As the Vision Fades, the Indignities Grow

New York Times: By KATIE HAFNER

As baby boomers grope their way through middle age, they are encountering the daily indignities that accompany a downward slide in visual acuity: trying to read a road map in a car at night; cellphones designed for 20-year-old eyes; the minuscule letters on a bottle of aspirin; nutrition information squeezed onto a bag of peanuts.

And unlike their parents and grandparents, they are not shy about expressing their displeasure, in some cases, taking matters into their own hands or prompting some companies to pay attention. ...

By their early 40s, many people are noticing the first symptoms of presbyopia, or “old man’s eyes.” As the eye ages, it is less able to take in light. At the same time, the lens inside the eye loses its flexibility. The result is blurred vision. ...

Craig Roessler, 60, a school superintendent in Silverton, Ore., said he prefers not to have to worry about losing his reading glasses and has devised a loose strategy. In addition to one pair of prescription reading glasses that he carries to work, he keeps eight or so pairs of inexpensive glasses scattered throughout his daily surroundings: two in his car, one in his golf bag, one in his desk drawer at the office and several around the house. He has also noticed that at the clubhouse of his golf club, a pair of reading glasses is tied to the computer terminal. ... And when reading glasses are not enough, out come the magnifying glasses and flashlights. ...

But Dr. Lewis has no such solution for the washing instructions on clothing labels. “You need an electron microscope to read them,” he said. ...

“There are efforts afoot to shift into next-generation technology, to produce more readable information, but it certainly isn’t happening overnight,” said Ray Bullman, executive vice president of the National Council on Patient Information and Education, a nonprofit organization based in Bethesda, Md.

Small print is not a new problem, Professor Bigelow, 62, pointed out. “The shapes of the letters in fonts such as Times Roman all derive from a set of complaints lodged by 14th-century scholars who wanted to read late in life,” he said.

Letting Go of the Rope -- Aggressive Treatment, Hospice Care, and Open Access

NEJM: Alexi A. Wright, M.D., and Ingrid T. Katz, M.D., M.H.S.

More Americans are choosing hospice for end-of-life care, but ironically, hospice patients increasingly are forced to give up effective palliative treatments along with aggressive medical intervention. For Joanne Doolin, a 64-year-old mother of three who spent her last 2 years of life fighting colon cancer that eventually made it impossible to eat, enrollment in hospice care involved a difficult trade-off: with only a few weeks left to live and her daughter's wedding approaching, Doolin was forced to choose between entering hospice care and continuing to receive total parenteral nutritional support.

Unfortunately, treatment options are often limited by the economic constraints of hospice care. The hospice that was the closest to Doolin's Boston-area home would accept only patients willing to forgo life-sustaining treatments, including chemotherapy and parenteral nutrition. It cares for only about 20 patients at a time with three nurses, a manager, a part-time chaplain, and a medical director who works there one morning a week. As a small program, it cannot negotiate pricing or spread the cost of expensive medications across many patients. A few large hospices offer what is called open-access care, which allows patients to add hospice care to their current medical treatment, but this option is not available in Massachusetts.

The Medicare hospice benefit reimburses hospices on a per diem basis, paying fixed inpatient and outpatient fees regardless of services provided. Despite adjustments for inflation, the fees have not kept up with the cost of cutting-edge palliative treatments. Many patients who meet the criterion for hospice care — having less than 6 months to live — still opt for palliation from oral chemotherapies, radiation, antiemetics, or blood transfusions. But these treatments can cost more than $10,000 per month — too much for most hospice programs. ...

Although some observers worry that nationwide open access could bankrupt Medicare, most agree that per diem reimbursement rates remain unacceptably low: in 2006, hospices were paid an average of $563 per patient per day for inpatient care (which represents 2.7% of Medicare's total hospice payments) (see Table 2). The average outpatient fee was $126 for a typical day of care, an amount that must cover nursing care; contributions from social workers, chaplains, and volunteers; and all drugs and durable medical equipment, as well as 13 months of bereavement support. ...

A few large hospices and insurance companies are trying to prevent these situations with open-access programs. Last year, Capital Hospice, based in Washington, D.C., paid for palliative chemotherapy, radiation, dialysis, blood transfusions, parenteral nutrition, antibiotics, and other expensive intravenous medications. With an average daily census of 606 patients, the program can spread out the expense. President and chief executive officer Malene Davis likens open access to "two ropes hanging from the ceiling. We've asked people to hold on to the aggressive-treatment rope with both hands," she says, "but when they go on hospice we tell them to let go completely. Open access gives people the choice to let go of active treatment with one hand and grab on to the hospice rope until they feel comfortable letting the other hand go."...

"Whoever wrote [Medicare's hospice] policy has never taken care of sick patients," argues Diane Meier. "Our patients are fighting for their lives and will do anything to extend the length of time they live, as long as they have some quality of life."

These issues arose for our family as we contemplated hospice care for my dying father. We were more sophisticated than many facing these choices, and fortunate that we had located an outstanding geriatrician used to working with hospice, and had private resources to supplement the Medicare hospice budget. While collaboration among physician, hospice team, and institutional staff was not seamless, and some tricky issues needed to be resolved, mostly it worked out, and hospice was a great help. But the integration of hospice philosophy and skills with mainstream medical care is very much a work in progress; we were very concerned that access to mainstream interventions for intercurrent illnesses and symptom relief might be curtailed or unavailable under the hospice contract we were presented with. We reached some informal understandings, which fortunately were never tested in reality; we can't know for sure what would have happened if they were.

Whether full "open access" is the right answer is not altogether clear to me, but the time is rapidly passing for viewing hospice and mainstream medicine as mutually exclusive alternatives; finding paths to more flexible and integrated options for patients and families represents the challenge for the coming generation of end-of-life care.

An interview with Dr. Timothy Quill, director of the Center for Palliative Care and Clinical Ethics at the University of Rochester, can be heard at www.nejm.org.

Cancer Patients, Lost in a Maze of Uneven Care

New York Times:By Denise Grady

Cancer, more than almost any other disease, can be overwhelmingly complicated to treat. Patients are often stunned to learn that they will need not just one doctor, but at least three: a surgeon and specialists in radiation and chemotherapy. Diagnosis and treatment require a seemingly endless stream of appointments. Doctors do not always agree, and patients may find that at the worst time in their lives, when they are ill, frightened and most vulnerable, they also have to seek second opinions on biopsies and therapy, fight with insurers and sort out complex treatment options.

The decisions can be agonizing, in part because the quality of cancer care varies among doctors and hospitals, and it is difficult for even the most educated patients to be sure they are receiving the best treatment. “Let the buyer beware” is harsh advice to give a cancer patient, but it often applies. Excellent care is out there, but people are often on their own to find it. Patients are told they must be their own advocates, but few know where to begin. ...

...When she joined a cancer support group, she recalled, “It was amazing to me the different experiences people were having based on what they could afford or who their provider was. I was able to say, ‘If the provider won’t pay, my family will. I don’t care, I’m going for a second opinion.’ ”

In the support group, it saddened her to hear other patients with advanced disease take the word of a single oncologist, because she believes that if she had done that, she would already be dead. She has come to think that survival may depend on money and access, and, she said, on “your own drive and motivation — are you Type A? — your education and your ability to sort through the medical world and the insurance world terminology.”

This promises to be quite a series.
For all the fuss and negative comment about Michael Moore's narrative techniques, he gets some big things right, as this more conventionally reported piece demonstrates.
Many American patients have their troubles securing a first opinion, let alone a second at a mega-center of their choice. And the disparities in approach, expertise, and outcomes are startling in a field supposedly dominated by science and widespread access to research reports. It would be interesting to know more about comparisons in these regards to the better rated universal systems, such as Canada, France and Germany. (Maybe not Cuba on this one, Michael.)

On Trial for your Life

New York Times:By Denise Grady

Presbyterian rejected two appeals, he took his case to a state review board, where he represented himself because he could not afford a lawyer. Presbyterian showed up with two lawyers, a doctor and a nurse. Dr. Bordenave and a gastroenterologist from Albuquerque testified on Mr. Hendrickson’s behalf.

Mr. Hendrickson and his wife had studied the details of their insurance policy and had also learned — with the help of M. D. Anderson — that in the previous five years, the five surgeons Presbyterian had recommended had performed a total of five Whipple operations.

Ultimately, Mr. Hendrickson won the case, and Presbyterian Health Plan paid the entire bill.

A spokesman for Presbyterian said the case had led the company to allow more patients to be treated at high-volume centers if there was evidence that the results would be better.

Mr. Hendrickson said it was “tough to stand up to attorneys and doctors. I don’t know why I was able to do it. I’m stubborn, I guess. I don’t like to be told what to do. Too many people, I know, they just let it go and they die.”"

Getting effective care for the seriously ill--known in the trade as "medical losses". There probably is an important place in any health care system for effective means of utilization review--that is, are patients receiving appropriate care likely to be helpful to their condition (and not just to the pocketbooks of those proving expensive interventions). It doesn't follow that reviewers should have strong personal financial incentives (amply documented in Michael Moore's SiCKO) to deny care. This is a challenge for any health care system, perhaps not best addressed at the bedside of each individual patient, but through research and medical consensus panels. Achieving universal coverage will not make all such problems go away, but it will give us a better shot at getting the incentives right--and considerably more humane (except for those patients with unlimited resources...)

Sending Back the Doctor’s Bill

New York Times: By ALEX BERENSON

“I always find it ironic that when I go to doctor groups and such, they always talk about the cost of prescription drugs,” said Dana Goldman, director of health economics at the RAND Corporation, a nonprofit research institute in Santa Monica, Calif.In the United States, nearly all doctors are paid piecemeal, for each test or procedure they perform, rather than a flat salary. As a result, physicians have financial incentives to perform procedures that further drive up overall health care spending.

Prescription drugs cost, on average, 30 percent to 50 percent more in the United States than in Europe. But the difference in doctors’ salaries is far larger, Dr. Goldman said.

Doctors in the United States earn two to three times as much as they do in other industrialized countries. Surveys by medical-practice management groups show that American doctors make an average of $200,000 to $300,000 a year. Primary care doctors and pediatricians make less, between $125,000 and $200,000, but in specialties like radiology, physicians can take home $400,000 or more.

In Europe, however, doctors made $60,000 to $120,000 in 2002, according to a survey sponsored by the British government in 2004....[T]he lower salaries are a significant part of the reason that European countries spend less on health care than the United States does — a fact liberals avoid mentioning when they preach the advantages of a European-style single-payer system. ...

Doctors are paid little for routine examinations and very little for “cognitive services,” such as researching different treatment options or offering advice to help patients get better without treatment.

“I don’t have a view on whether doctors take home too much money or not enough money,” Dr. Bach said. “The problem is the way they earn their money. They have to do stuff. They have to do procedures.”

Primary care doctors and pediatricians, who rarely perform complex procedures, make less than specialists. They are attracting a declining percentage of medical students, and some states are facing a shortage of primary care doctors. ...

Medicare, especially, does not like to second-guess doctors’ clinical decisions, said Dr. Stephen Zuckerman, a health economist at the Urban Institute. “There’s not a lot of utilization review or prior authorization in Medicare,” he said. “If you’re doing the work, you can expect to get paid.”

As a result, doctors have steadily increased the number of procedures they perform on Medicare beneficiaries — and thus have increased their income from Medicare, Dr. Zuckerman said. But the extra procedures have not helped patients’ health much, he said. “I don’t think there’s any real strong evidence of improvements in health status.”

Swabs in Hand, Hospital Cuts Deadly Infections

New York Times:

...Every room and corridor is equipped with dispensers of foamy hand sanitizer. Blood pressure cuffs are discarded after use, and each room is assigned its own stethoscope to prevent the transfer of microorganisms. Using these and other relatively inexpensive measures, the hospital has significantly reduced the number of patients who develop deadly drug-resistant infections, long an unaddressed problem in American hospitals.

The federal Centers for Disease Control and Prevention projected this year that one of every 22 patients would get an infection while hospitalized — 1.7 million cases a year — and that 99,000 would die, often from what began as a routine procedure. The cost of treating the infections amounts to tens of billions of dollars, experts say....

Several European countries, including the Netherlands and Finland, have all but eliminated MRSA through similarly aggressive campaigns. But at many American hospitals, experts say, high infection rates have been accepted as a cost of doing business. Barely a quarter of American hospitals screen patients for bacterial colonies in any methodical way, a recent survey found.

“People don’t believe it’s in their institution, and, if it is, that it’s too big to do anything about, that you just have to accept it...

...[S]ome infection-control experts warn that [certain measures] may have unintended consequences, including lesser care for patients who linger in isolation. Studies have found that patients in isolation are seen by hospital staff members half as frequently and tend to suffer more from falls, bed sores and stress. ...

A major emphasis at the Pittsburgh hospitals has been hand hygiene. Studies have consistently shown that busy hospital workers disregard basic standards more than half the time. At the veterans hospital, where nurses have taken to pushing elevator buttons with their knuckles, annual spending on hand cleaner has doubled.

A Day in the Life of Oscar the Cat

NEJM : David M. Dosa, M.D., M.P.H.

Making his way back up the hallway, Oscar arrives at Room 313. The door is open, and he proceeds inside. Mrs. K. is resting peacefully in her bed, her breathing steady but shallow. She is surrounded by photographs of her grandchildren and one from her wedding day. Despite these keepsakes, she is alone. Oscar jumps onto her bed and again sniffs the air. He pauses to consider the situation, and then turns around twice before curling up beside Mrs. K.

One hour passes. Oscar waits. A nurse walks into the room to check on her patient. She pauses to note Oscar's presence. Concerned, she hurriedly leaves the room and returns to her desk. She grabs Mrs. K.'s chart off the medical-records rack and begins to make phone calls.

Within a half hour the family starts to arrive. Chairs are brought into the room, where the relatives begin their vigil. The priest is called to deliver last rites. And still, Oscar has not budged, instead purring and gently nuzzling Mrs. K. A young grandson asks his mother, 'What is the cat doing here?' The mother, fighting back tears, tells him, 'He is here to help Grandma get to heaven.' Thirty minutes later, Mrs. K. takes her last earthly breath. With this, Oscar sits up, looks around, then departs the room so quietly that the grieving family barely notices.

On his way back to the charting area, Oscar passes a plaque mounted on the wall. On it is engraved a commendation from a local hospice agency: "For his compassionate hospice care, this plaque is awarded to Oscar the Cat." Oscar takes a quick drink of water and returns to his desk to curl up for a long rest. His day's work is done. There will be no more deaths today, not in Room 310 or in any other room for that matter. After all, no one dies on the third floor unless Oscar pays a visit and stays awhile.

Note: Since he was adopted by staff members as a kitten, Oscar the Cat has had an uncanny ability to predict when residents are about to die. Thus far, he has presided over the deaths of more than 25 residents on the third floor of Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. His mere presence at the bedside is viewed by physicians and nursing home staff as an almost absolute indicator of impending death, allowing staff members to adequately notify families. Oscar has also provided companionship to those who would otherwise have died alone. For his work, he is highly regarded by the physicians and staff at Steere House and by the families of the residents whom he serves.

Understanding Hospice -- An Underutilized Option for Life's Final Chapter

NEJM:Gail Gazelle, M.D.

It was Mr. G.'s third exacerbation of congestive heart failure in the past 6 months. Eighty-three years old, he had New York Heart Association class IV heart failure, end-stage coronary artery disease, and insulin-dependent diabetes. Although he had never wanted to be put on a ventilator, this time his shortness of breath was so terrifying that he felt he had no choice. After having a good response to diuresis, he was successfully extubated and transferred out of the coronary care unit.

Two days later, a hospitalist suggested to Mr. G. and his wife that given his advanced disease, he should consider going home and receiving hospice care there. Sensing the couple's fear, she reassured them that death was not imminent and that members of the hospice staff would work to ensure the best possible quality of life. Relieved, Mr. G. acknowledged that he would prefer to avoid rehospitalization.

Introduced in the United States as a grassroots movement more than 30 years ago and added as a Medicare entitlement in 1983, hospice care is now considered part of mainstream medicine, as evidenced by growing patient enrollment and Medicare expenditures ...But despite its increased use, many aspects of hospice care are still misunderstood by both physicians and patients. For instance, many would not consider Mr. G. to be a candidate for hospice care. He did not have cancer, and his death was probably months, not days, away. The fact is, however, that slightly less than half of hospice patients have terminal cancer; nearly 40% of hospice admissions are for end-stage cardiac disease, end-stage dementia, debility, pulmonary disease, and stroke.

Patients and clinicians may also not realize that hospice care at home is free. Medicare is the primary payer for hospice care in approximately 80% of cases, with care most often provided in the patient's home. Commercial insurers also provide hospice benefits, but the specifics of coverage vary. Under Medicare, most expenses related to the terminal diagnosis are paid in full, including all medication and equipment and all visits by hospice nurses and home health aides. ... Other hallmark hospice services include intensive emotional and spiritual counseling, 24-hour crisis management, and bereavement support for at least 1 year after the patient's death. ...
With the growing number of baby boomers seeking more control over all aspects of their health care, the use of hospice care will probably continue to increase. It is especially important, therefore, that physicians become more familiar with what hospice care offers and work to overcome barriers in talking frankly with patients about what lies ahead.

I have been a strong supporter of the hospice movement for almost thirty years. Our family's recent experience with hospice care for my dying father reinforces that support. He was, with hospice support, able to stay in his assisted care facility, without the need for a final disruptive and disorienting transfer to a hospital or nursing home. Care was provided with compassion and competence (after some initial challenges in getting all the care providers on the same page about treatment objectives and modalities). Hospice personnel also provided important support through Dad's final illness for my aging mother and for my brother, who bore primary responsibility throughout, and helped with bereavement care in the immediate aftermath.

The article's assertion that "hospice care is now considered part of mainstream medicine" may be somewhat more aspirational than established fact in some locales, but there is increasing recognition that hospice care need not and should not be limited to cancer patients in their final days of life, and provides a highly valuable option for a much broader class of patients approaching "life's final chapter," and for their families. I commend the New England Journal for publishing this piece, and for making it freely available on their web site.

Study Says Obesity Can Be Contagious

New York Times: By GINA KOLATA

Obesity can spread from person to person, much like a virus, researchers are reporting today. When a person gains weight, close friends tend to gain weight, too.

Their study, published in the New England Journal of Medicine, involved a detailed analysis of a large social network of 12,067 people who had been closely followed for 32 years, from 1971 until 2003. The investigators knew who was friends with whom, as well as who was a spouse or sibling or neighbor, and they knew how much each person weighed at various times over three decades. That let them examine what happened over the years as some individuals became obese. Did their friends also become obese? Did family members or neighbors?...

Dr. Nicholas Christakis, a physician and professor of medical sociology at Harvard Medical School and a principal investigator in the new study, says one explanation is that friends affect each others’ perception of fatness. When a close friend becomes obese, obesity may not look so bad.

“You change your idea of what is an acceptable body type by looking at the people around you,” Dr. Christakis said.

The investigators say their findings can help explain why Americans have become fatter in recent years — each person who became obese was likely to drag some friends with them....

The effects, Dr. Christakis said, “highlight the importance of a spreading process, a kind of social contagion, that spreads through the network.”

Of course, the investigators say, social networks are not the only factors that affect body weight. There is a strong genetic component at work as well. ...

It also may mean that the way to avoid becoming fat is to avoid having fat friends.

That is not the message they meant to convey, say the study investigators, Dr. Christakis and his colleague, James Fowler, an associate professor of political science at the University of California in San Diego.

You don’t want to lose a friend who becomes obese, Dr. Christakis said. Friends are good for your overall health, he explains. So why not make friends with a thin person, he suggests, and let the thin person’s behavior influence you and your obese friend?

That answer does not satisfy obesity researchers like Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University.

“I think there’s a great risk here in blaming obese people even more for things that are caused by a terrible environment,” Dr. Brownell said. ...

Does this finding carry over to students? Should informed consent be mandated when students attempt to register?

Diet soda, metabolic syndrome linked

Los Angeles Times: By Thomas H. Maugh II

Drinking as little as one can of soda a day — regular or diet — is associated with a 48% increased risk of metabolic syndrome, a key predecessor of heart disease and diabetes, according to results released Monday.

Researchers knew that drinking regular sodas contributed to the risk of metabolic syndrome, but this is the first finding implicating diet sodas, according to results published online in Circulation: Journal of the American Heart Assn.

The researchers were uncertain why diet soda seemed to have such a large effect.

The study's lead author, Dr. Ramachandran S. Vasan of the Boston University School of Medicine, said it was unlikely that an ingredient in soda caused the effect. More likely is that consuming sweet sodas changes dietary patterns or that soda was simply a marker for participants' poor eating habits, he said. ...

Soda makers rejected the study. "The assertions defy the existing body of scientific evidence, as well as common sense," said Susan K. Neely, president and chief executive of the American Beverage Assn.

She continued: "It is scientifically implausible to suggest that diet soft drinks — a beverage that is 99% water — cause weight gain or elevated blood pressure."

Traveler’s TB Not as Severe as Officials Thought

New York Times: By LAWRENCE K. ALTMAN

New tests of the Atlanta lawyer who caused an international health scare by traveling abroad with tuberculosis show that the form of the disease he has is not as severe as originally thought, federal officials and his doctors said yesterday....

Although the confusion as to who knew what and when was never completely explained, one fact was clear: Mr. Speaker had extremely drug-resistant tuberculosis, or XDR-TB, the hardest possible variety to cure, and it had been identified by the disease center in Atlanta.

Except that he did not have XDR-TB, the disease center and the National Jewish Medical and Research Center in Denver, where he has been a patient in isolation since June 1, said yesterday. A series of new tests at both institutions shows that Mr. Speaker has multiple-drug-resistant TB, or MDR-TB, still dangerous, but susceptible to more drug treatments. ...

The test findings also raised questions about the accuracy of TB tests at the C.D.C., a national and reference laboratory for the disease. The center reported in May that its tests showed that Mr. Speaker had XDR-TB, based on cultures from a lung procedure, a bronchoscopy, at a hospital in Atlanta. ...

In a statement expressing relief that he did not have the most severe form and harshly criticizing the government’s actions in his case, Mr. Speaker said his case had been misdiagnosed.

When the Surgeon Is Infected, How Safe Is the Surgery?

New York Times

Perspective on Her Side, Mrs. Edwards Enters Fray

New York Times:

Mrs. Edwards has also become a free operator on behalf of her husband of 29 years, a development that her friends suggest reflects the clarity and perspective that come from her cancer diagnosis, and her increasingly confident political instincts as she advises Mr. Edwards, a North Carolina Democrat, in his second White House bid.

When Mrs. Edwards called in to a television talk show this week to confront the conservative commentator Ann Coulter who had attacked Mr. Edwards this year, it was a decision that Mrs. Edwards said she made impulsively and on her own. The resulting dramatic four minutes of television created a surge of attention that at least momentarily electrified her husband’s campaign, winning applause from the left and apparently spiking contributions in the critical final days of this second-quarter fund-raising period....She argued vigorously with her husband over details of his signature health care plan — before an audience of transfixed campaign aides. (He won that argument, an aide said.)...

Her stamina on the campaign trail appears steady, and she and her husband frequently say that her cancer has proved no encumbrance on her daily life. Mrs. Edwards shows no visible manifestations of the disease — her hair is full, her skin color robust, and she bustles with energy. She often carries her own bags, aides say, and she can put in the standard 16-hour day expected from anyone in the business of running for president. She takes a little yellow pill once a day, oral chemotherapy, and visits a doctor’s office for treatment about once a month.

Study Says Chatty Doctors Forget Patients

New York Times: By GINA KOLATA

...That, a group of researchers say, is part of an actual conversation they recorded in the course of a study that showed that many doctors waste patients’ time and lose their focus in office visits by interjecting irrelevant information about themselves. ...

To their surprise, the researchers discovered that doctors talked about themselves in a third of the audio recordings and that there was no evidence that any of the doctors’ disclosures about themselves helped patients or established rapport.

Nor, in the vast majority of cases, did the doctors circle back to the personal conversation or try to build upon it.

“I think all of us on the team thought self-disclosure is a potentially positive aspect to building a doctor-patient relationship and that we ourselves were quite good at it,” said Susan H. McDaniel, a psychologist who is associate chairwoman of the department of family medicine at the University of Rochester and lead author of the study.

“We were quite shocked,” Dr. McDaniel added. “We realized that maybe not 100 percent of the time, but most of the time self-disclosure had more to do with us than with the patients.” ...

“I’d been saying for many years that disclosure was a form of patient support,” Dr. Beckman said. “If someone says, ‘I have a problem,’ and you say, ‘I understand because I have it, too,’ that would be comforting.” But, he added, “in truth that never happens.”

Patients were not comforted, he said, and conversations got off track. Four out of five times when a doctor interjected personal information, the doctor never returned to the topic under discussion before the interruption.

“We found that the longer the disclosures went on, the less functional they were,” Dr. Beckman said. “Then the patient ends up having to take care of the doctor and then the question is who should be paying whom.” ...

“We looked for any statement of comfort, any statement of appreciation, any deepening of the conversation,” Dr. Beckman said.

They found none.

This deserves a fuller discussion after I get hold of the full research report. I do worry that it will be over-read to support robot-like interactions with patients, already a problem in many settings.

It is peculiar to read of doctors wasting time on "irrelevant personal narratives" when there are so many credible reports of pressure on primary care docs to increase patient throughput (that is, see as many patients as quickly as possible), and when calls for improved informed consent and shared decision making are rejected on grounds that there is no time for such conversations. Very mysterious to me.

Kidneys and Hearts

Salon.com | News Wires: By LAURAN NEERGAARD (AP)

WASHINGTON -- Hearts and kidneys: If one's diseased, better keep a close eye on the other.

Surprising new research shows kidney disease somehow speeds up heart disease well before it has ravaged the kidneys. And perhaps not so surprising, doctors have finally proven that heart disease can trigger kidney destruction, too.

The work, from two studies involving over 50,000 patients, promises to boost efforts to diagnose simmering kidney disease earlier. All it takes are urine and blood tests that cost less than $25, something proponents want to become as routine as cholesterol checks.

'The average patient knows their cholesterol,' says Dr. Peter McCullough, preventive medicine chief at Michigan's William Beaumont Hospital. 'The average patient has no idea of their kidney function.'...

Indeed, the new research is highlighted in this month's Archives of Internal Medicine with a call for doctors who care for heart patients to start rigorously checking out the kidneys -- and for better care of early kidney disease.

The link sounds logical. After all, high blood pressure and diabetes are chief risk factors for both chronic kidney disease and heart attacks.

But the link goes beyond those risk factors, stresses McCullough: Once the kidneys begin to fail, something in turn accelerates heart disease, not just in the obviously sick or very old, but at what he calls "a shockingly early age."

Should insurance cover these drugs?

Salon.com | News Wires: By JILL LAWLESS (AP)

LONDON -- Pharmaceutical companies and Alzheimer's patient advocates went to Britain's High Court on Monday in a bid to force the state-run health service to give all patients access to three drugs to treat the brain-destroying disease.

The case is the latest in a series of legal challenges to Britain's National Health Service, which offers free health care and low-cost medicines to all Britons -- but is regularly accused of rationing access to treatment.

Drug companies Eisai Co. Ltd. and Pfizer Inc., along with the Alzheimer's Society, want to overturn a decision by the government's medicines watchdog not to approve a group of drugs known as acetyl cholinesterase inhibitors for patients in early stages of the disease.

The National Institute for Health and Clinical Excellence (NICE), which regulates use of prescription drugs, recommended last year that three drugs -- donepezil, rivastigmine and galantamine -- not be prescribed for patients with early stage Alzheimer's.

It said the treatment was not particularly effective for people with mild Alzheimer's and at about 2.50 pounds (US$5; euro3.70) per patient per day was not cost effective. It recommended the drugs for patients with moderate-stage Alzheimer's.

What are we to do with the current generation of Alzheimer's drugs? There is relatively little evidence that they make a large physiological difference for most patients. Many patients, family members, and physicians invest so much hope in these pills, in the absence of better tools against this awful disease.

The fact this particular episode is playing out under NHS in Britain reminds us that universal care, even if achieved, will not be infinite, and decisions will have to be made on coverage--certainly at the margins of effectiveness.

Meanwhile, my HMO as a relatively well-covered state employee (or "employe" as Wisconsin would have it--saves buckets of ink by dropping that final "e") does not provide full coverage for several of my highly effective prescription drugs--not on the approved drug formulary for my plan.

Autism in the Vaccine Court

New York Times (Editorial):

A federal vaccine court in Washington is confronting the contentious and highly emotional issue of whether early childhood vaccinations might have caused autism in thousands of children. Virtually every major scientific study and organization that has weighed in on the issue has seen no link. But many parents of afflicted children remain unconvinced. Their lawyers will try to prove that some 4,800 children were harmed by the mass vaccination campaigns that protect the nation’s youngsters from potentially devastating childhood illnesses. ...

In 2004, the prestigious Institute of Medicine concluded that neither the preservative, known as thimerosal, nor the measles-mumps-rubella vaccine was associated with autism and that various hypotheses about how they could trigger autism lacked supporting evidence. Even after thimerosal was phased out of pediatric vaccines, autism rates did not fall.

The vaccine court will be addressing the narrow issue of whether these families deserve compensation from a national vaccine injury fund. But the proceedings will inevitably affect all parents’ attitudes toward the measles vaccine and toward pediatric vaccinations in general.

We can only hope that, however the verdicts go, parents will remain eager to get their children vaccinated. Even the plaintiffs’ lead attorney acknowledged that mass immunization programs are “a great public benefit” that have prevented tens of thousands of deaths and serious injuries. Those who shun a vaccine are at far greater risk than those who take it.

British human rights law doesn't cover private homes

Guardian Unlimited:

Parliament is under pressure to block a legal loophole opened up on Wednesday by a Law Lords judgment that elderly and vulnerable people sent to private care homes by their local authorities are not protected by human rights laws.

Five Law Lords, by a 3-2 majority, rejected argument that a private home is 'exercising a public function' when it cares for people referred to it by a council, and is therefore bound by the Human Rights Act.

The decision, which could affect up to 300,000 residents throughout the country, came in the case of an 84-year-old Alzheimer's patient. Her lawyers argued that her threatened eviction from a private home would violate her right to family life.

Alzheimer's cases may quadruple by 2050

From Yahoo! News

WASHINGTON - More than 26 million people worldwide have
Alzheimer's disease, and a new forecast says the number will quadruple by 2050. At that rate, one in 85 people will have the brain-destroying disease in 40 years, researchers from Johns Hopkins University conclude. ...

The new estimates... serve as a sobering reminder of the toll to come if scientists cannot find better ways to battle Alzheimer's and protect aging brains. "If we can make even modest advances in preventing Alzheimer's disease, or delay its progression, we could have a huge global public health impact..."

The Onion has a video up on Alzheimer's. Too painful, and too close to home, for me to post. No point in raising questions of taste on Onion stories--goes with the territory.

Children with autism get day in court

Yahoo! News

WASHINGTON - In excruciating detail, an Arizona mother on Monday described severe autism and devastating health problems that plague her 12-year-old daughter and asked a court to find common childhood vaccines were the cause.

The test case is being closely watched by nearly 5,000 families of autistic children who have lodged similar claims for compensation from a federal fund.

The case of Michelle Cedillo, of Yuma, Ariz., is the first alleging a vaccine-autism link to be heard in the U.S. Court of Federal Claims. It and eight other test cases are important because they will guide the handling of the other pending claims. Most contend that a mercury-rich preservative called thimerosal is to blame for the impaired social interaction typical of the disorder.

Should they prevail, the families will be eligible for compensation from a federal vaccine injury fund established by Congress to ensure an adequate supply of vaccines by shielding manufacturers from lawsuits. No autism claim has been paid from the fund thus far. ...

The burden of proof is easier than in a traditional court. Plaintiffs only have to prove that a link between autism and the shots is more likely than not, based on a preponderance of evidence. But many parents say their children's symptoms did not show up until after their children received the vaccines, required by many states for admission to school.

"These are families who followed the rules. These are families who brought children in for vaccines. These are families who immunized their children," Cedillo attorney Thomas Powers said. Later, outside court, he cast aside any suggestion his clients were anti-vaccine. ...

In 1999, the U.S. government asked vaccine manufacturers to eliminate or reduce the use of thimerosal in childhood vaccines to limit infant exposure to mercury. Today, the preservative is no longer found in routine childhood vaccines but is used in some flu shots.

I supported the legislation providing non-fault compensation for vaccine injuries (having worked on research-related injuries during my time with the President's Commission on Ethics in Medicine and Research in the early 1980s). The legislation requires proof of some causal relationship between vaccine and injury, but not proof of negligence. So far, to the best of my (somewhat outdated) knowledge, the science has not supported the thimerosal connection. There is some risk recognizing these claims would break the bank, and undermine the principle of non-fault compensation. I'm glad the claims will receive consideration and appropriate scrutiny. Whatever the outcome, we need some social mechanism for helping families to cope with the onerous burdens, financial and otherwise, of children with severe autism.