Tuesday, August 30, 2011

Research in Guatemala Lacked Medical Ethics

The shocking details of  U.S. medical experiments done in the 1940's in Guatemala are just now coming to light.  A Presidential Commission for the Study of Bioethical Issues has been looking at medical "research" that was done from 1946-48 by the U.S. Public Health Service and the Pan American Sanitary Bureau.  This research in Guatemala was paid for by the U.S. Government and it involved deliberately infecting people with sexually transmitted diseases.  The researchers were trying to see if the new drug penicillin could prevent infections.

The full report is still pending but here is what we know now.  The researchers infected 1,300 soldiers, prostitutes, prisoners and mental patients with syphilis, gonorrhea or chancroid.  Only 700 of those infected received some sort of treatment and 83 people died.

One particularly egregious example involved seven women with epilepsy who were housed at the Home for the Insane.  They were infected with syphilis into the spinal column as a way to cure epilepsy (?).  All of the women got bacterial meningitis, likely from non-sterile injections.

Another female patient with syphilis was infected with gonorrhea in her eyes and elsewhere so researchers could see the impact of additional infections.  She died 6 months later.

Needless to say, none of this "research" produced any valuable information.  The main researcher, Dr. John Cutler also let experiments in Terre Haute, Indiana in which prison inmates were infected with gonorrhea.  The inmates were volunteers, although one has to question how much "freedom" an inmate would have had in 1943 to refuse.  The Guatemalan participants gave no informed consent.  Dr. Cutler was also involved in the Tuskegee, Alabama research where hundreds of black American men were deliberately left untreated for syphilis.  The experiment lasted a shocking 40 years, until 1972.

There is no doubt that these experiments are a crime against humanity.  Even though it seems like it was a long time ago and nothing like that could ever happen again, we must recognize that we face ethical issues in medicine all the time.  If we don't learn from the past, we are doomed to repeat it.  (Consider the genocide that is occurring right now in Darfur and the blind eye the world is turning toward it)

As shocking as these reports are, Dr. John Cutler was described as a research pioneer in his obituary when he died in 2003.  He rose to great prominence and accolades, despite behavior that should have led to jail time.   Check it out here.

Monday, August 29, 2011

Readmission After Hospital Discharge is Not an Indication of Poor Care

Hospitals across the country are working on quality initiatives to reduce re-admissions to hospitals.  There are consultants, conferences, forums, meetings, physicians, nurses and administrators who are spending hours upon hours (and lots of $$$) to find ways to keep patients who have been discharged from being readmitted within 30 days.  Why all of this activity?  It is one of the quality measures that is being tracked by Medicare and Medical (CMS) and decreased reimbursement will be next if a patient is readmitted to any hospital within 30 days of a discharge. The diagnosis doesn't matter.

A new study shows all of this focus and cost may not be worth it.  Readmission after a hospital discharge may not be an indication of poor care.

The study, published in the Canadian Medical Association Journal looked at 4,812 patients and had medical experts review the cases of the 649 who needed urgent readmission within 6 months. (Not one month as we are measuring).  They found that avoidable readmissions were relatively uncommon.  Only 16% could have been prevented by better care, oversight or management of their condition.  And a tiny number of readmissions within 30 days, as we are tracking, were potentially avoidable.

This makes sense to me.  They found patients who were readmitted had more previous hospital admissions and more extensive health issues.  And the patients in this study were even younger than the typical Medicare patient.  No one wants to be in the hospital.  Doctors do not want to admit patients unless they are very very ill.   Patients who have many medical problems like heart failure, strokes, liver failure, cancer etc tend to decline in health as time goes on.  All of the out-patient care and case management cannot always prevent declines.  The study points out that we might be measuring the wrong thing if we think it is a measure of medical quality. 

They did find some urgent readmissions were avoidable.  But it didn't vary by hospital ranking so either all hospitals are performing the same or it isn't really a measure of quality. 

Message to CMS:  Judgments about readmission cannot be determined on the basis of administrative data alone and it requires subjective judgement, detailed patient data, multiple reviewers and an analysis that accounts for differing reviewer accuracy when collating judgments.  This is a big waste of money.  Readmission within 30 days (or 6 months) of discharge is not a marker of quality care.




Thursday, August 25, 2011

Ten Things to Do Before Summer Ends

I can't believe August is almost over.  Here are 10 things to do before summer ends:

1.  Buy luscious fruit at a local farmer's market.  The tomatoes, corn,  peaches, nectarines and plums are in full bloom.  Buy local and enjoy tastes that need no extra sugar or seasoning. (I just ate the best cantaloupe I have ever tasted from our local market.  I didn't even know I liked cantaloupe)

2. Put on your favorite music and dance like no one is watching.  (Hey, no-one really notices except your teenage kid and who cares!)

3. Take a family (or best friend) day drive to a town or place you haven't seen.  (Be bold and spend the night at a cheap hotel with a pool, even if you have no reservations)

4. Get out in nature.  (Go on a trail walk, hike through the woods, take a picnic to the park)

5. Invite friends over for desert. ( No need to worry about dinner entertaining.  Wine and desert are perfect and stress free)

6. Walk barefoot in the sand or on lush grass.

7.  If you haven't taken a vacation, plan a "staycation".  (Take a week off work and sleep late, turn off the phone and computer, read a trashy novel and play with the kids or your friends.)

8.  Make a bread salad using farmers market or home grown tomatoes and bakery crusty bread.

9.  Buy fresh flowers for yourself and for a friend or neighbor (surprise them for no reason)

10.  Watch a sunset or a moonrise (or both). (For phases of moon see right side of this blog.)

I love summertime.






Wednesday, August 24, 2011

Price List for Medical Tests

I am smacking myself on the forehead and saying, "Why didn't I think of this?"  Dr. Richard Parker, Medical Director at Beth Israel Deaconess Medical Center,  has sent out a list to his physician colleagues of 56 common medical tests and procedures.  What is revolutionary is that there are prices next to each item.  You non physicians may be surprised to know that we doctors have no idea what the tests or drugs we order actually cost.  Unless we get billed as a patient, we are as clueless as you are.

As I wrote before, the ostrich excuse just won't fly any more.  We all need to be aware of the cost of care and have skin in the game.  Some will argue that price can't be the only driver.  I've heard physicians say you can't compare one price to another because "quality" costs more.  I say prove it.  If you have a quality product or are a higher quality physician, show us the results.  What are your outcomes?  Is your customer service better?  Is it worth the higher cost you charge?  Let's be transparent and let the patient determine what something is worth.

Separate from physician fees, however, is the variability and wide ranges in costs of similar tests. I hear from my patients who have high deductibles and pay first dollar coverage for their health care.   I frequently order a screening Vitamin D test and found out the patient was billed as much as $200 for one test.  A colonoscopy can cost as little as $1100 and as much as $2600.  That is a huge price variance.  What about ultrasounds and MRI scans?  The variation in price is astounding.

Dr. Parker says he "wants doctors to think about the cost of the things that they are doing." "We're not saying don't give patients what they need" , says Parker.  "We'll fight hard to get them what they need, but please don't give them what they don't need - we just can't afford that anymore."

I have been calling for transparency in pricing for a long time.  Patients and Physicians need to know what things really cost.  Maybe I'll try what Dr. Parker did for my area...if I can find out the prices, that is.

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Monday, August 22, 2011

Patients and Doctors Need Skin in the Game for Appropriate Care

Dr. Victor Fuchs, Ph.D. wrote an op-ed in the New England Journal of Medicine about "The Doctor's Dilemma - Delivering Appropriate Care".  Physicians are trained to deal with each patient one at a time and to make decisions based on that patient alone.  Now we are in an era when the high cost of treatment can actually bankrupt the system.  Rising health care costs are everyone's problem.  Employers are shifting insurance costs to workers and another article mentioned health costs as the biggest cause of bankruptcy.  Since the biggest driver of health expenditure is the doctor's pen, we can no longer think it is someone else's problem to solve.

A new Seattle Genetics cancer drug (Adcetris) will cost $121,000 for a course of treatment to treat Hodgkin's lymphoma. A new prostate cancer vaccine, Provenge, will cost $93,000.   When the FDA approves new drugs, they do not look at cost or cost/benefit ratios.  Most of the new drugs approved by the FDA offer marginal improvement over what is already available. The same is true for new medical devices (artificial joints, heart valves, robotics, and new scanners).

Is it worth $121,000 to live an extra 3 months?  What about an extra 6 months?  What about living an extra 6 months but spending most of that time in the hospital with serious complications? If the hospital down the street has a new $10 million dollar MRI scanner, to be competitive every other hospital has to buy one.  Does that raise the standard of health in society?  No, but it certainly drives up the cost of care for everyone.

None of these are easy questions and there are no easy answers.   What is "appropriate care" and who should be responsible for making cost-effective decisions?   On one hand we are seeing a Nationwide shortage of common drugs that are widely used because they are generic and the profit margin has disappeared for the pharmaceutical manufacturers. (I wrote about this a year ago!) The number of drug shortages has tripled since 2005.  A common cancer drug, Doxil, cannot be found and similar shortages of common antibiotics and anesthesia drugs are in short supply.  This is happening at the same time as the new $121,000 cancer drug is announced.

Make no mistake, we do have a fixed health care budget.  The Medicare bank is broken and the wave of baby boomers hitting Medicare age is just beginning.  Tough as it is, we need to develop policies that will allow everyone to live long and healthy.  We need to look out for the common good and society as a whole.   Determining appropriate care, based on our best science and evidence is a critical first step.

Doctors need to pull their ostrich heads out of the sand.  Patients need to quit demanding the "new new thing" that they read about or see on TV.  Everyone needs to know what items, tests and drugs actually cost.

Patients and Doctors need to tackle this one together and neither patients nor physicians have the luxury any longer of having unlimited health care resources without the responsibility of who will pay for it.

Saturday, August 20, 2011

Answer to Medical Challenge

The answer to yesterday's Medical Challenge is #3 - mucocele.

These lesions are nontender, smooth and usually translucent.  They are commonly found on the cheek or lip and can be the result of repetitive cheek or lip biting.  They usually disappear without any treatment.  Any new growth or lesion in the mouth should be checked out by a physician.

Thanks for playing.

Friday, August 19, 2011

Research Drug Might Extend Life for Obese

I usually choose not to write about the "new new scientific thing" that gets picked up by the press,  because early research is usually not reproducible and good science takes a long time to validate as true.  But since we know that mice and rats that are kept on low-calorie diets live 30% longer (and healthier) than their fat cohorts, I was interested in a new research compound, SRT-1720,  that was shown to protect obese mice from diseases of obesity.  Fat mice lived 44% longer if they were given this drug.

The "designer" drug works by chemically mimicking resveratrol which stimulates protective proteins called sirtuins.  These sirtuins regulate metabolism and are found with very low levels of calories.  Since most people cannot sustain a very low calorie diet indefinitely, nor can they drink 100 bottles of red wine a day to get resveratrol, SRT-1720 may lead to an answer to combat the obesity epidemic and the health problems that go with it.

Sirtris is the small pharmaceutical company that is studying SRT-1720.  They followed the chubby mice for three years and found SRT-1720 reduced the amount of fat in the liver and increased sensitivity to insulin.  Other drugs that are closely related to SRT-1720 are undergoing clinical trials in humans.

There should be much skepticism about this drug and others that promise longevity.  It is unlikely there will be a pill that will reverse poor eating habits or natural aging.  There have been hundreds (no thousands) of diet drugs and anti-aging drugs that have been developed and finally discarded when they do not work.  Even so, the diet business is a multi-billion dollar industry and big pharma will continue to try and develop a magic pill.

It is ironic that the more developed a country becomes, the more unhealthy the eating habits become.  




Thursday, August 18, 2011

Image Challenge

Here we go again where you get to be the diagnostician.  This young boy presented with a non-tender mouth lesion that developed with no known trauma or cause.  Can you guess the right answer?
Click on the image for a better view and then make your choice in the comment section.  Return tomorrow for the answer and bragging rights if you get it right.
1. Dermoid Cyst
2. Hemangioma
3. Mucocele
4. Mucosal neuroma
5. Pyogenic granuloma

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Sunday, August 14, 2011

What Pregnant Women Eat Influences Baby

Attention, pregnant women!  The foods you eat now might influence your babies' palates after they are born.  New research published in the journal Pediatrics, shows that the fetus actually drinks amniotic fluid in the womb.  The amniotic fluid is flavored by the foods the mother has recently eaten and flavors can be transmitted to the amniotic fluid and mother's milk.

It makes sense that as the baby is developing, memories are being created by a sense of taste.  Could what a mother eats influence food preferences and odor preferences for life?  Researchers fed babies cereal flavored with carrot juice vs. water.  They showed that babies who experienced daily carrots in amniotic fluid or mother's milk ate more carrot-flavored cereal and made less negative faces when eating it.

Julie Mennella studies taste in infants at the Monell Chemical Senses Center (Philadelphia) and she says it makes evolutionary sense because mothers tend to feed their children what they eat themselves and it is nature's way of introducing babies to the foods and flavors of their culture.  Babies need to like the food in cultures that eat spicy or pungent foods.

One thing I have observed is that babies will eat most anything (including vegies) until they are toddlers.  At that time they become picky eaters.  This, too, makes sense from a teleologic view because toddlers are on the move, putting everything in their mouths and a built in aversion to bitter or strong tastes could save them from eating poisonous plants.

Advice for pregnant moms:  Eat lots of deep green and colored fruits and vegetables as they have the most nutrients.  It's good for you and you might be helping your baby develop healthy taste.

Friday, August 12, 2011

Physicians and Pharmacists Scheme to Steal from Medicare

A large group of physicians and pharmacists were indicted today in U.S. district court of Michigan for healthcare fraud by billing Medicare, Medicaid and private insurers for illegally prescribed drugs.  Four physicians, 1 psychologist and 12 pharmacists used 26 pharmacies across Michigan to bill Medicare for Xanax, Vicodin and Oxycodone to the tune of at least $37.7 million.  They billed $20.8 million to the Medicaid program.

One pharmacist, Babubhai Patel, RPh, owned and managed the 26 pharmacies involved in the scheme.  He and his business associates gave kickbacks and bribes to physicians and podiatrists to write medically unnecessary prescriptions for patients.  They then billed third party payers for the fake encounters and bogus prescriptions.

What is even more astonishing is that these charges occurred since January 2009.  The pharmacies dispensed at least 4.6 million doses of Vicodin and 1.5 million doses of Xanax.  It seems that those amounts should raise a red flag somewhere.

I am pleased to shine a light on the indicted professionals.   I know they are presumed innocent until proven guilty but I expect a guilty verdict will be handed down so here they are:

Psychiatrist-Mark Greenbain, MD
General Surgeon and Internist-Paul Petre, MD
Internist-Mustak Vaid, MD
Podiatrist-Anmy Tran, DPM
Psychologist-Sanyani Edwards, PhD.

If guilty, I hope they serve long sentences for this crime.  It should be noted that the majority of physicians are struggling to survive under Medicare payments.


Answer -Scrotal Calcinosis

Readers of EverythingHealth have great diagnostic skill .  The correct answer to yesterday's Medical Challenge is #5- scrotal calcinosis.  These yellowish scrotal nodules are benign and have nothing to do with calcium or phosphate metabolism.  The cause is unknown.  It was first described in 1883.  Here is another photo of scrotal calcinosis.  




Thursday, August 11, 2011

This Weeks Medical Challenge

I know this will gross some of you out, but, hey folks, this is the wondrous human body!  (click on the image for a better view)

 Here is a hint:  These lesions are not tender and variations of this photo are quite common on men's scrotums.

Take your best shot at the diagnosis and make a comment.  The answer will be posted tomorrow so check back.  (Sign up on the right side of the blog as a subscriber and you will get an email link with each new post)

Tuesday, August 9, 2011

Family Diets

I'm just back from a safari in Tanzania and experiencing the culture, the animals and the beauty of that Country was a thrill.  Seeing how some of the traditional Massai and other African natives live reminded me of a fascinating comparison of how families around the world eat.  Check out Time Magazine's comparison photos from the book "Hungry Planet".  
One week diet for the Revis family of North Carolina

One week diet for the Aboubaker family in Chad


The Massai villages we saw were extremely impoverished and we were told they do not eat any fruits or vegetables.  I don't know how that is possible.  They have no water or electricity.   They walk miles daily to find water holes and one village has no water at all and needs to bring it in. (We paid $50 to visit the village and were told that money goes for water).

The Zebras, however, all are fat



This giraffe sucks on a bone to get calcium

This pair would rather mate than eat right now