every $1 paid for health insurance in Massachusetts goes toward 26 state-mandated benefits, from maternity and mental healthcare to infertility and diabetes services.

Graphic Estimated spending on mandated benefits
Statewide, the price tag is $1.3 billion a year, says the report released yesterday by the Division of Health Care Finance and Policy. It was commissioned in 2006 as part of the state’s near-universal health insurance law.

Insurers and small business groups said the findings show that mandates are helping to drive up costs, making coverage unaffordable as many businesses and workers struggle. The business groups said the mandates translate to roughly $1,300 annually per employee in a family healthcare plan.

But some mandates are also required under federal law, the report said, meaning that employers would have to offer those benefits even if the state mandates were not in place. Excluding such benefits, the report concludes that the cost of the state’s mandates would be no higher than $687 million a year, or roughly 6 cents of every $1 paid for health insurance.

State lawmakers are now considering proposals that could require employers to add more benefits, including expanded mental healthcare coverage.

“It’s getting harder and harder for both employees and employers to pay healthcare costs,” said Dr. Marylou Buyse, president of the Massachusetts Association of Health Plans, which represents most of the state’s health insurers.

“We believe there should be a moratorium on all new mandates until healthcare costs rise at the same rate as general inflation,” she said. “Right now, healthcare costs are about two to three times the rate of inflation.”

The report’s authors reviewed health studies about the various mandates and estimated that most of them are cost-effective. But they suggested that regulators may consider removing some that are not considered the standard of care, such as bone marrow transplants for treatment of breast cancer. The report also noted that just five of the mandates – maternity, mental health, home health, preventive care for children, and infertility services – account for 80 percent of the total cost of the mandated benefits.

Advocates for universal health coverage said these conclusions show that regulators and lawmakers are not going to be able to wring significant cost savings from slashing existing benefits.

“Healthcare costs are going to require serious grappling of root causes of cost inflation, which are not these mandated benefits,” said Brian Rosman, research director at Health Care for All, a nonprofit that lobbies for affordable healthcare and pushed for the state’s 2006 landmark health insurance overhaul.

The law included a moratorium on adding mandated health benefits until the state published a report detailing the costs of existing mandates. The report released yesterday effectively lifts that moratorium.

The report did not calculate the cost of mandatory prescription drug coverage, which is being phased in this year.

Small business owners say that that mandate alone is likely to boost costs by another 3 to 4 percent.

“Legislators think companies are all big businesses who can afford to pay, and that’s not true,” said Bill Vernon, state director of the National Federation of Independent Business, which represents small business owners.

Vernon said small business owners are bearing the brunt of the state mandates because most larger companies are exempt from state insurance rules under federal law.

He said healthcare costs are typically the second- or third-largest employer expense and that mandates make it tough for small companies to tailor their coverage to the benefits that would most help their employees.

“Perhaps the employees want something else, like higher pay or more 401K contributions,” he said. “It’s the [lack of] flexibility that really irritates small business owners.”

Popularity: 17% [?]

By RAHUL K. PARIKH, M.D.
Published: June 10, 2008

It wasn’t the boy I had a problem with. It was his mother.
 
We had met a few months earlier, when I gave her 14-year-old son a diagnosis of mild asthma. I didn’t mind her tough questions, but her tone of voice put me on edge. She seemed suspicious, almost angry. Still, in the end I decided she was just a smart, assertive parent, and I let it go.
 
This time, she was more confrontational. She complained she had been “forced” to bring in her son for a physical because his school needed a doctor’s clearance before he could play sports. What kind of racket did we doctors have with schools? Why did she have to bring in her son when she knew he was healthy? I was taking her money for doing this?

I bit my tongue and tried to tell her why I thought they belonged here. Yes, he was probably very healthy. But an annual checkup could help him learn to take charge of his own health as he grew up, and it would give me a chance to encourage healthy choices and to get a good sense his emotional health during these challenging years. Finally, I pointed out, he was due for a tetanus booster.

She was unimpressed. “I don’t believe in preventive care,” she said. “I’ll treat him for tetanus if he needs it.”

The rest of the visit went more smoothly, mainly because Mom left the room so I could examine her son. But before they left, she again accused me of taking her money, saying I hadn’t done anything different from their previous visits. Before I could reply, her son politely confirmed that this visit had been more comprehensive.

I have had my share of difficult patients and parents. But putting up with this lady had taken more time than it was worth, and it interfered with my taking care of her son. I wasn’t sure I wanted to do it again.

I considered my options. I could be stoic, do my job and keep the boy in my practice. I could call his mother and ask her to keep her opinions to herself so I could focus on her son, though my instincts told me that this wouldn’t stop her. Finally, I could decline to see her son, and therefore her, ever again. In other words, fire my patient.

The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation and that the patient will heed the doctor’s advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere.

By the same token, this mutual contract gives a doctor the right to dismiss a patient. The most obvious reasons are failing to pay or missing multiple appointments. Refusing to adhere to treatments can lead to dismissal. So can being abusive to the medical staff.

Of course, we need to exercise this option sensibly. Doctors cannot fire a patient in dire straits like severe pain, bleeding or a life-threatening situation. And of course, we cannot refuse to see patients because of their race, age, sexual orientation and so on.

But could I fire a patient because I didn’t like his mother? Colleagues who had studied the ethics and legal issues told me that the answer wasn’t clear-cut. Obviously, I couldn’t just abandon them. Yet like a lot of legal jargon, the word “abandonment” is open to interpretation. I decided it meant that as long as I wasn’t leaving anyone out to dry with a serious, immediate medical problem, that I gave a patient reasonable notice and provided options about where to continue getting care, I was within my rights.

I thought about our conversation on the tetanus booster, when the mother said she didn’t believe in preventive care. I’m a pediatrician — prevention is in my DNA. If I accepted her view, I’d be compromising my conscience and my professional ethics. I couldn’t do that.

I wrote a letter addressed to my patient’s mother and sent by certified mail. I kept it brief: “Sometimes, a patient or family and doctor aren’t compatible. … Therefore, I will be dismissing you from my practice.” I went on to advise them how they could get a new pediatrician and told them that until they found a new doctor, I would continue to care for her child’s mild asthma.

Two weeks later, I received notice that they had gotten it. The child had signed for it, which made me feel bad because I didn’t have anything against him. Checking his chart, I saw that his mother had chosen a new pediatrician, a colleague of mine. They hadn’t seen him yet.

I considered telling my colleague about my experience. Perhaps warning him so he could remember to take extra care would help get them off to a better start. On the other hand, perhaps I would unfairly bias him against this child and his mother.

I decided to keep quiet. After all, it could have just been me. 

Rahul K. Parikh is a physician in Walnut Creek, Calif. He writes about medicine for Salon.

Check other readers comments:  http://community.nytimes.com/article/comments/2008/06/10/health/views/10case.html

Popularity: 20% [?]

Popularity: 23% [?]

The Democratic Presidential Candidates participated in the first online only debate.  They weighed in on such issues as Iraq, education and healthcare. 

Yahoo! News asked users who they would vote for after seeing the online debate. Only a fraction of those who watched debate footage voted — more than a million people watched debate clips, but only 15%, or about 160,000 people, voted. That’s not so different from the low-turnout rates we usually see in actual elections.

 How do you feel about the candidates view on the state of healthcare and their plan to resolve the issue of the uninsured?

http://debates.news.yahoo.com/

Hopefully, we’ll have the opportunity to see the Republican mashup debate soon. 

Popularity: 23% [?]

Now before you read into the title, listen to what I have to say.  I read an article in the New Times dated: August 17, 2000 called: “Global Warming Could Worsen Allergies, Study Finds”   (http://www.nytimes.com/library/national/science/081700sci-environ-climate.html)

First of all, the article basically states the theory that as carbon dioxide increases; pollen should increase as a result of Global Warming.

Here are some excerpts from the article I found interesting…

“The ubiquitous weed makes nearly twice as much pollen now as it did 100 years ago and will likely double its production again over the coming century with predicted increases in carbon dioxide levels, the Agriculture Department study suggests.”

“A laboratory study done by USDA in 1998 and 1999 found that ragweed pollen counts went from 5.5 grams per plant at carbon-dioxide levels that existed in 1900 to 10 grams at current levels. At predicted CO2 levels in the year 2100, the pollen count would reach 20 grams per plant.”

“The USDA researchers expanded their ragweed study this summer by planting the weed in controlled conditions outdoors in Maryland.”

Plants that were set out in Baltimore, where it is hotter and carbon-dioxide levels are higher than outside the city, are growing significantly faster than at a rural site, said Lewis Ziska, a plant physiologist who is leading the research.  “The ones that are growing in the city are bigger and have more pollen, on the order of a third bigger,” Ziska said.

As you can see, according to the research of the Agriculture Department, ragweed makes more pollen today than it did 100 years ago.

The problem I have with this research is who was counting particulates in the air from pollen 100 years ago.  We are talking about 1907.  We just started flying airplanes within the past 60 years.  So how can they base this evidence as factual, when the data is going to be skewed based upon the change in technology.  This is not proof of a ragweed problem or of Global Warming.

The assumption for the increase is said to be caused by Global Warming.  The assumption is based upon research done in the laboratory.  How can a lab truly represent a “GLOBAL” event?  How can this be replicated? 

I realize that plants were set in Baltimore and found that they grew bigger than in the rural areas.  There are many factors that could contribute to their growth than just because there was more carbon dioxide.  Some of those factors can be related to elevation, average temperature, average moisture, precipitation distributions, average wind affects, location to direct sunlight, soil conditions, etc.  None of these things were talked about in the article, so you wonder if they were considered in laboratory.  I also wonder how the plants were cared for during this period of time.  The study states that it was conducted in a “Controlled Environment”, but I thought the environment was anything but controlled.

Now I realize that this is just a news article and we probably only got part of the truth – being that this is the News!!  But as soon as someone mentions key words such as “Global Warming” it becomes BIG NEWS and fact.

My point is that we should not take everything as fact.  There is not sufficient proof here for a growing health issue with allergies contributed by Global Warming.  I wonder if they considered conditions such as the fact that there is more wind generated in a city by passing traffic, wind tunnel effects from buildings, people walking on sidewalks, etc than in rural areas.  Thus, pollen may be naturally forced to increase into the atmosphere because of these daily events rather than Global Warming.

Popularity: 19% [?]

The federal government has made a disaster of Medicare, so why would anyone want them to manage health care! With the introduction of Medicare’s Part D prescription drug benefit, many seniors are paying more for their prescriptions than before this “benefit” went into effect. At 88 years old, my mother takes two prescriptions. Her total cost for these medicines was approximately $30.00 per month. Under forced enrollment in Medicare Part D her out of pocket expense is now $71.79 per month! There is always a huge price tag that comes with any government mandated program and I, for one, do not believe you get what you pay for when the federal government is involved. The members of the Congress and Senate have opted out of participation in Medicare and Social Security. Do you really want to put your healthcare coverage options in the hands of those that would never use it for themselves?

A high deductible health plan along with a health savings account makes the most sense for millions of consumers. With pre-tax contributions, non taxable investment earnings and year to year rollover, how can anyone go wrong? It’s not a case of use or lose it! Several years ago I had a primary care physician that had a medical practice in Canada, which has “socialized medicine”. Prior to meeting him I innocently thought that it would be great to have programs like that in the US. He quickly changed my mind when he told me about all of the problems that he encountered with the program. That was why he relocated to the US. He wanted the freedom to practice medicine the way he was taught and not have the government tell him what he could and could not do with his patients. When voting in this next election keep in mind that politicians, just like Michael Moore’s movie “Sicko”, never tell both sides of the story. We do not want to have universal health insurance forced upon us!

Popularity: 18% [?]

Guest post by the GoHealth Insurance Research Team

The State Children’s Health Insurance Program — better known as SCHIP — was created by Congress in 1997. It was designed to provide health coverage for uninsured children through a combination of state and Federal funds.

The $40 billion originally budgeted for SCHIP runs out this year. Congress now must re-authorize the program and determine how much more money will be spent. That issue has become the subject of a fierce debate — how much should be re-invested into SCHIP?

In President Bush’s budget proposal to Congress back in February of 2007, he allotted $5 billion for SCHIP over the next 5 years. That number was rejected by many lawmakers, who want to spend $50 to $75 billion and further expand the program. President Bush has since added $10 billion to his proposal, but it’s still well shy of what the opposition is demanding.

The Bush administration maintains the SCHIP program should be restricted to provide coverage for uninsured children in families with incomes of up to 200% of the federal poverty level. But many states have already been given the Federal go-ahead to extend SCHIP coverage to uninsured parents — a factor that’s contributed to the program’s budget shortfall. Now that the money is running out, the White House wants to cut off coverage for adults completely.

They want to restrict SCHIP eligibility because they see the expansion as a move toward universal healthcare. President Bush was quoted in the Los Angeles Times, saying Democrats are pushing SCHIP expansion because they want “to take incremental steps down the path to government-run healthcare for every American.”

Republicans tend to support a market reform — rather than universal healthcare — to make private health coverage more accessible. They argue that increased competition would drive prices down and make health plans for children more affordable for families with incomes above 200% of the poverty level.

It’s true that many Democrats are exploring the idea of universal healthcare for all Americans. But even politicians who don’t support universal healthcare have raised an important argument in favor of expanding SCHIP coverage to adults: when parents get coverage, it increases the chance they’ll enroll their children, too. When Mark McClellan was the administrator of the Centers for Medicare and Medicaid Services, he authorized grants to 13 states to extend the SCHIP coverage to parents.

“In support of that approach, there is no question that covering kids with their parents is more efficient overall. It’s a better way to provide coverage than to have separate plans for kids and parents,” explained McClellan.

Another concern of restricting SCHIP eligibility is that many children could lose coverage — especially if they’re above the 200% poverty level.

The question isn’t if SCHIP will be re-authorized or not. It’s whether eligibility will be restricted or expanded.

Who do you think should SCHIP cover?

Sources

Alonso-Zaldivar, Ricardo. Bush Criticizes Children’s Health Plan.
Los Angeles Times. June 28, 2007. http://www.latimes.com/news/nationworld/politics/la-na-kids28jun28,1,3165586.story?ctrack=1&cset=true

Freking, Kevin. States, Feds Split on Kids’ Health Insurance.
USA Today. June 18, 2007.

http://www.usatoday.com/news/health/2007-06-18-kidsinsurance_n.htm

Pear, Robert. A Battle Over Expansion of Children’s Insurance. The New York Times. July 9, 2007. http://www.nytimes.com/2007/07/09/washington/09child.html

SCHIP Waivers Allowing States To Expand Coverage To Adults Break From Bush Administration’s Position, Lawmakers Say. Medical News Today. June 25, 2007. http://www.medicalnewstoday.com/medicalnews.php?newsid=74982

Popularity: 44% [?]

Who would benefit from mandated health insurance? This is a major question moving through the health care delivery system. An unusual coalition that includes some of the largest companies: PepsiCo, General Mills, Pacific Gas and Electric. Wm. Wrigley Jr. Co. and The Kroger Co. was formed in California to launch a political campaign calling for medical insurance to be expanded to everyone.

The coalition also includes insures and drug firms that probably would benefit from mandated health insurance: Aetna, Blue Shield of California, Cigna Healthcare, Eli Lilly and Co. and PacificCare.

Who would benefit for Mandated Health Insurance, more importantly who would it hurt? Should we require all individuals to obtain health insurance?

Popularity: 40% [?]

Leslie Wines, writer for Market Watch, penned this article on President Bush call for a reform of the tax code to create a standard deduction for all Americans with Health Insurance.

“The reform would end a disparity that forces persons who pay for their own insurance to pay more taxes than those who are insured through their jobs, he said.

“Today, the tax code unfairly penalizes people who do not get health insurance through their job,” Bush said in his weekly ratio address. “If you buy health insurance on your own, you pay much more after taxes than if you get it through your job.” Read the address.

“I proposed to end this unfair bias in the tax code by creating a standard tax deduction for every American who has health insurance,” Bush said.

Bush said that, for example, every family that has health insurance could get a $15,000 deduction on their taxes. Such a deduction could also apply to payroll taxes, so that even those who pay no income taxes would benefit.

“Americans deserve a level playing field,” he said.” If you’re self-employed, a farmer, a rancher, or an employee at a small business who buys health insurance on your own, you should get the same tax advantage as those who get their health insurance through their job at a big business.”

The president said that health care costs are rising twice as fast as wages, making it difficult for working families to afford coverage.

“These rising costs also make it harder for small businesses to offer health coverage to their employees,” he said. “We must address these rising costs so that more Americans can afford basic private health insurance.”

“Bush said he has been speaking with citizens about health care reform and next week will visit a Tennessee to speak with people who do not have access to basic affordable health insurance.”

What are we missing here? It sounds good. The uninsured numbers are forcast in the 47 – 50 million range. Would this help the uninsured. Where do we get the dollars to fund this tax deduction? Do we cut Medicare and Medicaid?

Popularity: 14% [?]