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Archive for February, 2010

Thursday, February 25th 2010

Some Help Please (Or NATO’s raison d’etre)

One of my goals when restarting this blog was to be more focused and less off key. To keep Residency Notes centered solely on health care related issues.

Well, let me fail there for a moment. I’ve been thinking on the United States’ obligations to our allies since I’ve been interested in current affairs; I’m sure anyone with an interest in politics or world events has had the same thoughts. This week with Secretary Gates criticizing the demilitarization of Europe the issue comes forefront again,

“The demilitarization of Europe – where large swaths of the general public and political class are averse to military force and the risks that go with it – has gone from a blessing in the 20th century to an impediment to achieving real security and lasting peace in the 21st,” Gates said.

The perception of weakness in Europe could offer “a temptation to miscalculation and aggression” by hostile states, he said.

And while Europe shoots back they can hardly muster a convictionable excuse. The situation is that western Europe was allowed to flower into progressive liberal democracies, at THEIR discretion, behind a shield of American threat of force. Social spending in western Europe never could’ve been what it was through the 20th century without NATO. And NATO was little more than America’s guarantee to Europe (and Canada).

I’m hardly the first to say it. I’m hardly the most well read to say it. But it irks me that, whatever your convictions concerning the war in Afghanistan, America’s European allies seem so reluctant and seem to have contributed so little. I understand that NATO’s scope has been vastly expanded from its original premise by the September 11th attacks. That NATO was never intended to require its founding signatories to sign up for the projection of force outside of North America or Europe. But forget the official construct of America’s agreement with Europe.

The simple fact is that the promise, whether laid out in the North Atlantic Treaty or simply understood, of American force guaranteed European security throughout the Cold War. The NHS, French pensions, German infrastructure were paid for as much by American tax payers as anyone. Even a country like France who supposedly took on their own defense obligations: what would their defense spending have been at the height of the Cold War if not for the understanding that America would oppose any Warsaw Pact aggression? 8 or 9 or 10 or 15% of GDP? Not unrealistic. The lack of the obligation to fully supply for their own defense allowed for the growth of liberal Europe.

As The American Spectator quotes,

Vassilis Kaskarelis, the Greek Ambassador to the U.S., told the Washington Times: “They don’t have the capabilities, because in the last 50 years, the U.S. offered an umbrella in terms of military, security and stability.” So “You had the phenomenon [in which] most of the successful European economies — countries like France, Germany, the Scandinavians — channeled all the funds they had on social issues, health care, pensions, you name it.”

I’m not saying the United States didn’t have a stake in NATO. It did. But the benefits were lopsided in favor of the Europeans. And the costs were lopsided in favor of the Americans. America ponies up better than 2/3rds of NATO’s budget. Through the end of the Cold War America routinely mustered 5 or 6% of its GDP for its military and were lucky to see its European allies muster up 2%. Nowadays the situation is even worse. The SIPRI has a great resource looking at military budgets from the late 1980s.

And now America is facing its greatest threat to its national security since the fall of the Berlin Wall and some support would be lovely. What the European’s have at stake in Afghanistan is something less than what the Americans do. Fair enough. But those thirty or forty years of prosperity on American guarantees should count for something more than it has. From the Dutch government falling to limited engagement rules and caveats over their troops’ roles in Afghanistan to threats of British troops pulling out, evidence of a lack of commitment is all around. Support for America’s operations has been less than remarkable from the beginning.

I’m all for calls to leave NATO to the Europeans. That’s easy to say in the current enviornment with the threat of state versus state conflict in Europe at an all time low. I truthfully imagine the Europeans would regret that, when the current situation proves transient. Still I’m all for fostering unified European defense cooperation with North America stepping back.

Present-day Europeans — even Europeans with a pronounced aversion to war — are fully capable of mounting the defenses necessary to deflect a much reduced Eastern threat. So why not have the citizens of France and Germany guarantee the territorial integrity of Poland and Lithuania, instead of fruitlessly demanding that Europeans take on responsibilities on the other side of the world that they can’t and won’t?

But that’s for the future. I’ll be frank, the point I’m trying to make is that Europe owes the United States something in the present. If they garner nothing for their own security, if their populations are morally repulsed by the war…they should still muster up.

I’d like some payback for the thirty or forty years prior. I’d like Europe to remember what America meant to world security at its peak power; meant to their security at its peak power. Consider that petty but it irks me that Europe seems to have forgotten so quickly.

Monday, February 22nd 2010

White House Goes In

So Obama, after letting the Democratic caucuses flounder around for a year, has put his own proposal on his table. Nothing much new here. It tinkers with the Senate’s passed bill but in modest ways. The Wonk Room has a chart comparing the options.

It lacks any sort of public option in the form of new offerings or expansion of current government-as-payee offerings. It lacks even the national exchange. And of course it misses tort reform.

I know how the CBO scored the Senate bill, and Obama’s plan will get something similar and maybe something a little more impressive if the government actually gets to comment on each health insurance premium increase and such is passed on to providers. But real cost control and thus long term and permanent expansion of access to care is beyond the scope of Obama’s proposal.

Kent Bottles has a good summary of media coverage of why cost control is so difficult. I know plenty of pundits find him easy to disparage but I’m with Dr. Uwe Reinhardt on this. As Bottles’ quotes from a linked NY Times piece,

[R]eaders should replace the term ‘cost control’ in their minds with ‘constraining and possibly reducing the future incomes of doctors, hospitals, pharmaceutical companies, medical device companies and so on.’” He goes on to say that given our system of governance where political contributions mean so much, “the task of constraining or reducing the incomes of American health care providers will be a long and arduous battle with powerful, moneyed interest groups.

Only a global budget eases the political situation enough to allow for lower reimbursements and in turn reduced costs. Only a global budget can affect rationing in a sustainable way. Only a global budget can contain costs long term. Only cost containment on the order offered by a single payer or socialized system will allow the expansion of access to care enough to term it universal. Otherwise, forget that goal…at least not long term.

Not to sound like a progressive, I’m not as I cheered a Paul victory on at CPAC, but if Obama is really looking for reform he’s missed.

Saturday, February 13th 2010

The Power of Food

Jamie Oliver talking at TED2010 on childhood obesity.

Saturday, February 13th 2010

The Expanding Universe of Psychoactive Drugs

Newsweek ran a cover a few weeks ago bringing forward old, but hardly well publicized, research on antidepressants versus placebo to the public.

In just over half of the published and unpublished studies, he and colleagues reported in 2002, the drug alleviated depression no better than a placebo. “And the extra benefit of antidepressants was even less than we saw when we analyzed only published studies,” Kirsch recalls. About 82 percent of the response to antidepressants—not the 75 percent he had calculated from examining only published studies—had also been achieved by a dummy pill.

Here’s the 2002 paper Sharon Begley is referencing in her piece in Newsweek.

“Many have long been unimpressed by the magnitude of the differences observed between treatments and controls,” psychology researcher Steven Hollon of Vanderbilt University and colleagues wrote—”what some of our colleagues refer to as ‘the dirty little secret.’ “

Essentially except for those with severe depression, the vast vast majority of benefit seen with antidepressants can be attributed to a placebo effect.

The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.

That’s the reality that is hardly well penetrated into primary care and the non-psychiatric medical community.

Read More »

Tuesday, February 9th 2010

Physicians Refusing Medicare Is Hoopla

Medicare is the payee for healthcare services for more than 40 million Americans. It accounts for more than 30% of practice revenue by Center for Studying Health System Change measures.

And it’s fee schedule sucks and the proposal to freeze it, as in 2007, sucks; especially for primary care physicians. But even as MedPAC surveys find better than a quarter of Medicare recipients complain they have trouble finding physicians who accept Medicare, I continue to assert that a catastrophic access problem for those >65 is hard to imagine.

The possibility of a 5-year Medicare pay freeze is the latest twist in recent congressional efforts to fix the SGR problem. The current battle over healthcare reform legislation — and how to get federal spending under control — has made that job complicated.

[I]nternists…depend on Medicare for 44% of their revenue. In some ophthalmology practices, 80% of the patients are Medicare recipients, said Kristen Hedstrom, assistant director of legislative affairs for the American College of Surgeons.

Physicians who derive most of their revenue from Medicare can hardly afford to back out of the program, noted Ms. Hedstrom. For all practical purposes, they would not have a patient base anymore.

A single payer insuring 40 million; generating nearly half of all revenue for primary care. Unless primary care physicians are actively losing money, and I admit some of them are, where are the plurality of them going to go to create an access crisis?

As long as the vast majority of primary care physicians are at least breaking even on medicare where is this exodus going to come from?

And yet organized medicine and average docs continue to pretend they have a stick in the coming fight over the proposed freeze or in the fight to fix the SGR. We hear it from groups like The Heritage Foundation or in op/eds or even in New York Times pieces. Yeah, physicians will leave Medicare and we’ll hear the anecdote about the grandmother who can’t find a medicare physician in the middle of midtown Manhattan. But physicians fleeing on a scale large enough to cause outrage? To cause panic at the AARP? To force restitution and continued cost of living increases in the fee schedule?


If organized medicine staves off the freeze and, God willing, the SGR mandated cuts it’ll be because they greased the wheels appropriately and sold the above story. And truly I’m with them in trying to do that. But you don’t have to buy the hoopla yourself to try to sell it.

Monday, February 8th 2010

The Dangers of Radiation

It’s been more than a hundred and ten years since Marie Currie and her colleagues discovered radium and coined the term radioactive. Currie’s groundbreaking work on ionizing radiation would cost her her life. Since then and great realizations have been made about the therapeutic and disastrous effects ionizing radiation promises.

We’ve gotten smarter, more sophisticated, more skilled at manipulating radiation to do the most benefit in medicine and minimize harm. Ionizing radiation has spurned two whole medical specialties. Doctors now describe themselves as radiologists or radiation oncologists. Whole technology has arisen to more precisely diagnose diseases with radiation and to treat them. Radiosurgery, the use of linacs like the Gamme Knife or Cyberknife to more precisely target pathological areas and spare the normal, has been a huge development.

Of course the more technically complicated medicine gets, the more places things can go wrong. Nowhere is medicine as technically savvy or complicated than in in some of the ways we deliver radiation to patients. And, while admittingly slightly alarmist, the New York Times had a recent expose reminding us of that.

At a VA treatment facility in Virginia,

56 patients were treated incorrectly for cancer of the prostate, head and neck, lung, breast and two other malignancies. Thirty-six had been overradiated and 20 more subjected to “errors in technique,” the hospital said.

The Radiological Physics Center sponsored by the National Cancer Institute,

reported in 2008 that among hospitals seeking admission into clinical trials, nearly 30 percent failed to accurately irradiate an object, called a phantom, that mimicked the human head and neck. The hospitals were all using I.M.R.T., which shapes and varies the intensity of radiation beams to more accurately attack the tumor, while sparing healthy tissue.

“This is a sobering statistic, especially considering that this is a sample of those institutions that felt confident enough in their I.M.R.T. planning and delivery process to apply for credentialing and presumably expected to pass,” said a task group investigating I.M.R.T. guidelines for the American Association of Physicists in Medicine.

Not to quote a comic book or a Sam Rami film but with great power comes great responsibility. To err is human, but we shouldn’t accept it. Every error in medicine is something precious lost to someone, something that should be unacceptable. And when we push the boundaries of technology the odds of mistakes only tick up. Like so much in medicine and life, but to the margins, radiation is a boon and a bust; technology promises to potentially deliver it in more effective and safer ways but only if healthcare knows how to use such technology, only if healthcare respects the power of what it’s dosing out and works to prevent errors.

Sunday, February 7th 2010

When You’re Not A Vegetable

A joint British and Belgian group has published new findings with fMRI evaluating consciousness in patient’s previously meeting clinical classification for persistent wakeful unconscious states.

We used functional magnetic resonance imaging (MRI) to assess each patient’s ability to generate willful, neuroanatomically specific, blood-oxygenation-level–dependent responses during two established mental-imagery tasks. A technique was then developed to determine whether such tasks could be used to communicate yes-or-no answers to simple questions.

Of the 54 patients enrolled in the study, 5 were able to willfully modulate their brain activity. In three of these patients, additional bedside testing revealed some sign of awareness, but in the other two patients, no voluntary behavior could be detected by means of clinical assessment. One patient was able to use our technique to answer yes or no to questions during functional MRI; however, it remained impossible to establish any form of communication at the bedside.

The emphasis is my own because it is those findings which made the news as the NEJM published the study ahead of print online. While hyperbolic, the results have elicited titles in the media such as ‘I’m alive! ‘Vegetative’ patient speaks to scientists using his brainwaves‘ and responses from pro-life advocates such as ‘‘Stop dehydration deaths,’ says Terri Schiavo’s brother in response to new brain scan‘.

Functional MRI has been front and center in the news the past several years with claims of scans that can predict people’s responses and actions before they make them and decipher people’s motives or tell us when they’re lying or telling the truth.

And it’s true studies such as those by Monti, et al raise important and serious questions about the right to life and the right to die. In an editorial to accompany NEJM’s publication Dr. Allan Ropper says,

Even in a preselected population, brain activation was infrequent, but it occurred often enough that it will now be difficult for physicians to tell families confidently that their unresponsive loved ones are not “in there somewhere.”

Indeed, the MRC and Belgian group’s efforts are game changers certainly. It, and future studies along the same lines, have made and will make the main stream news and will no doubt be commonly quoteb by anyone faced with a loved one who is awake but seemingly not there by any measure short of fMRI. And they should be. For all the reassurance the medical community gives family and friends the misdiagnosis of persistent vegetative states is a problem. Now further uncertainty is thrown on it.

But as much as the preservation of life and function is an important goal, arguably secondary only to primum non nocere, I still think caution is in order when using information as Monti et al have provided. Dr. Ropper likely says it better than I can,

First, in this study, brain activation was detected in very few patients. Second, activation was found only in some patients with traumatic brain injury, not in patients with global ischemia and anoxia. Third, cortical activation does not provide evidence of an internal “stream of thought” (William James’s term), memory, self-awareness, reflection, synthesis of experience, symbolic representations, or — just as important — anxiety, despair, or awareness of one’s predicament. Without judging the quality of any person’s inner life, we cannot be certain whether we are interacting with a sentient, much less a competent, person. Moreover, persons who look to this study to justify continued and unqualified life support in all unresponsive patients are missing the focus of the findings.

The presence of some rudimentary preserved cognition that is indicated by means of functional MRI will no longer be in question, but its meaning will continue to be subject to interpretation.

Be gentle in how we use these new resources to define consciousness; how we use these new resources to define who is still is with us.