August 7th, 2009 by Jonathan Foulds, Ph.D. in Better Health Network, Opinion
Tags: Cigarettes, graphic, Quit Smoking, smoking cessation, warnings
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Now that the US Food and Drug Administration has been given the power to regulate tobacco products, one of its new powers is the right to change the health warnings on cigarette packs in the interest of public health.
So the first question is, are the current health warnings perfectly adequate? The answer to that one is clearly “no”. The boring small text warnings printed on the side of the pack have are almost perfectly designed to be ignored.
The second questions is, can we learn anything from the experience of health warnings in other countries? The answer here is a resounding “yes”. Numerous other countries have been using large mandated pictorial health warnings on cigarette packs for years and there is a growing body of research showing that these are much more impactful then prior text-only warnings. The warnings used in Canada present a good example to follow and can be viewed at:
http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/legislation/label-etiquette/graph/index-eng.php
However, I particularly like the style used in Australia, where they have, since 2006 also added the freephone number of the national stop smoking Quitline to the pictorial health warnings. Graphic images and explanatory messages cover 30% of the front and 90% of the back of the pack. The message “You CAN quit smoking. Call the Quitline 131 848, talk to your doctor or pharmacist, or visit www.quitnow.info.au” is also included on the back of all packs. The Quitline number is also “stamped” on top of the graphic image on the backs of packs.. A recent study by Dr C L Miller of the Cancer Council of South Australia concluded that introducing graphic cigarette packet warnings and the Quitline number on cigarette packets doubled demand for Quitline services, with likely flow on effects to cessation.
Other countries of the world (including the United States) that have not yet introduced large graphic health warnings on cigarette packs or the number to the national quitline should do so as soon as possible.
The research from Australia can be viewed at:
http://tobaccocontrol.bmj.com/cgi/content/full/18/3/235
This post, Should We Put Graphic Warnings on US Cigarette Packs?, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
August 6th, 2009 by GruntDoc in Better Health Network, Health Policy, Opinion
Tags: Cleveland Clinic, Cost of Care, Emergency Medicine, Finance, Healthcare reform, Hospitalists, Internal Medicine, Overhead, Salaried Physicians
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The Happy Hospitalist, generally an excellent blogger, wrote yesterday about how salaried docs must be delivering better care than those greedy FFS docs, because the Cleveland Clinic does a terrific job with docs on a salary. I suspect their excellent outcomes have nothing to do with reimbursement model and a lot more to do with systems and a strong gatekeeper model.
He totally missed the elephant in the room in the Big Group Clinic model: who gets the money for doing the work.
He cites as an example a GI doc who left the Clinic for independent practice and quadrupled his income. Let’s say he’s working as hard as he did in the Clinic; is he billing more than the Clinic did? I doubt the Clinic wasn’t billing the usual amount for the work, so 3/4 of this docs’ billing went where?
I suspect it went into the overhead of the Clinic. This isn’t a knock on them, it works for their group, so fine. Other groups do essentially the same thing. It’s legal and morally defensible, and some docs don’t mind being salaried.
Salaried docs in a big Multispecialty Clinic have different incomes, but not as radically disparate as the non-clinic model. As a way to somewhat equalize RVRBS issues it works (I wouldn’t want to be in the room when salaries come up, though).
What salaries do not do is get docs to work harder, see more patients. Some docs are very dedicated, motivated people who would work for rent and grocery money. Others on a salary would do the minimum: if every patient is more work and more liability without more pay, well, why work more/harder? As an incentive to produce nothing beats getting paid for it.
(This isn’t an endorsement of excessive or un-necessary procedures; there are greedy jerks in all professions).
Also, a happy side effect of getting paid for what you do rather than for having a pulse is those who work hard resent those that don’t (but who would make the same on salary) a whole lot less. Way less inter-group stress.
Salaries aren’t all bad, but they’re not the Key to Great Healthcare.
Discolsure: I’ve worked ED’s both ways, and much prefer fee for service.
*This blog post was originally published at GruntDoc*
August 4th, 2009 by DrRob in Better Health Network, Opinion
Tags: Dr. Benjamin, Obesity, Surgeon General, Weight Loss
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They gathered around the figure who was lying with face toward the ground. Holding stones, they demanded justice – that the sin of this person be exposed for what it is: inferiority. Her sin had been exposed for all to see and the righteous rage of those who were pointing fingers and holding stones was pounding at her on the inside, just as the stones would soon pound her on the outside.
“Her BMI is over 30! It may even be over 40!” one of them cried out. The others responded to this with a howl.
“How can she be fit for leading the country’s health if she can’t even fit into her pants?!” another asked, causing raucous laughter to echo from the crowd.
Nearby, a news reporter spoke into a camera: “People are questioning her fitness for surgeon general, as she obviously is overweight. The president had initially hoped the popular TV doctor would take the job, but fell back on Dr. Benjamin as a substitute. Clearly a president, who himself is a closet cigarette smoker, doesn’t see the fact that she is overweight as a disqualifying factor. These people, and many others around the country, disagree with that assessment.”
———————–
Forty years ago, people would also have cried out about this nomination. They would have said that a woman shouldn’t be in charge of the nation’s health, or that a black person doesn’t have the wherewithal to manage such a big task. Times have changed, as her nomination shows – nobody is talking about these facts that have nothing to do with her ability to do this job. We have truly progressed.
Sort of.
This objection, of course, is that her weight shows that either she doesn’t understand what is causing her obesity, or that she doesn’t have the moral fortitude to successfully fight it. Either way, she’s disqualified for the job. Right? It’s a sign of weakness to be overweight, and we certainly don’t need someone with a personal weakness to be in a leadership position!
It is clear that some view the overweight (which, by the way, constitute 2/3 of our adult population) as being emotionally weak and somehow inferior to everyone else. After all, study after study has shown that the way to beat obesity is simple: eat less and exercise more. It’s simple; and those who don’t do it are weak, lazy, dumb, or just plain pathetic.
It angers me to hear these suggestions. Racist and sexist people put down others because of the fact that they are different than themselves. But the moral judgment against the overweight and obese is not meant to be a judgment against something inherent in the other person; it is a judgment against their character, their choices, and their weaknesses. The implication is that they are somehow either smarter, stronger, or just plain better than the overweight. The implication is that the other is weak and they are not.
There is a word for this attitude: hypocrisy. A bigot is a person who hates those who are different; a hypocrite is one that hates others for something they themself have, but choose to ignore. Both mistakenly act as if they have the moral high-ground. Both disqualify themself from any argument based on morality.
Healthcare exists because of human weakness. We all are weak in various ways, and we all will eventually die when one of our weaknesses overcomes us. Obesity exists because of human weakness – either the genetic or biological miscalibration of the person’s metabolism, or the inability of that person to act in ways that are in their own best interest.
I have to say that I probably fall in the latter category, as my lack of desire to exercise and my exuberant desire to eat rich foods make it so I have struggled with my weight for years. Somehow the prescription: eat less and exercise more, is not very helpful for me. Yes, it is simple; but it is not easy. Having others explain it to me at this point is not only unhelpful, it is insulting. Of course I know that my weight is a problem! Of course I know I should exercise more and avoid that cookie dough in the refrigerator!
To successfully fight the battle against obesity in our country, we have to stop the condescending finger-pointing and instead ask the question: why is it that we humans don’t always act in our self-interest? Why do smokers smoke? Why do alcoholics drink? Why don’t people take their medications, eat enough vegetables, or go for walks instead of watching The Biggest Loser on TV? This seeming self-destruct switch is, to some degree or another, present (in my opinion) in everyone. It is the same drama with different actors and props. We all sell our birthright for some soup at times. We all go the route of easy self-indulgence rather than personal discipline.
Does that mean we are all weak? Yes, in fact, it does. My admission of my weakness has actually made it easier to have frank discussions with patients about their own personal struggles – be they weight, smoking, or other self-destructive behaviors. They listen to me because I don’t insult them with statements of the obvious. If it was easy to lose weight, don’t you think we’d have a little less than 2/3 of the population being obese? Does 2/3 of the people remain overweight because they want to be that way? No, the problem is not that simple; and suggesting otherwise won’t do much to deal with our national problem.
Dr. Benjamin has impressive credentials. She is a practicing primary care physician who cares for the poor. She’s not some subspecialist TV personality; she’s a doctor who has spent a lot of time face to face with the neediest people in our system. She doesn’t just know about the poor and needy, she knows them. She’s one of us; and her weight does nothing to lessen that – for me it actually makes her more relevant, not less.
So put down your stones, people. We are all weak. Having someone who understands the real struggle of the overweight may actually give us a better chance to successfully fight it. And if some of you still hold stones, let me rephrase a famous statement: The person without personal weakness can throw the first stone.
*This blog post was originally published at Musings of a Distractible Mind*
August 1st, 2009 by KerriSparling in Better Health Network, Health Policy, Opinion
Tags: Diabetes, Government-run Healthcare, Joslin, Single Payer, Valerie Jarrett
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Two weeks ago, I was in Washington, DC with the Better Health team, listening to people talk about voting down government health care.
Last week, I was in Chicago at BlogHer, part of a lunch meeting with Valerie Jarrett, Senior Advisor to the President and Assistant to the President for Intergovernmental Relations and Public Liaison, listening to women at BlogHer talk about passing the government health care bill.
And I have now just entered the land of confusion.
Valerie Jarrett spoke with a room full of bloggers about health care, but she also listened. She listened while women told their personal stories and she seemed to understand that health care situations aren’t as simple to solve as we’d like them to be. Women candidly told their stories and a few tears even slipped out. But she listened intently. And she said she wanted to give a voice to those who might not speak up for themselves.
“Often the people who need it the most don’t speak up because they don’t feel like they have a voice. Give the grass roots a voice, empower them, work together informing people within their communities. You can work to help them get their voice, get info that they don’t have.”
This lady is important. Her cell phone rang several times during our lunch (it could have been THE PRESIDENT, for crying out loud) and she had her assistant take the call so she could focus on us. She handed out her card and scheduled phone calls between some bloggers and her staff to help with the specific health issues that these bloggers were dealing with. Sure, for them it was a matter of being in the right time at the right place, but she really listened. I’ve never sat in a room before with a member of high political influence who paid attention to the people more than the information on her cell phone or in her planner. (Maybe that means I’ve been in the room with the wrong politicians?)
It was a remarkable experience, and the room was electric with hope.
And now I’m even more confused about this health care issue. I want insurance coverage, I want good coverage, but I don’t want to be excluded due to my pre-existing condition. I can’t find a happy mental medium with this, but I know there has to be a way for people like me to find health coverage despite diabetes.
With that thought, I’m off to the Joslin Clinic in Boston, with my pregnant best friend in tow, to immerse myself in the best that health care has to offer. And I hope that whatever decision made by our government leaves me with access to the people I need to help manage my care.
*This blog post was originally published at Six Until Me.*
July 29th, 2009 by KevinMD in Better Health Network, Opinion
Tags: Addiction Medicine, Emergency Medicine, Internal Medicine, Narcotics, Opiates, Pain Management, Physicians, Prescription, Pressure, Primary Care
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When it comes to opiate drugs, like morphine, there is a bitter debate between patients who are in chronic pain, and the doctors who are vilified for under or over-prescribing these medications.
But there are some other subtle influences that push doctors to prescribe these drugs, in some cases inappropriately. An ER physician talks about the issue, saying, “when dealing with a patient who is in pain, or appears to be, it can be impossible to sort out when a patient needs opiates for legitimate reasons, and when it is merely feeding a long term addiction. We are trained to provide comfort and relief from suffering to our patients, and we generally will err on the side of treating pain, rather than withholding addictive medications.”
There is also the pressure to provide “patient satisfaction,” and indeed, low scores in this area can place a doctor’s job in jeopardy. Taking a stand against those who inappropriately request opiates will result in low patient satisfaction scores, and “will often times result in arguments, profanity, and calls and letters to administration.”
What’s the answer? Perhaps a little less reliance on these scores, since a good patient satisfaction score is not necessarily correlated with proper medicine.
*This blog post was originally published at KevinMD.com*
