1.
Featured
Article: New
Predictors of Disease
Molecules called predictive autoantibodies
appear in the blood years before people show symptoms of various disorders.
Tests that detected these molecules could warn of the need to take preventive
action By Abner Louis Notkins
NOVEL
CRYSTAL BALL: One day Y-shaped molecules called autoantibodies in a patient's
blood may tell doctors whether a patient is "brewing" certain
diseases and may even indicate roughly how soon the individual will begin to
feel symptoms.
A
middle-aged woman—call her
Anne—was taken aback
when one day her right hand refused to hold a pen. A few weeks later her right
foot began to drag reluctantly behind her left. After her symptoms worsened
over months, she consulted a neurologist. Anne, it turned out, was suffering
from multiple sclerosis, a potentially disabling type of autoimmune disease.
The immune system normally jumps into action in response to bacteria and
viruses, deploying antibodies, other molecules and various white blood cells to
recognize and destroy trespassers. But in autoimmune disorders, components of
the body's immune system target one or more of the person's own tissues. In
Anne's case, her defensive system had begun to turn against her nerves,
eroding her ability to move.
Every story
of autoimmune disease is sad—but
collectively the impact of these illnesses is staggering. More than 40
autoimmune conditions have been identified, including such common examples as
type 1 (insulin-dependent) diabetes, rheumatoid arthritis and celiac disease.
Together they constitute the third leading cause of sickness and death after
heart disease and cancer. And they afflict between 5 and 8 percent of the U.S.
population, racking up an annual medical bill in the tens of billions of
dollars.
Recent
findings offer a way to brighten this gloomy picture. In the past 10 years a
growing number of studies have revealed that the body makes certain antibodies
directed against itself—otherwise
known as autoantibodies—years,
and sometimes a decade, before autoimmunity causes clinical disease, damaging
tissues so much that people begin showing symptoms. This profound insight is
changing the way that doctors and researchers think about autoimmune
conditions and how long they take to arise. It suggests that physicians might
one day screen a healthy person's blood for certain autoantibodies and foretell
whether a specific disease is likely to develop years down the line. Armed with
such predictions, patients could start fighting the ailment with drugs or
other available interventions, thereby preventing or delaying symptoms. . .
The
revolution in predictive medicine and preventive care will take time and effort
to effect. Many autoantibodies have been uncovered, but only a few large-scale
trials have been conducted to evaluate how accurately they can predict disease.
If inexpensive, quick tests for predictive autoantibodies can be developed,
though, they could become as standard a part of routine checkups as cholesterol
monitoring.
Early Insight from Diabetes
People
familiar with advances in genetics might wonder why researchers would want to
develop tests for predictive autoantibodies when doctors might soon be able to
scan a person's genes for those that put the individual at risk of various
disorders. The answer is that most chronic diseases arise from a complex
interplay between environmental influences and multiple genes (each of which
makes but a small contribution to a disease). So detection of susceptibility
genes would not necessarily reveal with any certainty whether or when an
individual will come down with a particular autoimmune condition. In contrast,
detection of specific autoantibodies would signal that a disease-causing
process was already under way. Eventually, genetic screening for those with an
inherited predisposition to a disease may help reveal those who need early autoantibody
screening.
Studies
of patients with type 1 diabetes provided the first clues that autoantibodies
could be valuable for predicting later illness. In this condition, which
typically arises in children or teenagers, the immune system ambushes the beta
cells in the pancreas. These cells are the manufacturers of insulin, a hormone
that enables cells to take up vital glucose from the blood for energy. When the
body lacks insulin, cells starve and blood glucose levels soar, potentially
leading to blindness, kidney failure, and a host of other complications. . .
Intensive
research over the past 20 years has uncovered three major pancreatic
autoantigens produced in people with newly diagnosed type 1 diabetes . . .
Interest
in the three autoantibodies escalated with the discovery that they appear long
before the onset of diabetic symptoms. In studies conducted by various
laboratories, investigators took blood samples from thousands of healthy
schoolchildren and then monitored the youngsters' health for up to 10 years.
When a child came down with type 1 diabetes, the researchers pulled the
individual's blood sample out of storage to see whether it contained autoantibodies.
The vast majority of children destined to become diabetic had one or more of
the three signature diabetes-related autoantibodies in their blood as long as
10 years before any recognizable symptoms arose.
Before
this work, some experts thought that type 1 diabetes developed suddenly,
perhaps within a matter of weeks. The new data demonstrated, instead, that in
most cases the immune system silently assails the pancreas for years until so
many beta cells die that the organ can no longer make enough insulin for the
body's needs. That is the point when the classic early symptoms of diabetes
arise, such as excessive hunger, thirst and urination.
More
important, these studies also raised the prospect that doctors might forecast
whether a child is at risk for type 1 diabetes by testing blood for the
presence of these autoantibodies. Clinical researchers found that an individual
with one autoantibody has a 10 percent risk of showing symptoms within five
years. With two autoantibodies, the chance of disease jumps to 50 percent; with
three autoantibodies, the threat rockets to between 60 and 80 percent.
The ability
to predict whether a person is likely to fall ill with type 1 diabetes has had
major repercussions for medical researchers trying to better understand and
prevent the disease. Before the discovery of predictive autoantibodies, for
example, it was almost impossible to conduct clinical trials of new preventive
therapies, because the disorder is relatively rare, affecting about one
individual in 400. Such odds meant that more than 40,000 subjects would have to
be entered into a trial in order to assess the effects of an intervention on
the 100 who would eventually be affected.
Now
scientists can select for study those people whose blood shows two or more of
the diabetes-related autoantibodies, because at least half the subjects, if
untreated, will most likely come down with the disease within five years.
Slashing the number of subjects who must be enrolled in a prevention trial has
made such experiments feasible for the first time. In one investigation, doctors
identified several thousand individuals at high risk of diabetes and tested
whether injections of insulin could avert the disease. Sadly, this treatment
proved unsuccessful; efforts to find useful interventions continue.
The
discovery that autoantibodies frequently herald the onset of type 1 diabetes
prompted scientists to examine whether the same might be true in other autoimmune
diseases. One that has been the focus of especially intense research is
rheumatoid arthritis, a debilitating condition that is highly prevalent,
afflicting about 1 percent of the world's population. In those affected, the
immune system attacks and destroys the lining of the joints, causing swelling,
chronic pain and eventual loss of movement.
Predicting Other Diseases
Immunologists
have recently unearthed an autoantibody that is present in 30 to 70 percent of
patients diagnosed with rheumatoid arthritis. The antibody latches onto
citrulline (a modified version of the amino acid arginine), which is present in
certain proteins. Studies have now revealed that the autoantibody appears in
the bloodstream before the first symptoms turn up, in some cases more than 10
years before. Further, the likelihood that the illness will develop is as much
as 15 times greater in people carrying that antibody than in those who lack it.
. .
For
certain other autoimmune disorders, the detection of predictive autoantibodies
could potentially enable people to shut down autoimmune activity by avoiding
certain triggers in their environment. A case in point is celiac disease. In
people with this condition, the gluten protein found in wheat, rye and barley
incites the immune system to attack the lining of the small intestine, which
then fails to absorb food properly; diarrhea, weight loss and malnourishment
then ensue. Patients must eliminate gluten from their diet, bypassing most
bread, pasta and cereal for the rest of their lives.
Investigations
into the underpinnings of celiac disease have revealed that many patients make
an autoantibody that reacts with tissue transglutaminase, an enzyme that
modifies many newly made proteins. This autoantibody emerges up to seven years
before symptoms do, suggesting that high-risk individuals might forestall the
disease entirely by eliminating gluten from their diet. This idea has not yet
been tested, however.
To
read the entire article, (subscription required) please go to
www.sciam.com/article.cfm?chanID=sa006&colID=1&articleID=CBD61A3D-E7F2-99DF-3151AFC554AD3D29.
* * * * *
2. In the News: FDA vs. Medical Self Defense
By Michael Arnold Glueck, M.D., and Robert J. Cihak,
M.D., The Medicine Men, Feb. 13, 2007
A recent ruling of the District of Columbia United
States Court of Appeals weakened the Food and Drug Administration (FDA)
drug-approval monopoly.
In the case of Abigail Alliance v. von Eschenbach, the
court ruled "in some circumstances there is a constitutional right"
to use drugs not approved in advance by the Food and Drug Administration (FDA),
according to Robert F. Nagel writing in "The Weekly Standard."
If other levels and branches of the federal government
maintain this ruling, it would put some additional meaning to Americans'
unalienable right to life and liberty, as articulated in our Declaration of
Independence.
UCLA law professor Eugene Volokh believes that access
to medicines not yet approved by the FDA could be defended under a right to
"medical self-defense."
Although Volokh describes the use of this right in
several other scenarios, in this article we are only looking at it in the context
of medicines not approved by the FDA for prescription or sale in the United
States.
In an article forthcoming in the April 2007 Harvard
Law Review, Volokh writes, "Lethal self-defense — protecting one's life
against humans or animals (or preventing serious injury, rape, or kidnapping) —
has long been a general exception to nearly all criminal laws, including laws
against murder, weapons possession, and the like."
Therefore, Volokh reasons, "why shouldn't I be
presumptively free to protect my life using medical procedures that don't
involve killing, such as ... the use of experimental drugs?"
He hopes that others "who feel strongly about the
right to lethal self-defense (as do I) ... will agree that the moral case for
medical self-defense is at least as strong as the case for lethal
self-defense."
Volokh prefers the term medical
"self-defense" over medical "necessity" because each of the
United States recognizes self-defense in state law, whereas only half the
states recognize a necessity defense.
Under the law of lethal self-defense, Americans can
defend themselves against being murdered by someone else by killing the
threatening person, whether or not the person has an evil intent or is
blameless because of insanity.
Likewise, the law of self-defense protects a person
killing a threatening animal, even if the Endangered Species Act would
otherwise protect the animal.
The right to medical self-defense would potentially
allow a patient to use whatever potentially life-saving medical means desired.
In contrast with lethal self-defense, patients using their own resources to
acquire the potentially life-saving medicine would not kill or harm other
people.
How did the FDA get between patients and medicines in
the first place? This history now goes back a century, with the government
first taking upon itself the authority to make sure that food and medicines
were pure.
Next, the government took the authority to define
whether medicines were safe.
More recently, federal laws called on the FDA to
identify whether or not drugs were "effective" for proposed medical
uses.
We've questioned the premise of FDA regulation of drug
safety and effectiveness for some time. See www.newsmax.com/archives/articles/2005/2/22/142508.shtml.
Some people want drugs that have no side effects and
are almost certain to have the desired effect. Others, such as patients with
advanced cancer, are willing to try drugs that have a minimal chance of benefit,
even less than 10 percent, and a high likelihood of bad side effects.
And people change their minds, sometimes from day to
day, about the degree of safety and risk that they want to accept. . . To read the rest of the story, please go to www.newsmax.com/archives/articles/2007/2/12/152734.shtml.
Editor's Note: Robert J. Cihak wrote this week's
column. Contact Drs. Glueck and Cihak by e-mail.
Michael Arnold Glueck, M.D., comments on medical-legal
issues and is a visiting fellow in Economics and Citizenship at the
International Trade Education Foundation of the Washington International Trade Council.
Robert J. Cihak, M.D., is a senior fellow and board member of the Discovery
Institute and a past president of the Association of American Physicians and
Surgeons.
* * * * *
3. International Medicine: A Single-Payer
Health Care System Can Prove Fatal
Hospital tells woman in labour: Sorry, we're full. Try
Yellow Pages 16 Feb 2007
She had attended parentcraft classes, met the midwives
and packed her bag.
But nothing could prepare Gail Jordan for what happened
when she rang the hospital to let staff know her baby was on the way.
A brusque voice at the end of the line told her all
the maternity beds were full.
And instead of arranging for Mrs Jordan to go
elsewhere, the nurse suggested she flick through the Yellow Pages to find
somewhere for her delivery.
After a frantic search Mrs Jordan and her distraught
husband, Dean, drove to another hospital 20 miles away where their son,
Alexander, was born.
"It's disgraceful that they can treat a woman in
labour like that," Mrs Jordan said.
"It's my first baby and I was absolutely
terrified – anything could have happened. It was a dreadful beginning to what
should have been a beautiful experience. They had held my hand every step of
the way and then at the end of it, when I needed them most, this happened. I
was really angry because her attitude was just 'tough luck, you can't come
in.'"
The drama unfolded when the 38-year-old marketing
director went into labour on January 31. She rang Solihull Hospital, two miles
from her home, to inform staff her contractions had begun. . . .
But when she rang a second time, having packed her
hospital bag, she was told there was no space for her and to ring round other
hospitals for a bed.
"This rude woman told me not to bother coming in
– it was as blunt as that," Mrs Jordan said. "
I explained I was having three contractions every ten
minutes and she said, "Well what do you want me do to about it?"
"I asked if they had any overflow hospitals and
she told me there were but I would have to look in the Yellow Pages for the
number.
"It was the most inappropriate time imaginable to
be dealing with somebody like this." Mrs Jordan and her husband, a
39-year-old marketing executive for Aston Martin, eventually found a bed at
Warwick Hospital. . . .
Mrs Jordan's claims come as dozens of maternity units
face closure in an NHS shake-up.
www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=436685&in_page_id=1774
The NHS does not give timely access to health care, it
only gives access to a waiting list.
When you're at the head of the list, and completed the
waiting queue, you still don't have access.
And when you're in labor and delivery is imminent, it
gives you the Yellow Pages.
Any American that wants this system should be given a
free ticket to the UK.
One caveat: You have to renounce your American Citizenship
so you can't come back.
* * * * *
4.
Medicare: The Rising Burden of Health Spending on Seniors, by Liqun Liu and
Andrew J. Rettenmaier
Executive Summary
The
United States spends about 17 percent of its national income on health care,
the highest in the world. Some have wondered how high spending can go and what
difference it will make. In thinking about that question, the experience of our
senior citizens provides a vital clue.
●
Today, more than two of every five dollars of total potential consumption by
the elderly (43 percent) is health care.
●
In just 17 years (by 2024), health care will equal 50 percent of seniors' total
consumption.
●
For the oldest seniors — age 75 and older — health care already makes up more
than half of all they consume.
Much
of seniors' health spending is paid not by seniors themselves, but by public
and private third parties like Medicare, Medicaid and previous employers.
However, as spending on their health care rises, seniors will be asked to
devote an increasing share of their own incomes to pay for it, crowding out
other items like food, housing and travel.
●
Today, seniors spend 17.2 percent of their cash incomes on health care, on the
average, including out-of-pocket expenditures, as well as premiums for Medicare
and individually purchased Medigap insurance.
●
That level will grow to almost one out of every four dollars of income (23.5
percent) by 2030, and by midcentury seniors will potentially spend almost
one-third of their cash incomes (31.4 percent) on health care.
Another
way to look at health care spending by the elderly is to compare their total
health consumption to their money incomes:
●
Including all the spending by third parties, an amount approaching two-thirds
of seniors' cash incomes is currently spent on health care.
●
In another three decades (by 2039), an amount equal to 100 percent of seniors'
cash incomes will be spent on health care.
Since
Social Security represents such a large portion of seniors' retirement income —
particularly for older seniors — examining health spending as a percentage of
Social Security benefits is also informative:
●
Today's seniors spend from their own resources an amount equal to 44.5 percent
of their Social Security benefits on health care.
●
That amount will almost double (to 81.3 percent) by midcentury.
If
health care spending rises as expected, seniors will likely be called upon to
share the burden.
That
means current and future workers will need to extend their time in the labor
market — or save and invest more money while working — to prepare for the
higher expected health care costs waiting for them in retirement.
www.ncpa.org/pub/st/st297; www.ncpa.org/prs/rel/2007/20070220.html
[When Franklin Delano Roosevelt initially
started social security, retirement was set at age 65 with a life expectancy of
age 62. If this had been partially indexed all these years, benefits would be
starting at age 75 when life expectance reached age 78. President William
Clinton did the greatest threat to social security when he made everyone
eligible for full social security benefits even while earning a full salary.
Most of us never expected to receive SS benefits until age 72 because we would
have forfeited all benefits while we were working. We then would have been near
to the age of 75 when benefits rightfully should be starting according to
Roosevelt's initial criteria. Then the full indexing to age 75 would have been
relatively painless. Then SS would not be in the current jeopardy. There is no
way that with the average retirement years of just three or so in the 1930s and
30 years today we should expect taxpayers to pay us an income for 30 years
instead of three years. No system could be sustainable with half a lifetime of
a free ride. Medicare should be indexed in the same fashion as social
security.]
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5. Medical Gluttony: ER overuse burdens health care
system by Michael
Wilkes, MD
. . . Emergency departments are crowded with more
people than ever. Each year, 20 percent of Americans visit the ER. This is
puzzling, given that the wait to receive care for non-critical emergencies is
often long and health care in the ER is extremely expensive. This is due in
part to the fact that ER doctors are trained to fear the worst, and they are
far more likely to order more blood tests and X-rays than general
practitioners, who can follow up with patients the next day.
A recent study looked at patients' and doctors' use of
the emergency room. According to both groups, most visits to the ER could have
been avoided had only their doctor's office or a trusted clinic been open. Many
patients reported that if they could have spoken to a doctor, they would not
have used the emergency room.
A few people are frequent fliers in the ER. Not surprisingly,
they are more likely to be those with chronic illness such as diabetes, asthma,
alcoholism or heart failure. They are also more likely to be low-income,
without access to a regular doctor, and see the ER as a convenient place to
receive routine care.
This practice is not fair to anyone. The chronically
ill deserve better. If their care was delivered by general doctors, it would be
higher quality, more personal and far cheaper than the episodic care delivered
by experts trained to care for people with life-threatening emergencies. For
those who come to the ER with life-threatening or near-life-threatening
conditions and need a doctor's immediate attention, it's not fair to have the
ERs clogged with people with routine health issues.
The solution to overcrowded ERs needs to come from all
sectors. Doctors need to provide care and advice to their patients in off
hours. Only one in five doctors sees patients after 6 p.m. and only a small
minority offer weekend appointments. Practices should be encouraged to use
advice nurses, pagers and cell phones so that a patient can talk with an expert
before going to an ER.
Patients should be told how to contact an expert for
off-hours medical advice. Insurance companies and employers need to develop
incentives to discourage non-life-threatening use of the emergency room. And
patients need to ask their doctors how they can be contacted in off hours.
To read the entire article, go to www.sacbee.com/107/v-print/story/131120.html.
[When insurance companies, or Congress, or employers
provide incentives for more appropriate care, we are always at cross currents
with different agendas. No one wants to face the real facts or the real
solutions. For instance, if a patient had to make a 20% copayment on all ER
visits (welfare and poor people a 2% copayment provides identical incentives),
that would provide the incentive that insurance companies, Ccongress,
employers or doctors should like. Thus, a patient who trades a $100 office call
for a $500 ER visit would increase his copayment from $20 to $100. (Welfare or
poor patients would increase their copayment from $2 to $10.) That disincentive
to ER usage would reduce all unnecessary ER visits quite effectively. Very few
would ever make that mistake a second time. What is the fallout from such a
truly market-based plan?
1. ER usage
would drop overnight from the majority being a clinic visit to the majority
being emergency visits. This would save high cost center dollars.
2. Patients
would start utilizing their private physicians more effectively saving personal
and health-care costs.
3. Costly
ineffective incentive programs could be abolished.
4. Patients
would automatically seek the least expensive care consistent with their own
evaluation of their medical needs, eliminating the cost of the insurance
companies oversight and policing programs.
5. Managed care
companies could also eliminate their pre-authorization policing activities,
saving huge oversight costs.
6. The quality
of care with the private physicians delivering consistent care would improve
over that of emergency trained physicians doing routine office evaluations
without benefit of the clinical record.
7. The cost of
care would decrease inasmuch as an emergency physician, who doesn't know the
patient and works in a high medical- and legal-risk environment, must practice
defensive medicine and duplicate many tests that may have already been
acquired, at huge unnecessary costs.
8. The hospitals
would revert to their rightful place as the center of acute, emergency, and
hospital care and not outpatient medicine.
9. Doctor's
offices would revert to their rightful place as the center of low-cost
outpatient medicine and could control their costs more effectively.
10. Insurance
companies could revert to their right place of insuring high-risk health care,
primarily hospital and surgical center health care.
Actuaries that have looked at this model have
predicted that this would cut the cost of this segment of health care by more
than 50 percent.
The only problem: Politicians would lose their
favorite subject in running for political office, which takes all the joy out
of the campaign.]
* * * * *
6. Medical Myths: American Health Care Is Unsustainable
Symptoms of an unsustainable system, By Jacob Weisberg, February 28 2007
America's healthcare system runs the gamut from
capitalist to socialist, pausing at various points along the way. At the
free-market extreme are the 10m people who buy private insurance without a
subsidy and the 48m who have none at all. At the collectivised end are 5m
military veterans who see government doctors in government hospitals, the 32m
covered by Medicare (retirees) and 37m on Medicaid (the poor).
In between are the majority of Americans – the 153m
workers and their families – who receive government-subsidised private
insurance through their employers.
A growing consensus recognises [sic] this patchwork as
economically disadvantageous and morally unacceptable.
Viewed as a whole, the American system is inefficient,
expensive and possibly unsustainable. It consumes 16 per cent of gross domestic
product and is growing 6.4 per cent a year. Europe provides universal,
high-quality care for half as much per capita. Employer-based coverage is a
drag on the economy, tethering workers to jobs they would otherwise leave and
adding to the cost of goods. Healthcare spending is everywhere a budget
wrecker. Yet, for all that the US spends, 16 per cent of the population,
including 8m children, must make do at the system's charitable margins.
If the status quo is untenable, the Euro-alternative
remains impossible to sell. Americans place a premium on personal liberty and
individual choice. A "single-payer" system, in which government
insures everyone directly, would diminish consumer freedom for the sake of
equity and efficiency. The US invariably resists making that trade-off. Oregon,
one of the most progressive-minded states, defeated a single-payer ballot
initiative a few years ago by a margin of four to one.
All the action at the moment is in the space between
these two extremes – the status quo and nationalised care. George W. Bush started the conversation last month when he
proposed capping the tax deductibility of employer-provided plans and creating
a deduction for individuals. By turning the healthcare tax deduction into a
kind of voucher, the president would discipline spending and allow more
individuals to afford insurance. But Mr Bush's plan risks undermining the
employer-based system without replacing it and fails to grapple seriously with
the problem of the uninsured.
John Edwards, a Democratic former senator, recently
became the only presidential candidate to get specific on the subject when he
laid out a plan bolder than Mr Bush's that would build on the employer-based
system. Mr Edwards would require companies that do not insure their workers to
pay into a fund for the uninsured. Following the trend in Massachusetts and
California, he would add an "individual mandate", a requirement that
anyone not covered at work buy insurance in a regulated market.
The chief advantages of Mr Edwards's plan are that it
achieves universal coverage without disrupting the way most Americans now
receive healthcare, and that it is explicit about raising taxes to pay for
extending coverage. The chief disadvantages are that it would do little to
control costs, and that it fails to break the anachronistic connection between
employers and insurance.
Ron Wyden, a Democratic senator from Oregon, would directly
sever that link. Mr Wyden is a savvy policy wonk who, in drafting the bill he
recently introduced, has tried to learn from previous Democratic mistakes. He
recently told me he had read The System, a massive tome on the failure of the
Clinton healthcare reform plan in 1994, no fewer than five times. (Apparently,
Starbucks now offers an intravenous drip.)
Mr Wyden's bill is 166 pages against Hillary Clinton's
1,364. Instead of trying to flatten the opposition as the Clintons did, Mr
Wyden is courting Republicans. He recently got five of the most conservative
men in the Senate to co-sign a letter to Mr Bush endorsing the principles of
universal coverage and cost containment.
Under Mr Wyden's plan, American employers would no
longer provide health coverage, as they have since the second world war.
Instead, they would convert the current cost of coverage into additional
salary. Individuals would use this money to meet the requirement that they be
insured. Buying coverage directly would encourage consumers to use healthcare
more efficiently. Getting rid of the employer tax deduction, which costs $200bn
a year, would free funds to cover those who are not poor enough to qualify for
Medicaid but not wealthy enough to afford insurance. The Lewin Group, an independent
consulting firm, recently estimated that Mr Wyden's plan would reduce national
spending on healthcare by $1,500bn over the next 10 years and save the
government money through greater administrative efficiency and competition. . .
The writer is editor of Slate.com: www.ft.com/cms/s/e76a290a-c758-11db-8078-000b5df10621.html
[If Jacob Weisberg, who writes for Slate.com, feels
the American System is morally unacceptable, please read Int'l Med above about
the NHS being more political thant any American System, and far more
tragic.]
America's "Run the
Gamut" Health Care System provides more complete coverage in time of need
than any foreign socialistic system.
* * * * *
7.
Overheard in the
Medical Staff Lounge: Do Doctors Donate Their Organs?
Dr. Sam: I had
a former drug abuser who had Hepatitis C and developed cirrhosis. He then went
into liver failure. As he was being evaluated for a liver transplant, he was
found to have developed cancer of the liver. It was the opinion of the
transplant team that the cancer would be removed with the liver and he would be
cured. After about one year, the cancer recurred in the transplanted liver and
he died a few months later. This waste of transplant organs made me pull out my
driver's license and remove the organ transplant authorization.
Dr. Rosen: I
attended a medical ethics conference at UCD and the subject of transplants in
inmates came up. I suggested a higher priority for a free man than an inmate.
The pastoral adviser stated that I made a value judgment and that the inmate
had every right to a transplanted organ that a free man did. I pulled my organ
donation card at that time, which was years ago.
Dr. Milton:
Having worked in a prison for a couple of years, I saw inmates cause their own
heart failure by not taking pills, or not taking their antibiotics which caused
them to become very sick forcing admission to an outside hospital. They also
feign diseases to make other stabs at freedom. One inmate came to sick call all
bent over as if in gallbladder or renal colic. The doctor examined him,
couldn't find anything to substantiate it, and told the inmate to return to his
cell. The inmate instantly jumped off the examination table and snapped his
fingers at fellow inmates bragging that he almost fooled the doctors. An inmate
with a transplant could easily cease taking his anti-rejection drugs and reject
his organ so the transplanted organ would be lost. This could result in
dialysis for life or another transplant organ when one became available and the
whole scenario would replay itself. This would result in high outside medical
costs.
Dr. Michelle: I
agree with the chaplain that the inmate has the same right to the donated organ
as you and I do.
Dr. Sam: So
you're saying that your contribution to society is no greater than the felon's
contribution to society? The felon is still paying his debt to society. Give me
a break.
Dr. Milton: We can't
forget the cost to society by the felon who requires dialysis or another
transplant. Take the routine scenario of dialysis three times a week. To
transport the felon to a private hospital or dialysis center would require two
police cars (there is always a chase car with any transport) and four
correctional officers, two in each car, being paid $25 an hour each for the six
hours minimal for the time from the prison to the dialysis center, guarding and
waiting for the dialysis to occur, and back to the prison. This is an
exorbitant cost, which would occur three times a week, not counting all the
complications that occur with dialysis.
Dr. Sam: So
it's not just a choice between two individuals, there are huge differences in
costs.
Dr. Rosen: We
could play this same scenario with an HIV patient with organ failure having
equal rights with the huge disparity in costs.
Dr. Milton: After
this discussion, I'm pulling my organ donation card.
[This conversation should not be construed to imply
that most physicians aren't organ donors. An open liberal dialogue should allow
all points of view.]
* * * * *
8.
Voices of Medicine: A Review of Local and Regional Medical Journals
Kelly Pfeifer, MD, discusses
The Best of Times in the Winter 2006 issue of Sonoma Medicine, the
Magazine of the Sonoma County Medical Association.
It was the best of times, it was the worst of times,
it was the age of wisdom, it was the age of foolishness … it was the spring of
hope, it was the winter of despair … — Charles Dickens
Physicians are practicing in times of such rapid change that
Charles Dickens' description of the French Revolution could just as well depict
the current state of Sonoma County medicine. Our era—with doctors in clinics
and small groups struggling for simple survival—often feels more like the worst
of times than the best. Many of our colleagues have simply given up and have
either left Sonoma County or the practice of medicine altogether.
Yet, in many ways, now is the best of times. Exciting
changes are occurring in medical practice, especially in primary care. Some of
the momentum for change comes from consumer advocates demanding that physicians
share power and decision-making. Other change is internally driven—physicians
are trained to strive for excellence, and are constantly reassessing medical
care and medical science, with a willingness to make improvements when needed
and an openness to learning when mistakes are discovered.
Clinics for the poor have long existed in the United States,
but they were generally dependent on insecure funding, and there was no
oversight to ensure that the care given met community standards. In the 1960s,
the number of free clinics increased dramatically; but over time they had
difficulty sustaining funding and staffing, so the Bureau of Primary Health
Care helped them transition to "Federally Qualified Community Health
Centers." The ensuing federal grants came with regulations and an
insistence on uniform structure. To this day, every clinic must have a
nonprofit community board, and half of the board members must be patients of
the clinic. Every clinic must have an executive director, a medical director,
and a quality improvement program; and clinic staff must design a health plan
with projects to be carried out in the next twelve months. The board of
directors is ultimately responsible for ensuring that the health plan is
completed.
Federally qualified clinics on the East Coast have
been thriving for more than 40 years, and some have multiple sites, serving
hundreds of thousands of patients. In contrast, most community health centers
in Sonoma County are still young and growing. The Petaluma Health Center, for
example, started 12 years ago as a small private practice. We had a free clinic
on Wednesdays, and during those three hours providers were exempt from the
worst headaches of modern medicine—no prior authorizations, no co-pays, and no
lab fees—but no salaries! We saw a large volume of patients, enjoyed the
camaraderie of dedicated volunteers, and had a wonderful population of grateful
customers.
The free-clinic providers excelled at treating sore
throats and abscesses, but were we good at preventing disease? There was very
little time, and no structure, to ensure that patients received Pap smears,
mammograms, and other cancer screens. We tried to help diabetics get their
medications, but we depended on free samples from drug companies, and we were
restricted by a meager formulary.
As the need for low-cost health-care services in
Petaluma continued to increase, we grew from that small private practice to a
federally funded clinic with 30 providers and more than 50,000 patient visits
annually. In the process, we had to completely overhaul every function in the
clinic, change all our protocols, and retrain all our staff. This was an arduous
endeavor at best. To add to the challenges, we were also hit with an unexpected
million-dollar shortfall in anticipated funding. We endured a year of painful
and desperate survival measures. Productivity was pushed to an exhausting
level. We didn't have enough staff, enough space, or adequate systems to handle
our existing patients, much less the new patients who kept rolling in the door.
Not surprisingly, many of our key staff members left during this time.
In the midst of our overhaul, government inspectors came
for their required periodic evaluation. They asked, "What are you doing,
and where is your data?" Clinics may initially be funded based on
community need; but that funding is only continued based on evidence of work
done and needs met. Each year, we are required to submit our upcoming year's
detailed health plan, and to review last year's results. We track pediatric
vaccine rates, for example, and monitor the percentage of female patients who
receive mammograms and Pap smears. We measure our adherence to national
guidelines for managing diabetes, high cholesterol, and heart disease. We track
our successes and failures with screening for adolescent sexually transmitted
disease. We judge ourselves, and are judged, on these facts. The inspectors asked,
"Why aren't your uninsured patients getting podiatry care?" I started
listing all the barriers our patients face, such as language, transportation,
and poverty. The inspectors cut me off, saying, "Don't make excuses. Solve
the problem." . . .
There is no reason why all of us who care for the
variety of people in our region—rich or poor, insured or uninsured—cannot work
together to accomplish meaningful and sustainable change. Many of the biggest
problems in health care have yet to find the best solutions, but perhaps the
Sonoma County medical community can learn from the achievements of our
community health centers. With creativity and perseverance, we have achieved
some success, even during these "worst of times."
The entire article can be found at www.scma.org/magazine/scp/wn07/pfeifer%20.html.
Dr. Pfeifer is medical director of the
Petaluma Health Center and co-medical director of the Redwood Community Health
Coalition.
* * * * *
9.
Book Review: The
Mailbox, by Audrey
Shafer, M.D.
Stephen Jackson, M.D, Editor
of the California Society of Anesthesiology Bulletin, reviews
The Mailbox and interviews the author, Audrey Shafer, M.D.
Audrey Shafer, M.D., is Associate Professor of
Anesthesia, Stanford University School of
Medicine, and staff anesthesiologist at the Veterans
Affairs Palo Alto Health Care System. She
directs the Arts, Humanities and Medicine Program
based at the Stanford Center for
Biomedical Ethics and co-directs the Biomedical Ethics
and Medical Humanities Scholarly
Concentration. She teaches creative writing for
medical students and is the author of Sleep
Talker:
Poems by a Doctor/Mother (2001). Her children's novel, The Mailbox, about
posttraumatic
stress disorder and Vietnam veterans was published
recently by Random House.
From the Editor
I
encourage you to read Dr. Shafer's first novel. Although proposed as a teen
novel, The Mailbox is a book for all ages as it cleverly evokes
powerful emotions of connectedness and caring so essential to the survival of
the human race. The author intricately and colorfully interweaves a mysterious
story of an orphan, unsuccessfully seeking to know more of his own traumatic
past, who is adopted by an eccentric uncle with a purposely secretive past.
Concomitantly, she inserts a subliminal spectrum of social, psychological,
political and ethical commentary worthy of our deliberation. The troubled lives
into which we are suspensefully enveloped occur within a milieu of sensitivity
and caring that leaves one with a powerful feeling of how even the most
challenging of lives can be fulfilled through a faith in the good that emanates
from human ties and associations.
What Prompted Dr. Shafer to Write The Mailbox
I work
at the Veterans Affairs Palo Alto Health Care System as an attending
anesthesiologist. In late 2002 and early 2003, during the build-up to the Iraq
War, I felt I became a witness for my patients. The veterans were anxious, as
was the country at large, about the impending war. In the short period of time
that I have to meet and talk with patients prior to entry into the operating
rooms, I found that my patients not only wanted, but needed to speak about
their own war experiences and to express their empathy for the soon-to-be
deployed soldiers. Just before induction of anesthesia may not be the best time
to talk about a buddy dying on the field in a war decades ago, but that is what
patients did. I was profoundly moved by this experience. I was honored to be
entrusted with listening to my patients' stories and concerns, and I came to
understand on a deeper level that the trauma of war experiences affects people
in various ways for the rest of their lives. . .
The entire review can be found at www.csahq.org/pdf/bulletin/issue_15/bk_revw_064.pdf.
* * * * *
10. Hippocrates & His Kin: Do All Federal Institutions
Squander Money?
Lawrence M. Small, the top official at the Smithsonian
Institution, accumulated nearly $90,000 in unauthorized expenses from 2000 to
2005, including charges for chartered jet travel, his wife's trip to Cambodia,
hotel rooms, luxury car service, catered staff meals and expensive gifts,
according to confidential findings by the Smithsonian inspector general.
Small, who in 2000 became the 11th Smithsonian
secretary, will earn $915,698 this year in total compensation -- more than that
of the outgoing president of Harvard University, which has an endowment about
30 times the size of the Smithsonian's. Over the past seven years, Small has
also received $1.15 million for making his house available for official
functions.
www.washingtonpost.com/wp-dyn/content/article/2007/02/24/AR2007022401510_pf.html
[At a $20 per year membership, looks like about 4500
members' dues were squandered on lasciviousness and, with a $2 million salary
plus housing allowance, another 100,000 members' dues were squandered. I'm glad
I gave up my membership last year. Looks to me like a few more Americans should
quit supporting government institutions.]
WellPoint
Announces the Retirement of Larry C. Glasscock as President & CEO
WellPoint, Inc. the largest U.S. health benefits
company, today announced that Larry C. Glasscock is retiring as President and
Chief Executive Officer, effective June 1, 2007. Glasscock will continue to
serve as Chairman of the Board. Concurrently, WellPoint's Board of Directors
has named Angela F. Braly as President and Chief Executive Officer and a member
of the Board of Directors, also effective June 1, 2007.
Glasscock, 58, has served as President and CEO of WellPoint,
Inc, (formerly Anthem Inc.) since 1999 and as Chairman since November 2005. He
joined Anthem Insurance in 1998. Under his leadership, WellPoint and its
predecessor companies grew from 6 million medical members and $6 billion in
revenue to more than 34 million medical members and more than $60 billion in
revenue today.
His supplemental retirement plan calls for a lump sum
payment of $31 million. Glasscock also has more than $55 million in
unexercised stock options.
But that's less than two dollars per member. Don't you
think that most Blue Cross members would want to contribute more to hishistheir
retirement so they doesnn't
have to downsize their homes and vehicles?
http://biz.yahoo.com/prnews/070226/nym081.html?.v=52
From London:
It is an extraordinary fact
that those who moan loudest about global warming, and enjoin us to alter our
lifestyles so as to minimise emissions, are very often themselves prodigious producers
of carbon dioxide.
This is not a case of
sinners who have repented urging us in the ways of righteousness. These people
are asking us to do what they refuse to do themselves.
Earlier this week, we learnt
[sic] that in the past 12 months the use of cars by government ministers
climbed by 20 per cent over the previous year. They bang on about global
warming and threaten us with new green taxes while actually increasing their
own carbon emissions. . .
The Mayor himself is a
serial flyer, accounting for 15 official flights abroad during this period, few
of which can have been absolutely necessary to the proper discharging of his
duties. . .
Even the saintly American
politician Al Gore, whose powerful film warned of the terrible dangers of
global warming, stands accused of consuming more electricity in his magnificent
20-room Tennessee home in a single month than an average U.S. household uses in
a whole year.
Despite his belief that
civilisation is threatened by man-made global warming, Mr Gore has been unable
to summon up the will to move into more modest premises, or to live by
candlelight in his existing mansion.
And so it goes on. Show me a
global warming zealot and I will very often show you a hypocrite.
A WWII veteran was seen and showed his Tri-Care card. He said it
took 57 years
for Congress to authorize what was promised him in 1945—TriCare for life—which
actually came about in 2002.
[There are still medical
societies that argue "government advocacy" as an inducement to
membership. But isn't 57 years longer than the average working lifetime?]
To read more HHK from our archives, please go to www.healthcarecom.net/hhk2000.htm#Top.
* * * * *
11. Organizations Restoring Accountability in HealthCare,
Government and Society: