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Archive for November, 2008

Sunday, November 30th 2008

The Future of From Medskool

I haven’t been updating with a lot of regularity recently. Such can be explained by the interview trail. So this huge and massive udpate of From Medskool may come as a surprise. If this is your first time here I’ve recently redone the entire theme. I really have updated everything about the site, including the back end with a new WordPress version, new plugins, updated SQL and all of that.

From Medskool has been going for more than three years now. I find that pretty remarkable. It is a cathartic piece of work, verbose and eccentric and poorly optimized for search engines and just generally not focused on building the biggest readership possible. It started out at Blogger before moving here to this hosting solution and URL provided by Blogs About Hosting.

I had an amazing custom WordPress template created by E. Webscapes and LeeAnn Wildermuth. It was incredible, especially considering how specific I was in my request and price they quoted me. But, in more than two years I mucked around with it, added trinkets, deleted things and before you knew it the tempalte was messed up. Beyond me being able to fix it by myself.

The fact is I’m about to graduate medical school. And while I’d like to continue this blog the title, and that first custom template and some of the themes I cover in my posts will have to change. I imagine my posting will get significantly less frequent as well.

What I want to do, what I’m planning to do, is to go back to E. Webscapes for a new custom design. I’d like to add some new features that promote a more community feel to the site. However, there’s no point in doing that until after I graduate and see what my future holds.

Until then, I’m pretty excited about this new redesign based off the free Mimbo theme. The theme was created by Darren Hoyt and I’m always extremely grateful for designers who put their stuff out for all to use. It has more of a magazine feel.

I encourage you to keep reading and see what the future holds.

Saturday, November 29th 2008

Where Now?

An Obama Campaign Video Addresses Health Care

I was pretty negligent with this blog during the election cycle. I didn’t even live blog the election as I did the midterms. And I certainly didn’t give the focus you might expect to the prospect of health care reform under both Presidential candidates.

That doesn’t mean I wasn’t paying attention; it just means the interview trail and the fourth year of medical school are weighing a bit right now.

But now we have a new President following an historic election. This is a President I happily admit I voted for despite some reservations about his plans to reform health care in this country. It’s important though to take a look at what those reforms may look like with the Democrats soundly controlling both sides of Congress and Barack Obama in the White House.

To be honest I have significant doubts about the possibility of ground shaking health care reforms occurring any time soon. The big hurdle is the economy. A massive shake up of how the U.S. finances health care is going to have significant launching costs; no matter the generous CBO estimates you read about any specific plan. In the current environment trying to cobble together a coalition to pass such costs, a challenge any day, is an even bigger hurdle. As well, we should be honest, despite polls showing the public’s interest in health care reform as a domestic issue, it likely to be pretty low on the agenda in Washington come January. Such is the state that Bush has left the country in. I also imagine some infighting amongst the Democrats themselves is inevitable. Various Democratic players already have a whole host of disparate plans they’ve introduced into the House and Senate over the years and since Obama’s election even more are coming out of the woodwork. I’ll get to some of those in a second. As well, the Party in power may be a little bit different but the major parties opposed to change continue to put money in the pockets of Blue Dog Congressmen and conservative minded Democratic Senators.

Still, I wanted to give a look at two things. First, what dream reform may look like for some Democrats (even if it turns out to be unpragmatic). Basically take a look at some of the plans for reform out there. Second, what may be more modest, but realistic goals for health care reform.

Much attention was focused on both candidate’s health care plans during the election. Obama’s ‘Plan for a Healthy America‘ got summarized by most major news publications, as well as some health care policy think thanks and health policy publications. The New England Journal of Medicine gave both campaign’s chances to editorialize their health plans and Obama’s campaign turned in this. The major points being:

  • “Through a national health-insurance exchange, people without employment-based insurance or who work in small businesses will have a choice of private insurance policies at rates similar to those offered through large firms. To promote competition among insurers, we will also give patients a new public-plan option, providing the same coverage that is offered to members of Congress and their families.”
  • “All insurance companies will have to take everyone, regardless of medical history.”
  • “My plan calls for investing $10 billion per year over 5 years in health information technology.”
  • “I will invest in programs, including loan repayment, training grants, and improved provider reimbursement, to give young doctors incentives to enter primary care.”

The most substantial reforms laid out in the Obama plan , financing wise, were the federal government entering the private insurance market, the regulation of health insurers to force them not to exclude people based on pre-existing conditions. and a pay-or-play mandate for employers of a certain size. The latter of these gets no mention in the NEJM piece.

Not entirely radical proposals but still not cheap. The costs of the full implementation of Obama’s plan has been put as high as $2.1 trillion over the first ten years of the plan’s life.

Health Affairs, the prominent health policy journal, criticized the plan thus,

It greatly increases the federal regulation of private insurance but does not address the core economic incentives that drive health care spending. This omission along with the very substantial short-term savings claimed raise serious questions about its fiscal sustainability.

This is certainly legitimate criticism. Obama’s plan would eventually almost certainly drive private insurers from the market and leave people with fewer options. Depending on the level of subsidization the government extends to those trying to buy insurance you may see mixed benefit in the affordability of insurance for families and questionable gains off the uninsured rolls. While true, specific provisions for controlling the seemingly unsustainable rise of health care costs may not be as overtly prohibitive to Obama’s plan as Health Affairs makes it out to be. Despite rising costs private insurers truly continue to reap record windfalls.

Don’t get me wrong, I’m not using ‘insurance company profit’ as a bad word. I personally believe we should let the current system lie. But, the point remains there is a discrepancy between what the insurers pay out to cover increasingly costly health care in this country and what they pull. Therefore, there is a margin for a federal plan working in the private market to succeed in. Such a plan would be significantly more efficient (in terms of bureaucratic costs) than any current private plan. Another boost to the margin.

So while there’s some validity to Health Affairs criticisms, it isn’t all disaster.

Other criticisms of Obama’s plan are of the more typical conservative variety. The American Enterprise Institute has been particularly critical, firing even since Obama’s election.

It’s easy to laugh at the AEI right now. Despite their stated mandate the AEI boasts far less libertarian thinking than say The Cato Institute or The Hoover Institute. The American Enterprise Instute really is more of a neo-conservative front. And after the disaster of the Bush presidency, which AEI visiting scholars and fellows helped shape, it will be hard for serious thinkers in Washington not to take the Institute’s proposals with quite a larger grain of salt for the next twenty years or longer. I say that without hyperbole. Policy wonks travel in small circles and such circles reliably don’t function as meritocracies. Your future success in the world of think tanks and political posts often has less to do with your credentials than who you know. Yet still, having an AEI Fellowship on your resume counts for something significantly less than what it did even four years ago. And their credibility counts for something less as well outside their own kind.

But still AEI fellows keep writing. Dr. Scott Gottlieb has published quite a bit on Obama’s health plan. The day before the election a piece went live on the AEI website which made the none too original claim that Obama’s plan would stifle biotech innovation; especially the pharmaceutical industry.

It’s easy to pick and prod at some of the ridiculous points Dr. Gottlieb makes to try to bolster his claim. It’s fun as well. Here’s what AEI has to say,

Obama has…championed a “comparative effectiveness” agency–styled after the United Kingdom’s National Institute for Health and Clinical Excellence (NICE)–that would conduct reviews and studies on the clinical and cost effectiveness of drugs to inform central rulings on which patients should be eligible for a new treatment.

NICE’s real mission is to protect the British health care budget. Since 2000 it has denied patients the ability to use the newest cancer drugs–by my count, in 226 different indications for which American insurers and Medicare currently pay and for which the National Comprehensive Cancer Network says there is “high-level evidence” or “uniform consensus” of clinical benefit. Cancer survival rates in the United Kingdom are substantially lower than in the United States, and the gap continues to widen.

This is a little bit terribly misleading. For one, the U.S. detects cancer at a more prominent rate and, more to the point, at an earlier stage. The prevalence of money making tests makes sure of that.

And while instinctively that might come off as a “good” thing, that isn’t always the case. Early detection also probably artificially inflates those five year survival statistics. What I mean is that, from that early point of detection of course cancer patients are going to survive longer.

But the biggest rebuttal is that despite UK’s lower five year survival (whether NICE is responsible or not) the fact remains that the United Kingdom’s universal health care contributes to their society’s impressive end health outcome measures. And across those measures they beat the Untied States (here and here and more).

No I’m not debating my long argued stance that things like life expectancy at birth and infant mortality are both: difficult things to actually measure at times and also the product of multiple etiologies, not all of which can be influenced in a physician office. But, it remains that health care access is important these kind’ve utilitarian health outcome measurements and the United States’ figures aren’t so impressive.

The point is, if you want to improve the health of the United States by quantifiable figures then improving access is a key (as I recently argued).

How Democratic health care reform may shape up, if it truly does, is still a bit nebulous.

Read More »

Thursday, November 27th 2008

Don't Run And Get A Bone Marrow Transplant Just Yet

An American living in Berlin has apparently been “cured” of his HIV infection after undergoing a bone marrow transplant as a treatment for leukemia.

While interesting no one currently living with HIV should run to their physician expecting for this to be a viable option. As a British ‘expert’ commenting on the case put it,

“The problem is most people with HIV live in sub-Saharan Africa and this is hugely expensive, you have to find a matched donor, and it’s a pretty severe and painful operation.

“So it’s going to be an option for very few people.”

Finding a donor is the key hurdle. When someone has leukemia one of the options is to kill off all of their hematopoietic stem cells which are making the leukemic white blood cells. Then you replace them with the progenitor cells from someone else. Such is what a bone marrow transplant is.

To make it clear even though HIV infects T Cells, a type of white blood cell; you are not clearing the viral infection by doing a bone marrow transplant.

Instead, in this particular case, the patient got a bone marrow transplant from a donor whose white blood cells are resistant to infection from the HIV. For years people have been aware about mutations in the genes that code for specific proteins on the surface of T Cells and these mutations appear to confer resistance to HIV infection. These proteins on the T Cells appear to be used by the HIV to gain entrance to the cells. Think of them as door handles, as one piece I was reading described it.

The most prominent of these proteins is CCR5. Theoretically, and as it apparently worked in this particular patient’s case, if you could replace the T Cells of a patient with HIV with cells who had the “misformed” CCR5 protein then the infected patient would now have resistance to HIV infection and the virus in his body (depending on the serotype) would no longer be able to enter and infect his white blood cells.

A novel idea which appears to have worked in this case. This patient needed a bone marrow transplant for his leukemia and so they found a donor who also had the CCR5 gene mutation and, apparently, “cured” the patient of both of his diseases.

Unfortunately finding a bone marrow donor for a patient is already difficult. Like in all transplants specific antigens have to match up. But to make it tougher only about 10% of the world’s population has the CCR5 gene mutation. You have cut the available pool to search for a bone marrow donor by 90%. Already bad odds have just gotten terrible.

Beyond the costs and the novelty, finding donors for huge numbers of HIV infected patients is simply not feasible. So, bone marrow transplant will likely never be a realistic “cure” for the vast majority of those suffering from HIV. It does however, as the story says, raise the profile of studies on gene therapy to grant those already suffering with HIV a mutated CCR5 gene.

I truly believe that a “cure” for HIV is within our grasp. Bone marrow transplant simply isn’t going to be it however.

Wednesday, November 26th 2008

Give A Mouse A Cookie And Then Try To Take It Away

If He’d Pressure His Publisher To Make It Available For The Kindle I’d Read It

Tom Daschle is going to be Secretary for Health & Human Services. Old news.

In a coming post I argue that health care reform is going to be relatively low on the agenda of the coming administration in some part because of the current economic climate. The reality is, although polls consistently have the public put health care reform high on the domestic agenda, there is, in reality a lack of passion behind it. As compared to, say, unemployment.

But if there is a choice to keep health care reform on the administration’s agenda it is, perhaps, Daschle. This man is a former Senate Majority leader and one of the most prominent Senate leaders over the past two decades. And he wanted to be Health & Human Services secretary.

Now I have briefly met current Secretary Michael Leavitt. Outside of the state of Utah, who in the world can tell me who Michael Leavitt is? Virtually no one.

But even the marginally politically interested have probably heard the name Tom Daschle. He immediately raises the profile of health care reform. An unfortunate thing.

I’ve been very frank in my discussion about government subsidized health care. I am not with organized medicine or most conservatives on health care reform. Not with them in the sense that I think their pragmatic arguments against government subsidized health care are ludicrous.

They are, frankly, ridiculous arguments. Absolutely no evidence points to their most dramatic conclusions. Yes, all health care systems have downsides and trade offs. Such will come with any attempt at further government subsidization of health care. As an example, I imagine rationing to expand and to become more overt under any single payer system in the United States. But to draw a line from such downsides to the claim that American health will actually suffer under a true single payer system is wrong.

I feel that many of my colleagues in organized medicine are intelligent enough to gather the true ‘benefits’ of a single payer system and yet continue to play fear monger and to attack such systems with meritless charges to try to sway public opinion. For those who truly buy the arguments they make, well…I just don’t know. There is nothing to be said except that all balanced evidence points otherwise.

Yes, the United States has demographics and social situations that differentiate it say, from Europe or Canada. America’s, relatively, poor life expectancy and our infant mortality figures are a product of multiple etiologies. But to imagine that the results of countries with “universal” health care don’t provide evidence that increased health care access in this country would not improve utilitarian health outcome measurements is stupid.

Of course it would.

This is not to say that I support further government subsidization of health care. I absolutely do not. I’m libertarian minded at my core and taking individual’s earned income to guarantee someone else’s access to health care; which is something I bemoan others declaring as a “right,” does not sit with me.

True, I believe it my personal moral obligation to provide care for the indigent and to work to provide health for all, as a soon to be physician. But, I would hope, we could all agree that imposing a standard of morals on society is far from government’s role. I’m repulsed by the idea that government should attempt to impose such a moral obligation on the entirety of our society.

Health care is not a right. And to define it as one and to deny the public of their right to property in order to uphold some ill defined right to health care is, in and of itself, stupid.

Which brings me to the point of my post. I am scared of Tom Daschle as Secretary of Health and Human Services. I am scared of such a prominent individual; someone with Obama’s ear actually sitting in Washington and advocating for substantial health care reform.

I’ll spare you an account of Obama’s health care plan and the Democratic alternatives in this post. I am working on a lengthy post to cover such.

The point is that any reform is likely to succeed. Government subsidization of health care can work and will be cheered by the masses. Especially as the wealth gap continues to grow in this country.

Such is the argument a U.S. News blog recently made.

Let me tell you something, if Democrats take the White House and pass a big-government healthcare plan, that’s it. Game over. Government will dominate the economy like it does in Europe. Conservatives will spend the rest of their lives trying to turn things around and they will fail.

The key point is this: you will never be able to take away government subsidization of health care costs once they exist. Give a mouse a cookie and he’ll keep it for himself. As a saying I just made up goes. The entitlement society does not give up what it is has earned been handed.

And Tom Daschle makes such reform all the more likely.

Maybe my acquaintances and friends who see the ‘benefits’ of health care reform for most Americans, and yet continue to oppose it, are on to something. It seems there is no alternative. We are fighting entropy, the inevitable, here. It’s worth it, even if it may be a losing path in the long term. Let’s keep fighting against Tom Daschle.

Monday, November 24th 2008

Sitting Here With A Beer…

…when I should be out on the streets with a protest sign, I suppose.

The growth of the bailout of the U.S. financial industry U.S. corporate interests is depressing. Maybe easily foreseen, but still depressing. Yesterday the federal government agreed to guarantee crappy assests of America’s largest bank and give it a further injection of cash.

First, the U.S. Treasury and the Federal Deposit Insurance Corporation (FDIC) will backstop some losses against more than $300 billion in troubled assets.

Second, the Treasury will make a fresh $20 billion investment in the bank. The government has already injected $25 billion into Citigroup as part of the $700 billion bailout passed by Congress in October.

Another step in the wrong direction. Bolstering the private financial sector with public money ultimately does not solve the irresponsibility that led to these problems to begin with. Even when it comes with further market regulation. The government, through regulatio,n cannot halt America’s declining production base, our uber-consumerism, our lust for credit, or our negative savings rate.

Sure the financial sector took on bad debt. There were others however, on the other end who were gobbling that credit up.

We have become a nation of spending. We believe we have come to deserve. Luxuries have become rights and financing those luxuries means everyone has to spend more than they truly have. It is shocking.

Claims that the financial sector’s major players are “too big to fail” is absurd. Sure, it will be painful but rebuilding our economy on a viable base is arguably impossible unless people get burned a little bit. We have too short of memories unless there is some pain involved in our learning.

Let the financial sector fail and declare bankruptcy. And then let us start moving towards some real solutions.

There Is Nothing The Government Can Truly Do

The above is unlikely of course. Congressman Louis Gohmert has thrown a bill into the hopper which would repeal the Emergency Economic Stabilization Act of 2008. If it even gets a vote in committee I’d be stunned.

Oh well, I’ll sit here with my beer imagining what my protest sign should say.

Saturday, November 22nd 2008

It Could Be A Tumor…

…It’s Not A Tumor

The Barrow is certainly an expert at promoting itself in the media. And rightfully so based on some of the cases they managed. There is a new case report from BNI which is making its way through the international media. This one is making the news, not for the technical difficulty of what was achieved, but because of the peculiarity of what was found during the case.

A woman in Arizona was thought to have a tumor in her brainstem, but when the neurosurgeon went in he found a tapeworm. Taenia solium is a bad little critter whose larvae infect the human nervous system as an intermediate host. You get it from either undercooked pork (as pigs are its primary host) or from ingesting human fecal material from someone infected with the worm.

The BBC has a video, including a blip from the operation itself when they discovered the worm.

The blog Neurophilosophy has a more detailed and well written discussion of t. solium infection.

Saturday, November 22nd 2008

World's Oldest Neurosurgeon

I’ll Be So Lucky To Practice This Long

Tuesday, November 4th 2008

Kim Jong-Il(l)

The Real Question Is If He’s Even Still Alive?

The reclusive dictator of North Korea hasn’t been seen in a while. He recently missed a major military parade, which was just another step in many national spying agencies calling into question his health. Now word is spreading that his son has recruited a French neurosurgeon to travel to North Korea.

New doubts over the health of North Korea’s “Dear Leader” have arisen after Kim Jong Il’s eldest son was filmed in Paris apparently soliciting the services of a top brain surgeon.

The footage, shot by the Japanese Fuji Television, has rekindled conjecture that Mr Kim is gravely ill and has possibly had a stroke.

The footage shows a man, identified by North Korea watchers as “undoubtedly” Kim Jong Nam, entering a Parisian clinic for a discussion. Two days later, an unnamed French doctor was filmed arriving at Charles de Gaulle airport in a car owned by the North Korean mission to Unesco. When asked, the doctor did not deny that his destination was Pyongyang.

There are obviously too many reasons why one would need a neurosurgeon to start speculating on Mr. Kim’s health. However, going over the conjecture The Times makes that Mr. Kim may have had a “stroke.”

If Mr. Kim has had a stroke and we’ve reached a stage where surgery may be a necessity then the North Korean dictator is at a dire point. A decompressive craniectomy or digging around to remove an intraparenchymal clot or performing a “strokectomy” to decompress, make it very unlikely the dictator will ever return to rule over North Korea, assuming he is to survive.

It may be quite a while before more substantial word on Mr. Kim’s condition (or even word of his death) out of the most closed society on earth.