The Doctor Weighs In

 

By Dov Michaeli MD, Ph.D

An article in the Sept. 17 2007 issue of Time magazine tweaked my interest. In it the author, John Cloud, argues that the recent crop of Republican homosexual legislators deserves our understanding of their weakness, rather the opprobrium of hypocrisy. To quote Cloud, he is offering “a moistly liberal request: Can we have a moment of pity for moralizers who fall?”

His argument runs as follows:

“Hypocrisy is among the most universal and well-studied of psychological phenomena, and the research suggests that Craig, Haggard and the others may be guilty not so much of moral hypocrisy as moral weakness. The distinction may sound trivial at first, but as a society, we tend to forgive the weak and shun the hypocritical.

Assume for a moment that Craig and Haggard actually believed what they said--that homosexuality is sin. They spent most of their lives fighting for the conservative cause. But in Craig's case, the Idaho Statesman has published allegations that there were at least three other slipups involving men, beginning in 1967. What if, like the radio host who gets fat but commits to losing weight, the moralizers were trying through their "pro-family" endeavors to expiate their lustful sins? You may think they are wrong about homosexuality (I do), but that doesn't make them hypocrites.”

With all due respect, this argument is not “moistily lliberal”, it is down right wrong on scientific and moral grounds.

What did  Larry (wide stance) Craig actually say? Here is one quote: “It is important for us to stand up now and protect traditional marriage, which is under attack by a few unelected judges and litigious activists”. Here is a man who married a woman and for decades fought against equality for gays.

So that we are not accused of picking on one unfortunate soul, remember Mark Foley?

Here is what he said: “For those pedophiles and predators across this country that have harmed or are considering harming a child, let me tell you that you are on notice… Your days in the shadows are over.” How prophetic, and how poetically just. This is the stuff Greek tragedies are made of.

Is it classical hubris, or is it hypocrisy?

The classical Greeks did not have Freud to kick around. They attributed human failings to hubris, a cardinal sin in the eyes of the Olympian gods. And the retribution that followed was swift and merciless. No moistily liberal excuses for them.

Two thousand years later, Shakespeare took a more nuanced approach to human failing. The hubris of the proud and vain King Lear had to be paid for, and dearly. But the process of suffering cleansed him of his hubris and opened his heart to love. His tragic death broke the hearts of millions.

Enter Freud, about 300 years later. His original psychoanalytic theories have been largely discredited, but the psychobabble residue they have left behind is still with us. Hence the “psychological” and moral sleight of hand a la Cloud: these people are not hypocritical at all, they are just weak.

Neurobiology refutes this argument

A recent review in Science (“Social Decision-Making: Insights from Game Theory and Neuroscience”) makes the point that social decision-making is controlled by a complex network of centers in the brain. The middle area of the prefrontal cortex (MPFC) and the area just below it (the orbitofrontal cortex, or OFC) constitute the “executive center”, making final judgments that balance inputs from the anterior and posterior cingulate cortex (ACC and PCC) which are the reward areas, and from the amygdala and the insula (AMY and INS), which process the more primitive urges, such as fright, aggression, hatred, rage, etc (Dr. Freud, is this the anatomical locus of your concept of the “subconscious”?).

What is important about this new research is showing the part of emotions in the overall mix of inputs into our decision-making. And this brings us to a potential explanation for what is called “cognitive dissonance”. What is meant by that is the nagging, and sometimes profound discomfort we feel when our behaviors don’t align with our beliefs. Our prefrontal cortex will keep nagging us, disturbing our peace of mind, interfere with our sleep, afflict us with unpleasant dreams—until we bring our behavior into alignment with our beliefs, which in reality are the products of the judgments made in the prefrontal cortex.

I accept that if you say one thing and then do another, the cognitive dissonance you will suffer is a result of your weakness. But when you do one thing and then say another—this is no weakness, this is willful hypocrisy. Larry Craig did not become a homosexual last month or last year. He was probably gay before he was a senator. Science tells us that he probably was born a homosexual. Mark Foley didn’t discover children when he first saw a congressional intern. They were most likely the objects of his desire decades ago.

Which leads me to the most “unmoistily liberal” conclusion: these people are hypocritical. The excuse of weakness or “the devil made me do it” doesn’t wash: Your prefrontal cortex warned you time and again that your behavior is reprehensible; you chose to ignore it. You did one thing and then chose to say or do something antithetical, in order to advance your political career. If the consequences began and ended with you alone—nobody cares. But your decision-making had social consequences. Your words, votes, actions— they inflicted grave harm on innocent people who have done you no wrong.

Dov Michaeli MD, Ph.D is in biotech and brooks no B.S.

by Pat Salber, MD

The cabbie who drove me from the airport to the hotel on my last business trip probably weighed 400 pounds.  We made small talk during the trip.  He told me he was hoping to leave Nevada soon and move to Oregon.  But, he said, it was tough getting the time and resources to make the move.

He works 12 hours days, six days a week.  The cab company deducts chunks of his pay  for their share of his revenues and to cover his health insurance premium and a tax on his tips.  His take home pay is $500 every two week pay period.

As we started talking about his health insurance, the conversation naturally drifted to health.  He is prediabetic, he told me, and his brother is a type 2 diabetic who has already had some toes amputated.  He knows he is facing the same future if he doesn't lose weight, but how can he do it?

When you drive a cab 12 hours a day, you often eat on the run.  That means fast food, high fat, and lots of calories.  Also, how do you fit in exercise?  Should he try to walk before the 12 hour shift or, perhaps, go out in the middle of the night when his shift is over? 

I found myself wondering what I would do if I were his doctor.  Of course, I would recommend he lose weight, alot of it.  And, I would tell him to get moderate to vigorous exercise 30 to 60 minutes a day.  I would prescribe any needed medications.  And, I would tell him to join WeightWatchers, or better yet an on-line weight loss support program, like PEERtrainer (www.peertrainer.com).

Chances are, in my 15 minute office visit, I wouldn't have learned about the challenges presented by his daily schedule.  I wouldn't understand that my recommendations were unlikely to be followed -- not because he wouldn't, but rather because he couldn't.

If something doesn't change, his prediabetes will most likely become diabetes.  He will probably have a heart attack or stroke or maybe, like his brother, he will end up with toes or feet amputated -- all potentially preventable if he could change his lifestyle.

At the end of the ride, all I could think of to say was that he needed to get a new job -- one that is less stressful and would allow him to exercise and eat better.  But I knew this too would be a daunting task given the long hours he already works and the meagerness of his financial resources.

I keep mulling over his story and wondering, how could you help this man?  I haven't come up with an answer.  Can you?

This is an oldie, but goodie, first published on TDWI September 15, 2006

by Pat Salber, MD

A small story in the business section of USA Today is good news (I hope). It says eleven major food companies, including giants Coca-Cola, Pepsi, and McDonalds will announce changes in how they advertise their products to kids. The Council of Better Business Bureaus (CBBB), in an effort to respond to the epidemic of childhood obesity, has organized the Childrens Food and Beverage Advertising Initiative to get food companies to “pledge” to stop advertising unhealthy products to children. These voluntary measures are supposed to go into effect by the end of 2008.

Evidently each company is making its own pledge. McDonalds, the article notes, will only promote meals with “no more than 600 calories, no more than 35% of calories from fat, 10% of calories from saturated fat and 35% total sugar by weight.” Is that dinner they are talking about? Or a mid-afternoon snack. When it comes to healthy eating, the devil is always in the details.  Products in Kraft Foods' Sensible Solutions line, which has less fat and calories than their other foods, will be the only types of products advertised to kids.

Although, the USA article was pretty positive about the Initiative, it did close with a quote from Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University. Brownell says that the food companies’ voluntary guidelines for advertising to kids “are a good move in the right direction, the risk is that it stops here.” We’ve all seen that happen before, right? It is the rare industry that voluntarily reigns in bad practices that are highly profitable.

 

Digging Deeper

This article motivated me to dig a bit deeper. According to a press release found on the CBBB’s website, the eleven companies* participating in its Childrens Food and Beverage Advertising Initiative, have

“pledged to focus essentially all of their advertising primarily directed to children under 12 on products meeting better-for-you standards or refrain from advertising to that age group.” (Better-for you, compared to what?? … the high sugar, high fat they were advertising to kids before?). Steven J Cole, President and CEO of the CBBB goes on to day, “These expansive commitments significantly exceed the Initiative’s baseline requirements.”

 

The Pledges

Here are some of the pledges:

McDonalds:

All advertising primarily directed to children under 12 will be for meals that meet “specified calorie, fat, saturated fat, and sugar limitations consistent with the Dietary Guidelines for Americans 2005 and other government standards. They will restrict their advertising to the “Advertised Meal” that must provide no more than 600 calories; and no more than 35% of calories from fat, 10% of calories from saturated fat, and 35% total sugar by weight

The “Advertised Meal” will either be a 4 piece Chicken McNuggets® Happy Meal with low fat white milk and apple dippers with low-fat caramel dip or a Hamburger Happy Meal with low fat white milk and apple dippers with low-fat caramel dip. Scroll down to Appendix A of the pledge to see the details of what’s actually in the “Advertised Meals”

Kraft Foods

Kraft has pledged to only advertise products to children that meet its Sensible Solution nutrition criteria. Cool Whip Lite, Honey Maid Bees, Oscar Mayer Fat Free Wieners, and Lunchables Pizza are some of Kraft’s Sensible Solution products.  (Want to see the rest?  Here's the link to Krafts' Sensible Solutions products.)

General Mills

General Mills will no longer advertise to children foods with more than 12 grams per serving. (Be careful with this one, serving sizes are usually a fraction of what actually gets poured into the bowl or put on the plate). They also pledge to advertise only Healthy Dietary Choices to children under 12.

In fact, according to information on the CBBB website, General Mills has partnered with Nickelodeon (scroll down to page 4 of the pledge) to bring the popular Nickelodeon characters SpongeBob SquarePants, Dora the Explorer and Diego to frozen and canned vegetables. The goal is to make eating vegetables fun for kids. Each package of frozen vegetables will also include stickers featuring the characters that parents can use to reward children for eating their vegetables.

Note, these are frozen and canned vegetables – not the fresh kind that you can get for a fraction of the cost in the veggie section of your local market. And, it is of interest, that the brands touted in the pledge are frozen beans and frozen broccoli with butter sauce!

 

Never good enough.

I could go on and on, but you are probably thinking. What a crab…nothing is ever good enough. Well, in the midst of an obesity epidemic that threatens the world’s children with early onset chronic diseases and a shortened lifespan, then, heck yeah, promoting frozen buttered broccoli instead of the fresh kind and “apple dippers with low-fat caramel dip” instead of real low fat, fresh apples is not really good enough.

Let’s keep on pushing and pushing until the industry really gets it right. But, we have to do more than blab about it. We have to buy better, cook better, eat better and, in this way, fundamentally change the market for food.

Big job? You bet? But it can be done. Just the fact that these eleven companies are now trying to figure out how to market healthier foods indicates that they will respond to consumer demand (and regulatory threats). When more and more of us choose to shop in the outer perimeters of supermarkets (where the fresh foods are) or in local farmers’ markets, you can bet that industry will be watching.

Pat Salber, MD

By William Bestermann MD

 

Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions.

Many professionals in positions of leadership today were educated in the 60s, opposed the Vietnam War, and viewed military intelligence as an oxymoron. But my oldest son, a West Point graduate, has taught me lessons that have changed my life and are relevant to the major conundrum facing medical practice today.

West Point places a primary stress on technical adaptation.  These young cadets are taught “Tactics Lag Technology.”  That is to say if the officer applies tactics appropriate to the last war in the face of more deadly weaponry in the current war, he will likely be responsible for the deaths of hundreds if not thousands of his personal friends, team mates, and countrymen.  Military officers, in their movement upward in rank and responsibility, learn of our own new technical capabilities, those of potential enemies, and how to integrate these into best military practices to minimize casualties while increasing the likelihood of success of the mission.  This is a central focus in military culture.

First, a bit of military history

These cultural attributes of the modern American military officer did not just drop out of the sky.  West Point cadets study the American Civil War in some detail.  That conflict saw the beginning of dramatic technical change including railroads, rifles in large number, and trenches that transformed warfare forever.  Prior to the War Between the States, for thousands of years, generals managed the attacking force in the same way.  The defenders would line up over a broad front, in ranks perhaps two or three deep, over a couple of miles depending on the size of the force. The attacking force would assemble in front of them in full uniform with color guards and regimental bands playing marching music.  Then the attackers would march to within effective range of their weapons.  As the Civil War began, most units were armed with muskets and the effective range was 40 yards.   So the Union and Confederate units would march to within 40 yards, fire one volley or perhaps several followed by a bayonet charge.  The carnage was not terrible and the loser was the one who lost his nerve and abandoned the field.  

As the war progressed, both sides replaced muskets with rifles and the defenders dug trenches.  As the Confederates prepared for Pickett’s charge at Gettysburg, the Union troops were behind a stone wall defense and armed with rifles.  Nearly a mile of open field lay between the opposing forces.  The Southern Commander Robert E Lee had ordered the charge, but Corps Commander Longstreet objected, simply knowing by observing the situation that the mission was impossible.  General Lee ordered him to charge the Union force in spite of the objection and Pickett’s Division was cut to pieces in a matter of minutes.

The following spring, US Grant had assumed command of all Union armies.  He was determined to end the war by capturing Richmond and crossed the Rapahannock River to begin what became the Overland Campaign.  In battle after battle, the Union forces charged entrenched confederates, with the same resulting horror the Confederates suffered at Gettysburg.  General Grant suffered 60,000 casualties in the month of May 1864 alone.  The puzzle of the rifle and the trench never was solved in the Civil War.

Amazingly, when WWI started 50 years later, tactics had still changed very little, though the technology of war had changed dramatically.  The forces involved had tanks, airplanes, machine guns, repeating rifles, mortars, breech loading artillery, trenches, and barbed wire at their disposal.  The method of attack had not changed.  The frontal assault was still the order of the day.  The British suffered 60,000 casualties on the first day of the Somme offensive.  The generals still did not get the message and over the new few months 500,000 promising young men were shot down in that single campaign.  WWI ended and the puzzle of the repeating rifle, trench and machine gun was still not solved.

The wrath of the status quo

The terrible carnage of WWI broke the spirit of Europe and there are still residual cultural effects on that continent.  In the aftermath, the promising young American officers Dwight Eisenhower and George Patton wrote infantry journal articles describing a new kind of attack that would later be called “blitzkrieg” or lightning war.  In this assault, all of the heavy weapons of the attacking force would be combined in units actually making the assault.  All of the tanks, artillery, bombers, machine guns, mortars and mechanized infantry would be thrown at the weakest point in the enemy line. They would break through, and turn left and right to “roll up” the force in the trench.  History has shown this to be a brilliant disruptive innovation in warfare and frontal assaults no longer occur.

How did the senior army leadership respond?  The Chief of Infantry called Eisenhower in and told him that his articles did not represent sound infantry doctrine and that if he wrote any more articles of that nature he would be court-martialed.  Billy Mitchell actually was court-martialed for advocating similar valid innovative disruptions in the army air corps.  Thank goodness the innovations advocated by Eisenhower, Patton, and Mitchell were adopted and played a critical role in WWII.

The change from frontal attacks to the attack of supreme violence aimed at a point is a very dramatic example of paradigm change.  The whole dynamic of combat changed from a defense that could not be overcome to an attack that could not be resisted.  The officers directing the blitzkrieg assault were not more diligent, more industrious, smarter, brighter or more dedicated than their predecessors.  No, they were not superior in any way-they had simply used a new system, a new application that was more effective.

So what does all of this have to do with medicine?  

You might think “How could these people be so blind? We would never do such a thing.”

Think again!  The science around medical practice in the treatment of atherosclerotic vascular disease has utterly changed.  The evidence that demands a change in paradigm has become irrefutable.  The technology of vascular medicine has progressed at a pace fully equal to that seen in the military.  The old attack on vascular lesions in stable patients aimed at fixed narrowings – bypasses and stents – are as thoroughly discredited as frontal assaults in the face of machine fire. (More on this in another post.)

The Institute of Medicine is the medical arm of the National Academy of Sciences.  The IOM membership is composed of 1,400 of the best minds in medicine.  In its 2001 report, “Crossing the Quality Chasm,” the IOM summarized what was needed to treat chronic conditions:

“The current systems cannot do the job. Trying harder will not work.  Changing systems of care will.”

This document is the medical equivalent of the infantry journal articles written by Patton and Eisenhower.  It is a call to action and change, yet little in practice has changed since it was published in 2001.  Why?  The Chief of Infantry is alive and well.  Paradigm change has dramatic consequences and, for the leaders of the old order, the changes are negative.

The consequences of the utter failure of leadership in this case are exactly the same as a frontal assault: thousands of dead and disabled as a monument to our inaction.  Heart attack and stroke accounted for roughly 800,000 deaths in 2003. Many of these deaths were premature and avoidable. The bodies may not lie in heaps before a trench-line, but they mean the same thing: a failure to bring the full benefit of new technology to those we have promised to protect. 

There is a very real price to be paid for our failure to translate our new scientific knowledge about vascular disease into practice.  The Steno II trial compared optimal medical care (that is, drug therapy) in type 2 diabetes to usual care, and reduced the number of vascular events by half.  Only a small percentage of the study's patients had to be treated more aggressively to prevent a heart attack or a stroke.

The type 2 diabetic has a lifetime risk of dying from a vascular event of 65-80%.   Each risk factor - glucose, pressure, and cholesterol - treated to goal using the right medication reduces the risk of a vascular event by half.  Only 7% of type 2 diabetics have all three risk factors simultaneously to goal. 

Our failure to provide more aggressive risk factor management in these patients obviously is very damaging to their health.  The economic cost is equally painful.  Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions. In stable angina patients, optimal medical therapy was just as good in preventing a heart attack in a stable angina patient as optimal medical therapy plus a stent—for one third of the cost.

If current trends are any indication, medicine, the insurance industry and government will be slow to lead on transformation.  Patients and businesses that pay the bills must demand better or continue to receive medical care that is not what it could be.

Dr. Bestermann is medical director of the Vascular Medicine Center at the Holston Medical Group in Kingsport, Tennessee.

by Brian Klepper

I routinely hear well-intentioned people say that, if Americans, and most particularly kids, would just become more responsible for their own health and start eating right, then our obesity and diabetes epidemics would turn around.

I don't think this is going to happen, at least not anytime soon. The blunt truth is that, to a large degree, we have an obesity epidemic because Congress ensures that the food industry has free rein with their marketing practices.

Late last year, Pat Salber wrote a post – she had a corresponding video commentary on Medscape – on advergaming. An important study had been released on the Kaiser Family Foundation website that detailed how food companies were using the Web to influence kids' eating behaviors, building on their TV advertising tactics. Here's a quote from the press release:

The report, “It’s Child’s Play: Advergaming and the Online Marketing of Food to Children,” found that more than eight out of ten (85%) of the top food brands that target children through TV advertising also use branded websites to market to children online. Unlike traditional TV advertising, these corporate-sponsored websites offer extensive opportunities for visitors to spend an unlimited amount of time interacting with specific food brands in more personal and detailed ways. For instance, the study documents the broad use of “advergames” (online games in which a company’s product or brand characters are featured, found on 73% of the websites) and viral marketing (encouraging children to contact their peers about a specific product or brand, found on 64% of sites). In addition, a variety of other advertising and marketing tactics are employed on these sites, including sweepstakes and promotions (65%), memberships (25%), on-demand access to TV ads (53%), and incentives for product purchase (38%).

In 2005, Consumers Union issued a report on the food industry's advertising campaigns. That press release headline read:

Certainly, the data say we're losing the war on obesity. Data from two National Health and Nutrition Examination Surveys show that the prevalence of obesity in adults (aged 20–74) more than doubled between the end of the 1970s to the early 2000s (from 15.0% in the 1976–1980 survey to 32.9% in the 2003–2004 survey).

Children and teens also grew significantly plumper. The prevalence of obesity in children 2–5 years rose 2.5 times, from 5.0% to 13.9%; for those aged 6–11 years it nearly tripled, from 6.5% to 18.8%; and for the 12–19 year olds, it more than tripled, from 5.0% to 17.4%.

It's worth noting that, while obesity has intensified throughout the country over the last several decades, certain areas, like the South, are consistently worse than elsewhere. This is traceable in part to regional dietary habits that, of course, long predate the food industry's influence, as well as to the role of poverty.

Percentage of Obese Americans - 2005

BMI > 30, or ~ 30 lbs. overweight for 5'4" person

 

 

 

 

 

 

 

Source: Centers for Disease Control, Behavioral Risk Factor Surveillance System, 20006 

(If you're interested in seeing the CDC's 20 year (1985-2005) annual trend data on overweight by state, go to http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm, and look for the link that says "Download the Obesity Trends Map." Play the slides in quick sequence. It's very alarming to watch as the entire country lights up, reflecting how quickly we're getting fatter.)

The reality is that most of us are susceptible to the marketing, and can't withstand the barrage of enticements. And they're everywhere. Every day, Americans are bombarded by come-ons for fast, prepared and junk foods. This diet has become part of many people's regular routine. The industry now vies to subsidize school districts in exchange for the unrestricted ability to advertise, put in vending machines and have their products available in cafeterias. They have developed books for very young children with appealing characters to create brand loyalty early on,

And except for the unhealthy part, what's not to like? These foods are cheap, readily available and, lets face it, all that salt and fat taste really good. Only the most optimistic among us can imagine that, unless something dramatic changes, we'll be able to reverse our love affair with bad food. Nor will any of the other developed and developing countries that all have the same problem.

The food industry has virtually unrestrained promotional access because Congress has willfully ignored their role in the obesity problem, preferring instead to argue that if people were just more responsible as individuals, they'd get this under control. (A quick glimpse of our Congressional representatives shows that, when they preach restraint and self-control, they're talking about us, not themselves.)

 The threats are to the national health and the national pocketbook. At the moment, for example, diabetes and related conditions alone cost Americans about $165 billion a year, about 8 percent of the national health care spend. And we're just getting going. As the population gets fatter, this is going to be a blockbuster national health care problem. Nobody will be able to afford what, in today's terms, we'll be expected to pay to keep all these people alive, semi-well, and consuming.

Congress has good reason to advocate for the food industry, in the form of millions of dollars in lobbying funds that go to buy influence. Skeptical? Go to www.opensecrets.org, the site of the Center for Responsive Politics, a non-partisan group dedicated to accountability in government, and do some checking yourself. Big dollars from the food, beverage, candy and restaurant industries to Congress, part of the larger $2,5 billion dollars that were distributed in 2006 to our 535 representatives. This is the way it is with virtually all special interests. Most effective groups lobby. Why? Because it works!

There are, of course, precedents for change. Congress decided that the tobacco and alcohol industries would be limited in where and how they could advertise, actions that have had profound impacts on America.

It's absolutely in the national interest to turn this problem around. But unless we have dramatic change from elsewhere – chemical concoctions that make junk food taste as good but have no ill effects, or some miraculous national consciousness-raising (Not impossible. Check out the teen fitness program Dance Dance Revolution or consider how the green movement is sweeping across the globe.) – we won't change our obesity and chronic disease problem. To fix that, we'll need a change in how the food industry behaves. And to get that, we'll have to change how our government works.

(The same is true, by the way, for health care reform, but that's another post.)

Brian Klepper is a health care analyst based in Atlantic Beach, Florida. You can reach him at bklepper@gmail.com.

Welcome to Margaret (aka Maggi) Cary, MD, our newest TDWI writer.  Maggi is a Washington DC-based physician executive and writer who will share her stories about doctors and patients.  Here is her first TDWI post - a story she previously published in The Washington Post:

 

Answering a Cry for Help With a Touch of Humanity

By Margaret Cary

Special to The Washington PostMonday, November 7, 2005; C10

 

"My papers . . . my paaaapers."

I was at a Falls Church superstore checkout counter when I heard her cry. My first reaction to nonthreatening inappropriate sounds is to ignore them and leave the area as soon as possible.

"My papers . . . my paaaapers."

I turned to look and saw three store employees around a sobbing middle-aged woman. I returned to the checkout.

"My papers . . . my paaaapers."

I was tempted to just leave the store with my purchases and go on to the next errand. I walked toward the woman instead.

By now there were four people around her, all looking uncomfortable. Store security had arrived. I said, "I'm a doctor." They looked at me with the tiniest hint of relief.

It had been so long since I was in the doctor role that I took a few minutes to think this through. I am in administrative medicine, so I do not carry malpractice coverage nor am I licensed in Virginia. Fortunately the old training seems to be hard-wired and returned immediately.

Rising above all other thoughts in my mind was that this was a person in trouble. And the folks who would like to help her were at a loss. Mental health issues are still not understood. People with them are not given the same sympathy and patience given to heart attack victims or amputees.

I took stock of her: White female, between 50 and 60 years old, she looked well kept, was wearing clean clothes, gold jewelry -- just enough, not flashy, had a nice haircut and was sitting on the bench at the store's entrance, wailing. Stroke? Maybe, but not anything that affected her physical mobility. Yes, she was using a walker, but did not seem to favor one side. Her facial muscles were intact. She was perseverating, repeating the same phrase over and over. Maybe a mental challenge? Could be. You know how you know when pets are lost and not strays? They have the look that someone cares for and about them. She had that.

I sat on the bench beside her. I looked into her eyes and said: "I'm a doctor. Can I help you?"

I wanted to touch her, to make that human connection. Touching, now there is something that has changed in the last couple of decades. The only safe place to touch someone is on the shoulder and elbow and the upper arm. I took a chance and touched her forearm, then held her hand.

"My papers . . . my paaaapers."

She started to make a call on her cell phone and then handed it to me, seeming confused. No numbers saved. When I handed it back, she called a number and howled into the telephone. She handed the telephone to me again. I introduced myself and then asked with whom I was speaking. He told me he was her husband and that she had lost her prescription, but her brother, a doctor, would call in a new one. He could not come to get her because he had bad knees.

At the end of the call, she jumped up and started across the store, tears dried, and retraced the steps several store employees had already made, looking for her lost prescription. I walked alongside and called her husband. I asked him to explain to her that she would get a new prescription, which he did and she stopped.

I retrieved my cart and started to leave. "Thank you for your help," a store employee said. "You were really good with her." I sensed that the employee wished she could have done more for the woman.

"Anyone could do it," I said. It's about talking with someone at his or her level. It's also about the physical contact. I remember a teacher once telling me to touch patients or they might believe you thought they were untouchable. Of course, you have to be careful.

I thought to myself, we lose something by being afraid of each other.

I was relieved that store personnel had not called the police, which people sometimes do when others are acting oddly, seemingly without reason and creating a scene. That is often the quickest, easiest way to eliminate someone acting out of the ordinary. We are unused to helping someone who might benefit from our taking the time to listen. We don't know what to do and so calling the police or an ambulance often seems the most expedient solution. We still have a long way to go with mental health patients.

I reflected on my initial reluctance to get involved -- too busy, I might be sued, what can I offer anyway.

Fortunately, my core, unprocessed feelings came to the surface, overriding the cool, "sane" approach. I helped someone in trouble, one of the main reasons I went into medicine. That compassion and desire to be of service were still with me.

I headed for the door.

Dr. Cary is Director of the Washington, DC office of the Institute for Medical Leadership.

by Pat Salber

When I wrote about the food industry marketing sweetened, energy dense foods to kids in my post titled: "Is the food industry playing games with your children:  You bet it is," I got the usual spate of email comments telling me that it is not industry, rather it is parents, that should be faulted. After all, these folks argue, parents, not kids buy and serve the food. (Yeah, but I contend the industry wouldn’t market this stuff to kids if it didn't pay off…but that is another story.)

Now, the NY Times tells the story of an angry mom taking on junk food in her kids’ schools. The story, titled Child Nutrition: Two Mothers, a Camera and a Look at School Lunches, was emailed to me by Karen, my husband’s daughter and the mother of our lovely 3-1/2 year old granddaughter, Rebecca (nicknamed Tupy). Karen is also an angry mom…angry about the food being served at Tupy’s preschool. Read what she has to say:

“It’s gratifying to read about pissed-off parents in other places. I’ve been battling her daycare on the food issue for months. I’ve hated to be a hothead there because, after all, Tupy still has to go there. I don’t want her to be treated poorly because of her outspoken mother, but the menu is truly appalling. She used to love vegetables and beans and fish, and the day she came home asking “why can’t we have donuts and hot dogs like at school?” is the day I went to war.” 

The NY Times tells the story of Susan P. Rubin, a woman on a mission to improve the quality of food in schools:

“She has emptied a bag of vending machine items onto a principal’s desk; she has delivered impassioned testimony to members of the Institute of Medicine of the National Academies in Washington while holding up potato chips and lollipops; and she has sneaked cafeteria food out of her children’s school after being barred from showing up without an appointment.” (Barred from her kids’ school? Come on now.)

Susan Rubin and another angry mom, Amy Kalafa, a filmmaker from Weston, Connecticut have made a film on the topic. “Two Angry Moms” is a 90-minute documentary that…

“…presents the good (a schoolyard in Katonah where students grow their own vegetables), the bad (chips and soda for lunch), and the ugly (what it is really like inside a school cafeteria kitchen).”

The Katonah-Lewisboro School District that is featured in “Two Angry Moms” paid attention to Susan Rubin. According to the NY Times article, “the district changed its lunch policy, even hiring an outside chef to train food service staff. ‘We went from refrying processed chicken nuggets to grilling fresh chicken breasts and making homemade apple crisp,” said Donna D. Walsh, a member of the Katonah-Lewisboro Board of Education.’”

Rubin has formed a better school food advocacy organization, named, obviously “Better School Food.” There is a lot of good information on the site. If you are a parent, aunt, uncle, teacher, friend or neighbor of a school kid (remember the concept: “it takes a village” -- then check out their website.)

Rubin and Kalafa plan to spend the summer trying to raise money for the film’s national distribution in the fall. If you want to learn more (or write a check), there is a link on the Better School Food website that will help you do that. You can also view clips from the film.

Here’s to all of the angry moms and dads and grandparents out there who believe we can do better and then roll up their shirtsleeves and get to work. Thanks, Karen, for sending me this article.

Pat Salber, MD

Here is the first post of new TDWI writer, Brian Klepper, PhD -- a different kind of doctor, true, but one who knows the health care industry inside and out.  Dr. Klepper is the Founding Director of the Center for Practical Health Reform, a broad-based non-partisan effort to re-establish stability and sustainability to American health care.  He is also an independent health care analyst.

 

Here you go:  The cognitive dissonance of conflicted care

A few days ago the New York Times ran yet another article exploring the deep financial conflicts in oncology drug prescribing. This one described two facts.

First, even though Medicare has limited the profits of oncologists who prescribe drugs, Medicare’s total cancer care expenditures keep rising because oncologists have found new treatments and procedures to bill for.

Second, the rules guiding Medicare reimbursement for cancer and drug rebates are complex, compromising the financial abilities of some oncologists – particularly those in smaller practices – to administer drugs to their patients. As a result, those patients often must receive the drugs in more costly and possibly less-friendly hospital settings.

Over the last year, the Times has been on this topic like white on rice. Last month it ran an article on conflicts in anemia drugs, which demonstrated just how much money was available to doctors who prescribe them. A just-fired practice administrator of a six-oncologist group in the Pacific Northwest presented the Times with papers from Amgen. They showed that, over the past year, physicians in that practice had written $9 million in prescriptions for the two anemia drugs Aranesp and Epogen. Amgen returned the favor with $2.7 million in "rebates." These numbers work out to $1.5 million/physician in prescriptions, with returns of $450,000 (30%) per physician and profits of $300,000 (20%). The Times also ran a chart showing that dosing levels in the US, where rebates that encourage more prescriptions are standard practice, are as much as three times higher than in other countries where the rebates aren’t permitted. (Whether outcomes are better here is not clear.) These drugs were only two of many that oncologists prescribe, and there are rebates associated with many of those others as well. Of course, oncologists also make money, though far less, for actually being doctors.

I distributed the anemia drug rebate article to my network, which includes a number of cancer professionals. One response, from a nationally known oncologist, said, “If I don’t have the rebates, my income will go down!”

I first became interested in oncology drug practices about a year ago when the Times reported on a study that had been published in Health Affairs showing that oncologists prescribing behaviors were influenced away from best practice and toward the incentives provided by their rebate arrangements. The study had been conducted by highly credible health services researchers using a large sample of Medicare claims data from 1995-1998.

While the study’s findings were interesting, they were hardly news. After all, financial conflicts permeate every area of health care. Far more interesting was the righteously indignant response from the Community Oncology Alliance, a professional group that represents private practice oncologists. In the opening sentence of a remarkable email distribution to its membership, Steve Coplan, the administrator of the West Clinic in Memphis, called the report “incredibly outrageous and unsubstantiated” and “an unbelievable rehash.” Sentence two referred to “incomprehensible statements by government bureaucrats, so-called oncology advocates, well-paid consultants, non-practicing physicians, payers and specialty pharmacies.” In other words, only community oncologists can understand or question the deep complexities inherent in the practice of cancer care. Everyone else is infused with malevolent intent.

Many oncologists will tell you that rebates cover the costs of drug administration and are necessary because 1) Medicare doesn’t pay for office administration and 2) Office administration costs far less than it would in a hospital setting. In effect, the drug companies convinced Congress to let them pay for these services, though the compensation is far more than Medicare would ever pay. This gave them significant influence over the practice patterns of the nation’s community oncologists.

Medicare could correct this situation by outlawing drug rebates to oncologists (and other physicians), while paying doctors a reasonable rate to administer the drug. Medicare and commercial plans could offset the additional cost by reducing reimbursement to the drug companies by about 20 percent, or the amount of the doctors’ rebates.

The recent exposure in the Times, the Wall Street Journal and other major papers has shone a bright light on the uncleanliness of these practices, and many oncologists have complained to me that they’re feeling picked on. I’m sure the drug companies aren’t crazy about it either. The typical oncologist now makes about twice as much from drug rebates as from practice. Of course, they’re not happy at the prospect of losing any of that income. We can be certain there’s a great deal of maneuvering going on behind the scenes by pharma and the oncology lobby as Medicare reassesses its approach.

It’s a fascinating problem. Oncologists (correctly) see themselves as righteous practitioners, caring for very sick and sometimes terminal patients and families in the most distressed periods of their lives. It appears very difficult for them to confront the fact that the way the money works maybe isn’t so healthy. They argue that they’re simply following the incentives that have been set up for them, without acknowledging that their complicity compromises patient care, their own position, and the stability of the larger health system.

I have an article in the journal Community Oncology this month that calls on oncologists to look squarely at this problem, understand the damage it's doing to their credibility and reputation, and work with the various payers to remedy it. The rebuttal article, by the prominent and dedicated Linda Bosserman MD, raises all kinds of peripheral questions involved in drug rebates that were, to me, obfuscatory and beside the point. And there lies the rub. Ultimately, she argues for the same things I do – for changes to the reimbursement mechanisms that keep clinical decision-making detached from financial consideration. But it is difficult for her to directly confront the financial conflict inherent in the current system.

As Dr. Michaeli has argued in this blog before, a new transparency is uncovering excesses in every health care sector. People outside the industry are shocked by what they see as egregious behaviors, and hopefully their recognition will eventually have a cleansing impact on how health care is supplied, delivered and financed in this country.

We know that half or more of health care cost is wasted, inappropriate or unnecessary, largely the result of the behaviors discussed here. Until financially conflicted health care is addressed in oncology and elsewhere, we don’t have the remotest chance of re-establishing stability and sustainability to American health care.

 

Photo by Mark Boster, LA TimesThis story, from the Los Angeles Times,  is so outrageous I have to take a few deep breaths before I tell it.

Edith Rodriguez died in the ER…not on a gurney surrounded by doctors and nurses desperately trying to save her life. She died on the floor of the lobby, lying in her own blood as a janitor mopped up around her.

Jose Prado, her partner, tried to get the attention of Los Angeles’ King-Harbor ER staff, but he was ignored even though Edith was writhing in pain and spitting up blood as she lay on the floor. He called 911 from a pay phone only to be told “Paramedics are not going to pick…his wife up, from a hospital, because she’s already at one.”

An unidentified woman, perhaps another patient, jumped in to help. She also called 911. According to the LA Times, here is what took place:

“After a short debate about whether the call was an emergency, the dispatcher scolded her and insisted that it was not. The 2-1/2 minute call ended on a hostile note. ‘May God strike you too for acting the way you just acted,’ the frustrated caller told the dispatcher, just before 2 am on May 9. ‘Negative ma’am, you’re the one,’ the dispatcher responded before disconnecting.”

Edith Isabel Rodriguez died 17 minutes later. She died of a perforated bowel.

Ms. Rodriguez had sought care at the King-Harbor emergency room three times in the days leading up to her death. A perforated bowel leads to peritonitis one of the most painful conditions known to man. Each time, after she was seen, she was discharged from the ER with a prescription for painkillers. As an emergency physician, I am appalled that this diagnosis was missed – not once, not twice, but three times.

On the day before her death, rather than leave the hospital, she lay down on one of the benches in front of the main entrance. The police found her there and helped escort her back to the Emergency Room where she was summarily dismissed:

“A triage nurse told Rodriguez that nothing could be done to help her.”

I think what the nurse was really trying to say was that nothing would be done to help her.

This story shows a failure, not just of King-Drew hospital, but of the entire health care system. This story
King Harbor Hospitalhappens to be about a hospital in Los Angeles with a troubled history: The US Centers for Medicare and Medicaid Services has repeatedly found Martin Luther King Jr.-Harbor Hospital out of compliance with its minimum standards. In September of 2006, the hospital was informed that it had failed a critical inspection and that it would lose annual funding of about $200 million (more than half of its budget).

Rather, the failures here are much larger than any one hospital. It starts with our country’s refusal to enact universal health care coverage. Although it may seem like it saves money, at least in the short run, by not providing care to poor people, it does not. An analysis by the New America Foundation, in support of Governor Schwarzenegger’s universal health care proposal, shows that costs actually increase when large numbers of people are uninsured. That is because, most of the time, we don’t let people die - untreated - on the floor. Instead, we provide the care and shift the costs onto insured people – raising costs for companies and public entities that provide health insurance.

Then, there is the callous disregard for human suffering shown by the individuals manning the phones at the 911 station. I know these jobs are stressful, but arguing with desperate callers about what is and is not an emergency is dismaying.  But, missing the diagnosis of a treatable condition on three different occasions is inexcusable. Perforated bowel and peritonitis are not subtle conditions. Even in the busy, overworked and understaffed conditions of a county hospital, surely someone could have recognized that this woman was really sick.

And, finally, letting a woman die in a pool of blood in the lobby of an emergency department is nothing short of criminal. What did they think?…she was faking her symptoms?

If I had told you that this took place in the inner city of some third-world country, you probably would have clucked your tongue and thought to yourself: “How lucky I am to live in America.”

But, guys, this is America. This happened in Los Angeles, home to the rich and famous. This is a story that ought not to die. It should be cited repeatedly in the next months and years as we debate how we are going to -- finally --  reform health care in this country.

Edmundo Rodriguez, Edith’s 25-year-old son is quoted as saying “We know we have the responsibility to make sure justice is done for our mother. We just don’t want this to happen again.”

I say, the responsibility should not rest solely with Edith’s loved ones. It needs to belong to all of us. We all helped create the environment that led to this tragedy. And, so we all need to tell this story to our politicians and policy makers, over and over again.  We should not -- must not -- stop talking about Edith Isabel Rodriguez until we have fixed this terribly broken “system.”

Pat Salber, MD

 

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There is alot to like about Arnold's health care proposal

As I wrote earlier, President Bush has vowed to veto the bipartisan Stem Cell Research Enhancement Act, SB5, when he returns from his European trip. This bill offers hope of a cure or, at the very least, more effective treatments for many chronic illnesses, including Types 1 and 2 diabetes, Parkinsons, Alzheimers and many others.

In an eloquent Op-Ed in the San Francisco Chronicle, Dwight Holing, a member of the national Board of the American Diabetes Association, explains why this bill is so important. (I have had the pleasure of serving as President of the SF Bay Area's ADA Leadership council with Dwight serving, until recently, as Chairman.  When Dwight speaks on the subject of diabetes, we all should listen.)

Here are some excerpts from his opinion piece [with my comments inserted in brackets]:

 

Dwight Holing, ADA board member"Like his failure to take global warming seriously, President Bush's decision to [once again] ignore science and veto the recently passed bipartisan bill that would permit federal funding of embryonic stem cell research within an ethical framework spotlights an inconvenient truth. All Americans, not just those who have diseases such as diabetes, Parkinson's and Alzheimer's, will pay the price."

 

 

[This bill will provide hope to millions of Americans with diabetes]

"Take diabetes, for example. Leading scientists say embryonic stem cell research holds great promise for finding better treatments and a cure for the nearly 21 million Americans, including 2 million Californians, who have the disease. And that's not to mention the 54 million who have pre-diabetes, meaning their blood glucose levels are higher than normal and they're at increased risk of developing the disease.... "

 

[And it is not just about hope, it is also about economics]

"...Why's that important? Because, left uncured and untreated, diabetes comes with enormous human and economic costs that affect us all...Every year, diabetes contributes to more than 224,000 deaths....Diabetes is also the leading cause of blindness, kidney failure and non-traumatic lower limb amputation. Whether as employers, taxpayers or people with the disease and their family members, we're all picking up the tab. Diabetes costs the country more than $132 billion a year in medical expenditures and lost productivity. One out of every 10 health care dollars is spent on diabetes; and 1 out of every 4 Medicare dollars."

 

[Stem cell research will provide valuable information that could change the future for the billions of people on earth who have incurable chronic illnesses. Think of it!]

"Stem cell research allows scientists to better explore how to control and direct stem cells so they can grow into other cells, such as insulin-producing beta cells. Creating new beta cells could mean a cure for Type 1 diabetes as they would serve as a source of cells for islet cell transplantation. They could also provide a powerful tool for controlling Type 2 diabetes. Already, many of the genes involved in pancreatic development have been identified, and recent discoveries have allowed scientists to overcome the difficult task of getting stem cells to produce the necessary proteins -- in the correct sequence -- that will allow them to become insulin-producing islet cells. Just as we all bear the cost of uncured diseases such as diabetes, Parkinson's and Alzheimer's, it will take us all to convince our elected representatives to override Bush's veto of the stem cell bill."

 

[So what can you do? Plenty. Read on.]

"The vote is sure to be close, and the best hope is to win in the Senate where four senators are needed to join the 63 who originally voted for the bill in April. Many are saying an override is impossible and we should wait until a new president takes office and then reintroduce the bill. But every 21 seconds another American is diagnosed with diabetes. By Inauguration Day in 2009, there will be 2,382,171 more diabetics awaiting a cure or better treatment for this cruel, costly and deadly disease. I say we must override now. We can't afford to wait."

 

[Take action now!]

If you agree that we need to expand Stem Cell research, then please click on the following link and tell your Senators to override Bush’s Veto of SB 5, the Stem Cell Research Enhancement Act:

http://main.diabetes.org/site/VoteCenter?page=voteInfo&voteId=6101&JServSessionIdr010=fc4b0wmv21.app20b

Posted by Pat Salber, MD

Yesterday we highlighted the background for the failure of the FDA alert physicians and patients to the dangers of Avandia, a diabetes drug marketed by GlaxoSmithKline. We ascribed the sorry state to which the FDA has sunk to the system whereby the drug industry funds a major portion of the new drug examination process. This allows them to gain faster examination and approval of their drugs. Just as important, the insidious influence of money “buys” them the loyalty of the agency’s management.

Today, the New York Times  published an article titled “Potentially Incompatible Goals at FDA.”  Here are some choice quotes, with my comments in italics.

· “A series of drug-safety scandals has led many on Capitol Hill to question whether the Food and Drug Administration has failed to strike the right balance between speed and safety. A clear sign of this imbalance, these critics say, is the increasing number of F.D.A. drug-safety officers who say they have been punished or ignored after uncovering dangers of popular medicines.”

· “The latest to suffer this fate is Dr. Rosemary Johann - Liang, 42, who recommended more than a year ago that the diabetes drug Avandia carry the agency’s strongest possible safety warning for its effects on the heart.”

· “Dr. Avigan (her boss) took over the supervision of the safety review of Avandia and Actos and told Dr. Johann-Liang that she could no longer approve strong safety recommendations without his say-so, she said. Over the next year, she was increasingly excluded from crucial safety reviews and meetings, which contributed to her decision to leave the agency on Friday, she said. In an interview, Dr. Avigan said that he did not intend to punish Dr. Johann-Liang. “My view was simply that when there were conversations going on about important safety issues that were likely to garner a lot of attention, that I needed to be in the loop,” he said”. C’mon, how long have you been in management? Is this the only way, or even the preferred way, to stay in the loop? This is either managerial incompetence, or an insult to our intelligence.

· “At least four other F.D.A. safety reviewers in recent years have been punished or discouraged after uncovering similar drug dangers, according to Congressional investigations. Among them:

¶In 2003, Dr. Andrew Mosholder discovered that antidepressants led some children to become suicidal. When his findings were leaked to a reporter, the agency began a criminal investigation. Dr. Mosholder was prevented from speaking to an advisory committee about his analysis, and the agency hired Columbia University researchers to reanalyze the data; they concluded a year later that Dr. Mosholder had been right.

¶In 2006, Dr. David Ross became increasingly concerned about reports of serious illness and death from patients taking the antibiotic Ketek. Dr. Ross met with top agency officials and pleaded with them to take action. Nothing happened, he said. A month later, Dr. Ross complained privately to Congressional investigators. After articles about Ketek’s safety problems appeared in The Wall Street Journal and The New York Times, the agency and Ketek’s maker, Sanofi-Aventis, agreed to take actions.”

· “After the articles were published, Dr. von Eschenbach held a meeting with Dr. Ross, Dr. Johann-Liang and other safety officials in which he urged them to keep their disagreements “inside the locker room,” Drs. Ross and Johann-Liang said. Those who discussed issues with outsiders would be “traded from the team,” Dr. Eschenbach said, according to Drs. Ross and Johann-Liang .. “ Andrew, you are soiling your reputation as a brilliant oncologist and scientific leader with this kind of talk. "

· In interviews, safety reviewers said problems at the agency could be traced back to a deal struck in 1992.

In the 1980s, the F.D.A. took nearly three years to approve most drugs. The AIDS crisis demonstrated that such long delays could condemn to death patients who might have been helped by recent scientific breakthroughs. F.D.A. managers said they did not have enough people to assess reviews more quickly.

So in 1992, Congress helped the F.D.A. and the drug industry reach a deal. Companies agreed to pay millions of dollars in fees, and the F.D.A. guaranteed that drug reviews would be completed within a year or as little as six months for a life-saving medicine.

At the time, it seemed a good solution. But the deal’s fine print soon came to haunt the agency. Drug makers refused to let their money pay for the routine monitoring of drugs’ safety once they were on the market. As the agency began to depend more and more on industry fees, those parts of the agency slowly withered.

Perhaps even more important, the culture at the F.D.A. shifted toward valuing speed over safety. The 1992 deal required annual reports to Congress listing review times, but no such reports were demanded of the agency’s assessments of the safety of drugs already on the market.

Managers are now largely judged on how quickly their employees make a decision on new drug applications, safety officials say. Questions about the safety of already-marketed drugs are increasingly seen as sand in the gears, they say.”

· “If managers were held accountable on safety issues, they’d pay more attention to them,” said Dr. Victoria Hampshire, who was disciplined and investigated criminally in part because of her work to uncover the dangers of a heartworm medicine that killed at least 500 dogs.”

So there you have it. The disheartening fact is that the FDA is not an isolated case. The assault on science, fueled by corporate special interests, is widespread throughout the Federal government. How did Jim Cramer put it? “of the corporation, by the corporation, for the corporation”.

Dov Michaeli MD, Ph.D