Monday, December 28, 2009

Happy Holidays

I recently got a generic holiday card (I won't say where from) spewing with relativistic thought. I guess that's what it takes to survive this pluralistic world. Here's the text:

Whatever is beautiful,
whatever is meaningful,
whatever brings you happiness ...
May it be yours this Holiday Season
and throughout the coming year.

So if you're a child molester and that's what makes you happy, go for it this holiday season!

Tuesday, December 22, 2009

Taxes and more taxes

Got a lot to write about, Senate headed towards passing their version of health reform. More on that later, though. First off, I have decided to start using typical capitalization. I realize it's a lot easier to read than the all lower-case version. Sorry e.e. cummings, you were an inspiration but it did not last.

I have never been a huge fan of lifestyle taxes--you know, additional taxes on cigarettes, alcohol, soft drinks (proposed). In case you missed it, included in the Senate bill is a 10% tax on tanning salons. You heard that right, tanning salons. The government is delusional enough to believe this will bring in $2.7 billion dollars over the next 10 years to help pay for reform. This information is in today's Wall Street Journal. Originally, there was supposed to be a 5% "Botax" on cosmetic procedures which would have brought in an estimated $5.8 billion. Not surprisingly, the AMA and AAD (Dermatology group) opposed this idea and somehow, they decided to tax tanning salons instead. Even before the article, I thought it would hurt many of the small businesses that operate these salons, many which are already failing without the tax. Pun intended, let's face it, an additional 5% tax on cosmetic procedures isn't going to ruin any dermatologist or patient seeking said procedures. Nevertheless, that's why you need a strong lobby in D.C. and apparently the tanning industry's isn't.

What gets me even more ("what grinds my gears" in the words of Peter Griffin) is the condescending attitude of people like Dr. David Pariser, president of the AAD. I guess feeling a little smug at his victory on Capitol Hill, his justification for the tax is because "Indoor tanning is a practice which is a known carcinogen." Are you kidding me? Newsflash, Dr. Pariser: the sun is a known carcinogen. Do you propose additional federal taxes for swimming pools, beaches and any business with outdoor exposure? Furthermore, sticking needles into and cutting or freezing body parts is also a known hazard, increasing risks of infection, bleeding and other problems.

This doesn't even cover Obama's pledge not to increase taxes a single cent on anyone making less than $250,000. That's why he's a smart man. I guess he means no tax increase on anything that actually shows up on a federal tax form but if you increase taxes on every other area of life, that's okay. But of course, as I've mentioned before, the "fee" proposed for not having health insurance really is a tax anyway, collected by the IRS.

Wednesday, September 23, 2009

tough crowd?

from the new york times, monday september 21:

"Mr. Obama is not usually one to avoid high-risk interviews or dodge hostile crowds. He was the first sitting president to appear on “The Tonight Show With Jay Leno,” ... "

so leno is now a "high-risk interview" or has a "hostile crowd"? now that's funny.

the above quote was in a story regarding obama's record 5 sunday am interviews pushing his healthcare agenda. most of the interviewers tossed softball questions. kudos, however, to george stephanopoulos. he tried to challenge the president about the "tax" under the house and senate plans for people who are able to afford insurance but choose not to get it. as you can imagine, this is a problem because obama promised to raise no taxes of any kind for those making under $250,000 a year. here's another good analysis of it. it's almost as confusing as clinton's definition of "is." basically, it's not a tax because he says it's not? even though the bill says it is and the irs would be the ones collecting it? as pointed out in the ap piece, of course the tax issue is already moot with the passage of schip which raised tobacco taxes and predominantly affects those making less than a quarter mil. and as a refresher, i'm getting tired of the car insurance analogy. we can opt out of paying car insurance by not having a car--a way of life many people in this country live. the only way to opt out of a health insurance "tax" is by not making any money or being low-income which isn't exactly a motivating policy.

Tuesday, September 08, 2009

healthcare reform 2.0

well, it's the eve of obama's big speech to a joint session of congress trying to sell his healthcare reform. or is it health insurance reform? regardless, here are a few random thoughts on this whole mess.

1. upon further inspection, the additional 2.5% tax on adjusted gross income isn't completely unprecedented (see prior post). heck, we already pay a whole bunch in medicare and social security so the idea isn't new. it's not necessarily a tax on being alive but a tax on making money. so technically you can opt out by not making any money but that makes life a little difficult. plus, we already pay enough taxes.

2. i'm not necesarily against a public option per se. it's true a type of public option already exists with medicare and medicaid. so if there was a public option to cover those who can't afford any insurance and to cover catastrophic events, that's not necessarily a bad thing. but the problem is, how will we afford this??? i am in awe (in a bad way) when i hear people talk about how medicare is not that bad and why not expand it to everyone? hello?! it's about to freakin' go bankrupt, that's why. recently they moved up the estimated year when this thing would go belly up unless something changes, see here. if we can't even keep up with medicare costs, how in the world are we going to afford this for everybody?

3. i still don't understand how you can focus on cutting costs in healthcare without addressing tort reform. well, okay, it's easy to understand from this perspective: trial lawyers are a big part of the democratic party. that's why obama doesn't want to add tort reform to this bill. howard dean himself acknowledged this point (do a search for "trial lawyers" on the link). it is simply not an honest discussion about cutting costs if this issue is not addressed.

dean's comment is so telling. this bloated 1000 page bill covers almost everything under the sun including how to change time accounting for training resident physicians yet they didn't want to add more by addressing one of the most important issues?! that is nonsense.

why the need to tackle so many issues in such a large bill that many haven't even read? this whole reform started on a platform of "the 47 million uninsured" but has now encompassed more than they can handle. why not just start with the few important issues and settle those without trying to disrupt the whole system? some will say that it's because the whole system needs fixing, which i don't necessarily disagree with but it's not in ways that these guys are talking about. i will discuss those below and in later posts.

4. i'm tired of hearing all the complaints about the republican party. now, for full disclosure, i do tend to align myself with conservative ideas usually but am certainly not a card carrying republican. nevertheless, the democrats have a filibuster-proof majority. if they want to pass a plan, they can, so quit complaining about the republicans and formulate a plan that your own party can at least approve. the opposition party is not the problem when you have a majority congress and the white house!

5. it's a myth that anyone can guarantee that you can keep seeing your same doctor under the current proposal. see section 102 and 142 on the prior post with the link to the full summary of the bill. first of all, obama wasn't even familiar with the details of the bill as is evidenced here. section 142 basically sets up a health care "czar" who can force all plans to meet certain requirements. section 102 says that if you are in a plan after the bill takes place, that plan has 5 years to meet these requirements. now, i don't want to sound skeptical of our government, but if they decided to formulate the requirements in such a stringent way that no limited resources private plan could meet it, that would essentially eliminate all other plans. since this is more than a remote possibility, the fact is, if you have a new doctor and new plan after the bill (theoretically) passes, you ARE NOT guaranteed continuity of care. this is made even worse by employer-based health insurance which needs to be eliminated. more on that later.

6. what i find most amazing is some of the comments obama has made regarding physician practices. not surprisingly, most of these comments are made ot (off teleprompter). for example, remember the july 22 press conference when he said the following (full text here):

"And part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works -- because that's not how it's working right now. That's not how it's working right now. Right now doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there.

So if they're looking -- and you come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, you know what, I make a lot more money if I take this kid's tonsils out. Now that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies, maybe they have something else that would make a difference."

are you freakin' kidding me? is this how he thinks doctors think and act? now i know he never took any type of hippocratic oath in law school but most doctors i know act in the best interest of their patients. you'd be surprised to find out how frequently surgeons are actually unwilling to cut! and while we're on this topic, can we please dispell another myth? most doctors do not get paid by ordering more labs and tests and scans. this is patently false and ridiculous. this is only true if they own their own lab or testing machines which is not the majority of doctors.

now, if you thought the above statement was crazy, the one below is more unbelievable (from august 11):

"All I'm saying is let's take the example of something like diabetes, one of --- a disease that's skyrocketing, partly because of obesity, partly because it's not treated as effectively as it could be. Right now if we paid a family -- if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's $30,000, $40,000, $50,000 -- immediately the surgeon is reimbursed. Well, why not make sure that we're also reimbursing the care that prevents the amputation, right? That will save us money. (Applause.)"

now, in all fairness his main point is to pay primary care providers more money for preventive care. not gonna argue against that. but again, he shows his incredible ignorance (most likely ot again) about how doctors get paid in this country. there is a wide gap between what a hospital might charge for a procedure and how much a doctor actually gets paid. in fact, medicare pays aorund $1000 to a surgeon for an amputation, not tens of thousands of dollars! and to assert that this reimbusement is immediate??? are you kidding me? yeah, what you do is bill medicare and hope to get money within 90 days for services you already provided.

in all honesty, this is the kind of stuff you would expect spewing out of the mouth of w, not this supposed post-partisan president who is such a fluent orator.

7. the big question comes up, how are we going to pay for such sweeping reform? not receiving as much press is the question as to who is going to take care of all these patients? already many do not want to go into primary care for a variety of reasons so you can expand health insurance to every plant and animal in this world but if there aren't the doctors around to take care of them, have we solved anything?

who is for this bill?

8. why is the ama for this reform bill? who knows but one thought is because they got a deal from obama to eliminate the sgr, the sustainable growth rate which is an archaic formula that medicare uses to pay physicians. that itself is actually a good thing but the ama is a joke and the organization does not represent the majority of doctors. is there some other reason they are supporting this bill? i have no idea.

9. why are the hospital organizations for the bill? section 1156 which essentially eliminates physician-owned hospitals as of this year by choking off the current supply. here's a commentary.

10. why is pharma (pharmaceuticals research and manufacturers of america, the umbrella organization for the nation's drug companies) for reform? because they get the guarantee that the governmentwon't negotiate for lower prescription drug prices. here's one article on this. another slate article.

so then, what's the answer? read this article for a closer glimpse into the problem. here's another one but i'm not sure how long it will be accessible. first off, you have to identify the real problems. the first article is written by david goldhill, a democrat but a businessman and he identifies many problems very well from a business perspective (although i don't agree completely with all his solutions). the second article is written by whole foods ceo john mackey. the essence of both articles is actually to use less insurance and to increase transparency in pricing. this will promote more competition but to facilitate this, you also need to remove barriers to insurance access, in particular allowing portability of insurance across state lines. it's too late to get into this in detail right now so i will in a post to come real soon i hope.

Saturday, August 22, 2009

a birthday semi-tribute

i have kept a mental list (and a short one on my iphone) over the months about how our little love child is like me and how she is like karen in certain ways. as it turns out, today is baby momma's x5th birthday (i know, 25, can you believe it? she doesn't look a day over 24.) so this is a tribute to her. i think last year i hacked into her blog and wrote an entrance as kate. heck, maybe i'll do that again. that was fun.

ways that kate is like ...

me: stubborn as heck sometimes

karen: loves cookies and chick fil-a

me: laughs at her gas expulsion (not always though and let's be honest, it's not ALWAYS funny, just usually)

karen: nosey as can be. kate has backed off a little but months ago she would just stare down people and watch them as they passed and even stretch her neck around you to get a better look. anyone who knows karen can attest to her nancy drew ways.

me: physically active (not to say i am now but i really was as a kid). kate before she was 2 was already climbing the rock wall type section on playground sets all by herself, with a little supervision by me of course. here's the vid, check it out yourself.

karen: loves green beans, too, one of the few vegetables kate eats. don't get me wrong, i like green beans, just more of a corn man myself.

me: picks her nose in public. hey, just being honest. at least i try to hide it.

karen: artsy. kate loves crayons, painting, drawing, coloring, you name it. karen isn't exactly artsy like that but creative and crafty (insert beastie boys riff). kate definitely did not get that way from me.

me: loud. karen will be happy when kate learns what "inside voice" means. also ask karen how my being loud was a stumbling block in our marriage early on. ha ha! funny times.

karen: just as pretty as can be, you can't just stop looking at them!

well, that's a short list, i had many more i didn't write down and now i don't remember them because i'm getting old but happy birthday to my beautiful wife!

Monday, July 27, 2009

health care (?) reform

well, as we are being told now, we're in the midst of health insurance reform, not health care reform. i guess our health care is good enough. it's the insurance that needs work.

i thought i would finally weigh in on the debate a little. by no means will this be an exhaustive evaluation; heck, i'm here with a glass of wine with cnbc on in the background. not exactly the setting for changing national policy, i'm sure.

as a reference, here's a link to a detailed summary of the house bill which has been proposed. since this thing is already out there, i guess a few comments about it would be in order.

problem 1
one proposal i find very unamerican is the 2.5% tax added (see section 401) if you refuse to sign up for any insurance. now, in the spirit of full disclosure, i actually thought this idea should be considered several years ago but have since changed my mind. i haven't done any significant research into this yet but can you think of any other tax that you have to pay just for being alive? people compare this to car insurance which is also mandatory but plenty of people opt out of car insurance by not owning or driving a car. you can opt out of property tax by renting. you can opt out of sales taxes by not buying stuff (or not buying as much). you can opt out of just about any tax currently out there one way or another (may not necessarily be the most feasible option in the world but possible) but you can't opt out of this health insurance tax unless you die! THAT is unamerican. next thing you know, i'm gonna have to pay tax for breathing. oh wait, that's probably gonna happen soon too.

problem 2
before i go on, i have to reference an npr story that aired a couple of weeks ago. you can read the transcript here and here is a link to an explanation of the story. you should read some of the comments in the original article. pretty funny stuff. some guy even posted a link to i think a washington post article (okay, can't help myself, click here) this same chick did about buying the right mattress. hard hitting stuff april fulton has been working on. anyway, the npr article was one of the most grossly biased and misleading things i have ever heard on the air. now that's saying something, even for npr! you hear this business about the public plan option and the reason for its being to keep private companies honest. the administration has even said it. for people who honestly believe this, i would encourage you to think about it further. let's take the example of private versus public primary/mid/high schools and use this as a substitute in the npr piece. do you see a large population of private schools who are "nervous" about public schools because "people really like it" and it offers such a value? are private schools drastically slashing their prices to "attract customers back" because the public schools are stealing all the students away? that is ridiculous. in the same way, don't expect the public plan option to all of a sudden make private insurance plans so much better. you know what? if there are unscrupulous activities going on in private insurance (which is definitely the case for patients AND for physicians) then fix those problems. don't expect a public plan to do it for you.

there are many more things to discuss. more later.

Tuesday, June 30, 2009

practice makes perfect?

in case you were wondering if that med student or resident physician seeing you had any clue what they were doing, check it out. good to know mannequins are making it into the world of "intimate exams." we actually had the opportunity in med school to do intimate exams during our physical diagnosis class by joining groups with members of the opposite sex. needless to say, no one volunteered. talk about awkward. what would you talk about at parties? in some other classes, however, i did hear of students who were enthusiastically recruiting people for the group. yes, these same people could be your doctor. just saying.

Thursday, June 25, 2009


a somewhat controversial bill quietly zipped through texas recently. check out this article. i can't say i'm all for the bill. i'll elaborate on why later but i wanted to put up the link so i wouldn't forget.

Friday, May 15, 2009

missing the point

this is crazy. there was a recent meeting at the white house consisting of "stakeholders" in the debate to lower healthcare costs. here's a link to the people who showed up to the meeting. what group is noticeably missing? how about representatives from the american bar association? i would have liked a commitment from their members to not file frivolous lawsuits against physicians but that will never happen. obama doesn't have the guts to call his own people out on it either. don't get me wrong, i know we need lawyers and there are plenty of good ones out there but isn't this a huge piece of the puzzle as to why healthcare costs are so high?! many physicians practice defensive medicine, ordering too many tests they feel they probably don't need but are afraid of missing some rare problem that can get them into trouble. and when that one-in-a-million problem occurs or the patient is the one to blame for a certain problem, bam! lawsuit. unbelievable. with socialized medicine, missed diagnoses will likely increase in frequency because not everyone with foot pain is going to be able to get an mri. plus you'll have limited access to life-saving therapies. here's a nice opinion in a recent wsj.

Thursday, March 19, 2009

it's match day!

today, senior med students around the land find out where they will be going to residency courtesy of a computer somewhere out there which spits out a list combining the wishes of students and the residency programs. i think they find out at noon or sometime no too long thereafter. let the parties begin because starting july 1, your life is over. ha! good luck to all, i'll be seeing a few of you in july.

Tuesday, March 17, 2009

jama--journal of the american medical association ... losing relevance?

i recently read such an outlandish story, i had to come out of hiatus to report it. here's a link to an article in the wall street journal from their health blog section. apologies if you can't get to it, can't remember if you need to be a subscriber to access it. just in case you can't get to it, i have an excerpt below. as a background, there was an article in jama about using antidepressants in stroke patients prophylactically (using them to prevent depression). well, it turns out that one of the authors used to get paid by the company who manufactured the drug in the study. this information was not disclosed in the article (and it should have been) so upon discovering this, a neuro-anatomy professor from lincoln memorial university in tennessee, jonathan leo, wrote a letter to the british medical journal exposing this problem and that's when it gets interesting. the wsj folk took hold of this story and below are some quotes from the editor-in-chief of jama, dr. catherine deangelis.

from, published march 13, 2009:

In a conversation with us, DeAngelis was none too happy to be questioned about the dust-up with Leo. “This guy is a nobody and a nothing” she said of Leo. “He is trying to make a name for himself. Please call me about something important.” She added that Leo “should be spending time with his students instead of doing this.

When asked if she called his superiors and what she said to them, DeAngelis said “it is none of your business.” She added that she did not threaten Leo or anyone at the school.

yes, my friends, the editor-in-chief of what is reportedly one of the most important medical journals went on the record lashing out on someone trying to set the record straight. according to leo, the executive deputy editor actually called first, essentially banning him from the journal for life. of course, the author eventually submitted a letter stating the very information dr. leo claimed (apparently an error "of memory"). if you read the wsj story, you can't believe dr. deangelis is behaving in such a manner--so defensive, angry, vindictive. even more amazing is the hypocrisy involved. read this article written by none other than dr. deangelis herself. i read many of the comments left by wsj readers. some called for dr. deangelis' resignation and cancelled their subscriptions. i feel the same way. jama and the ama has seen their day. this isn't the first time, nor will it be the last that these organizations have done questionable and unprofessional things. at the least i think physicians should call on dr. deangelis for a formal apology if not her resignation itself. this is medical arrogance at its finest.

Sunday, January 25, 2009


this post is in response to another post by a real medical writer friend regarding screening tests for certain diseases. see the related post here.

basically, the question is, when should you start looking for diseases in people even if they have no symptoms (hence, screening)? a reader on the other post commented about ovarian cancer. she is a little on the younger side for women who get the disease; furthermore, it seems she actually had symptoms which is a separate issue. anyway, the reader suggested getting ultrasounds on all women but the question about screening turns out to be a lot more complex than it seems.

the first problem starts with the disease itself. the earlier you catch something, the harder it is to tell if it's a real problem. is that "spot" on your lung something that will one day turn into cancer or will it just stay a "spot"? is that cyst on your kidney or ovary just a cyst or are there features that make it worrisome for something more sinister?

then it gets into the realm of the actual test and interpretation. people tend to think a ct scan or an ultrasound is foolproof. but the fact is, there is no test in medicine, blood work, scan, algorithm, prediction score, you name it, that is 100% accurate. NOTHING. not even a pathologist examining something under a microscope is 100%. sometimes things that look like cancer turn out to be nothing and things that appear harmless turn out to be malignant. and not to malign pathologists, but radiologists are probably even more notorious for disparate readings. "impression: normal ct of the aorta. addendum [days later]: aortic dissection noted." don't get me wrong, these guys are smart, usually among the smartest in their class but we all miss subtle and not-so-subtle findings.

okay, so far you have a disease you're not sure is there, a scan that you're not sure how accurate it is in picking up the disease, and a radiologist who might be reading the scan incorrectly but it gets worse!

unfortunately, then the economic side of things rears its ugly head. let's use the ovarian cancer example. this is unfortunate. we've all seen it. i've seen metastatic colon cancer in patients in their 20's although it's a disease that you typically screen for when you're 50. the question then is, when do you start screening for ovarian cancer? no matter what age you start (heck, unless you start in prepubescent kids), you will probably miss some cases. there are always outliers. so, in order to catch that one in a million patient, can you justify starting screening at, say, age 30? 25? 20? who is going to pay for all this?! that, in today's economy and presidential administration, is the million dollar question. these tests can get expensive and you simply cannot screen all people for everything without completely obliterating the finances of this country.

so you start ovarian cancer screening at age 20. then how frequently do you repeat the testing? when is it safe to stop? how do you know when to act on some small finding? this now gets into the criteria needed for a screening test to be a good one. among them, the test has to be pretty accurate (namely, good "sensitivity," meaning you minimize the number of patients who have the disease but have normal tests, i.e. "false negatives"), the test isn't too costly, there are minimal side effects from the test itself and many other criteria.

then there's the whole question of whether the disease would have killed you anyway. now, in the patient with metastatic ovarian cancer, this is not as relevant since, again, it seems the patient had symptoms already. another dirty little secret: cancers detected incidentally or by screening that are not causing any problems do not always need to be treated. now that statement at face value sounds very controversial but the fact is, it's true. check out this controversial study. furthermore, take for example prostate cancer. unfortunately, many men will die of prostate cancer but many more men will die of heart disease and other cancers and stroke. frequently, some screening blood test or exam will reveal some abnormality which then requires biopsy or some other type of treatment that frequently will lead to incontinence or impotence or a myriad of other problems when there potentially may have been little or no benefit to the screening from the beginning. this is why there is such controversy in the realm of prostate cancer screening.

i think that's enough about screening but the thing is, so much more could be written. you see why it's such a complex topic when it seems so simple. the fact is, at least with cancers, some patients will get a fairly aggressive form and at a much earlier age than expected. most, however, will not and right or wrong, the policy is to try to implement the appropriate screening programs that are most cost-effective to benefit the most number of people while leading to the least amount of harm. primum non nocere--first, do no harm.