April 25th, 2008 by Dr. Val Jones in Expert Interviews
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In my quest to bring the best possible health advice to the Revolution Health community I am actively pursuing interviews with credible sources. At the top of the list is America’s #1 doctor, the Surgeon General. I recently had the opportunity to sit down with Vice Admiral Richard H. Carmona, M.D., who served as Surgeon General from August 2002 to August 2006. He addressed a range of health issues facing Americans today. I am posting the interview in segments; the following post is part of that series.
Dr. Val: Obesity rates continue to rise each year. Does obesity lie at the core of the chronic disease crisis and if so, what can America do to reverse this trend?
Dr. Carmona: Obesity is absolutely at the core of the chronic disease crisis. When we look at the relationship of obesity to other diseases that plague society today (such as asthma, cancer, cardiovascular disease, and diabetes) obesity increases the incidence of each of them, and can even accelerate some of them. Losing weight is not about trying to emulate models in fashion magazines, it’s about being healthy.
If we could only address one major public health issue as a nation, I would focus on the obesity crisis. Weight loss could have the greatest impact in decreasing the chronic disease burden in America.
Dr. Val: So what can we do about obesity?
Dr. Carmona: That question is simple on the surface but incredibly complex when you begin to analyze it carefully. First of all we have to identify the variables that contribute to this problem, because it’s a multi-factorial issue. The socio-economic determinants of heath are inextricable from the health status of individuals and communities. That means that if you’re poor and have less education, you’re going to experience health disparities. You can’t afford to buy healthy food, you don’t live in a neighborhood where you can walk at night and get exercise, and so on. So understanding all the determinants of health to address obesity is important.
Let me describe just one significant variable contributing to the obesity epidemic: the sedentary lifestyles of children. Thirty years ago it was commonly believed that physical education in school was not important, because kids played during all the hours that they are out of school. Parents reasoned: ‘Why should I pay a teacher to have my kids play ball at recess? I’d rather have her teach them math and science.’ So there was a sweeping trend to discontinue physical education at school. Now, however, kids spend too much time on playstations rather than on play grounds – or they watch over 4 hours of TV a day. They’re sedentary at school and at home.
Other variables that influence obesity rates in kids include the accessibility to fast food, the increased rate of single parenthood, and the change in cultural traditions around meal time. For wealthier families, easy access to large volumes of food of every possible kind can create an environment where people overeat.
The solution to the obesity crisis is not “one-size fits all.” The approach to obesity must be tailored to the cultural and socio-economic sensitivities of the sub-population that you’re trying to reach.
Ultimately we need to change behavior – walk a little more, eat a little less, buy some healthy foods. But targeted interventions must be culturally sensitive and socio-economically relevant. For example, the government is funding programs to make healthy foods more accessible to underserved areas, and physical activity programs are being reinstated in schools. But the effects of these programs are not going to be seen for many years because it takes time for the culture to catch up. Also, the approach must be comprehensive. If we were able to get all of our children enrolled in a daily game of baseball (to increase their physical activity), that would not solve the problem of fast food and video games.
There needs to be a community approach, so that no matter where the child turns they’re getting positive reinforcement of healthy behaviors. That’s part of what I’m doing with the national non-profit health organization that I’m president of now – Canyon Ranch Institute.
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The Surgeon General series: see what else Dr. Carmona has to say about…
Cost Savings Associated with Preventive Health
Consumer Directed Healthcare and Health Literacy
Complementary and Alternative Medicine
Preventing Chronic DiseaseThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 24th, 2008 by Dr. Val Jones in Expert Interviews
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Here it is… the long anticipated interview about chronic disease with Dr. Richard Carmona, 17th Surgeon General of the United States. I asked him 5 key questions and will split the Q&A into 5 posts. Enjoy!
Dr. Val: What do you say to those who argue that disease prevention is critical for quality of life, but does not ultimately reduce costs?
Dr. Carmona: The real value of prevention is best captured by some of the simpler interventions that have little or no cost to implement, such as smoking cessation. The returns on these prevention strategies are huge, and the only “cost” is in educating people to change their behaviors. Another great example is childhood vaccination – it costs pennies per child but protects them from polio and other deadly diseases.
In the recent past there have been a number of editorials where learned individuals have cited examples such as the cost of treating hyperlipidemia in the population at large. For every heart attack that lipid-lowering drugs prevent, it costs hundreds of thousands of dollars to provide the drugs to the population with high cholesterol. I guess if you’re the one with the heart attack it is worth it. But not withstanding that issue, I think the argument is a misapplication of the concept of prevention.
If you look at prevention in the appropriate light, you can make the business case for it. Health itself and quality of life are priceless things. We need to provide the right drug for the right person at the right time. But better yet, lifestyle interventions like physical activity and healthy eating behaviors can eliminate the need for many medications.
The real issue here is how to attain optimal health and wellness through appropriately vetted prevention strategies that will reduce the cost of care while improving the quality and quantity of life. That is the challenge we have before us and I’m working to answer as chairperson of the Partnership to Fight Chronic Disease.
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The Surgeon General series: see what else Dr. Carmona has to say about…
Obesity is America’s #1 Health Concern
Consumer Directed Healthcare and Health Literacy
Complementary and Alternative Medicine
Preventing Chronic DiseaseThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 23rd, 2008 by Dr. Val Jones in Expert Interviews, News
5 Comments »
Imagine that you were diagnosed with cancer, and were told that you had one of two treatment options: 1) you could receive a one time dose of a medicine that will go directly to the tumor cells and kill them only, having very few noticeable side effects or 2) you could undergo months of exposure to toxic chemicals that will kill the tumor cells and many other healthy cells as well, resulting in hair loss, bowel damage, nausea, and vomiting. Which would you choose?
Unfortunately, choice number one may no longer be an option for lymphoma patients due to government funding cutbacks, and the development of such treatments for other cancers is in jeopardy as well.
Radioimmunotherapy (RIT) is a relatively new approach to cancer treatment, new enough that the government is having difficulty categorizing it correctly. (RIT involves targeting cancer cells with special antibodies that carry tiny, lethal radiation doses to individual cells.) In fact, drugs like Bexxar and Zevalin have been misclassified by CMS as “supplies” rather than medications, and so the reimbursement allowed doesn’t come close to covering the cost of the therapy. Although there are many new targeted therapies under development, investors are worried that the drugs will never be used in patient care because the country’s number one payer (Medicare) is unwilling to cover their costs. Other health insurers often follow the government’s lead when it comes to treatment coverage policies. If no one will pay for the cost of the drug, then ultimately no one can afford to make it available.
Similar funding problems are beginning to limit access to diagnostic nuclear imaging modalities like PET scans, PET CT, cardiac SPECT scans, and bone scans. Reimbursement levels that do not cover the cost of the imaging drugs means that facilities cannot afford to offer these diagnostic technologies to patients, and centers are slowly reducing the number of tests they offer. Nuclear imaging studies are often critical in diagnosing heart problems, infections, and early detection of cancer. Senator Arlen Specter had his cancer recurrence diagnosed at the very earliest stages thanks to PET scanning technology. Early treatment offers him the best possible prognosis, but he is in a dwindling group of people who have access to this imaging modality.
I spoke with Dr. Peter Conti, professor of radiology at the University of Southern California, and former president of the Society of Nuclear Medicine, from Spain this week – as he is attending the 6th International Workshop for Nuclear Oncology, a lymphoma conference where the crisis in reimbursement for targeted cancer therapies is being discussed, along with exciting advances in treating patients with lymphoma. The two different RIT drugs (Bexxar and Zevalin) for non-Hodgkin’s lymphoma are in jeopardy of not being available to Medicare patients due to proposed cuts in reimbursement. Recent plans to cut payment for these drugs have been halted by a temporary moratorium from Senator Kennedy. Here’s what Dr. Conti had to say:
“Let’s face it, lymphoma is not as high profile as other cancers such as breast, colon, or prostate. However, we’ve found a fantastic treatment option for it, and there are implications for the more common cancers, but that treatment option is being denied to lymphoma patients because facilities cannot cover the costs of offering it. I’d like the entire cancer community to rise up in support of lymphoma patients so that Congress will tell Medicare to fix the funding problem. If this doesn’t happen, it’s only a matter of time until novel RIT treatments are no longer an option and we’ll be stuck in the dark ages of non-specific chemotherapy and radiation treatments that harm the good cells with the bad. Personalized, targeted therapy is the future – and we’re missing the opportunity to further develop these novel therapies due to budget cuts.”
I reached out to the current president of the Society of Nuclear Medicine, Dr. Alexander J. McEwan, for comment:
“Molecular imaging offers critical tools for the early detection, diagnosis and treatment of many life-threatening diseases, including cancer. SNM recommends that CMS establishes appropriate reimbursement for all forms of nuclear and molecular imaging and radioisotope therapies at levels that allow optimum access and improved outcomes for all patients.”
Denial of RIT to lymphoma patients may be the first sign of a new trend limiting the development of high tech therapeutic innovations. Will America’s research engine run out of gas before we figure out how to treat cancer without side effects? Should we buy one more tank to get us over the crest of the targeted therapy hill? This is a judgment call that affects all of us at a time of great need and limited resources. What’s your take?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 22nd, 2008 by Dr. Val Jones in Medblogger Shout Outs
5 Comments »
Welcome to Grand Rounds 4.31, Dr. Val’s edition of the weekly rotating carnival of the best of the medical blogosphere. There are many approaches to summarizing submissions to Grand Rounds, and I have chosen one that has never (to my knowledge) been used before.
That’s right – I’m taking my inspiration from the limbic system, and have organized the posts according to the dominant emotion they elicit from readers. And because Dr. Val was one of those annoying medical students who brought 10 different colored highlighters to study class, I will also label some of the posts with the following tagging system (in brackets) to offer advanced readers an additional nuance:
[:-)] = A post that demonstrates literary excellence
[{] = Early bird – an author who got his/her submission in early, which is really convenient for the host(ess)
[:-/] = Naughty – an author who forgot to submit an entry to Grand Rounds but who was included nonetheless
So without further ado, here’s the Grand Rounds that will make you laugh, cry, stomp your feet, and become enlightened in the process.
Amusing
The fun begins with the Clinical Cases and Images Blog, featuring a hilarious blogger “sweat shop” video to illustrate the heart attack-inducing stress that bloggers face on a daily basis. His post is called: “Death by blogging?”
Dr. Rob Lamberts from Musings of a Distractible Mind has some parenting tips (including pole vaulting avoidance strategies) in his post called “The Sins of the Father.”
Happy, the Happy Hospitalist offers his perspective of what it would mean if physician satisfaction surveys (rather than patient satisfaction surveys) mattered.
Allen Roberts of GruntDoc describes how one misspoken word can result in unexpected innuendo.
[:-/] Dr. Wes predicts an upcoming hospital “performance Olympics” after one patient receives a record fast, door-to-balloon cardiac intervention.
Touching
[:-)] Laurie Edwards of A Chronic Dose tells the touching and amusing story of how one sick young girl was ostracized at summer camp – and how new camps designed for chronically ill children are revolutionizing the camping experience. Her post is called, “Summer Camp: Sick Style.”
Barbara Kivowitz, from In Sickness and in Health, describes a husband who knows just the right thing to say in a stressful time. Her post is called “Mars/Venus Who Cares?”
Lisa Emrich, from Brass and Ivory describes what it’s like to experience a relapse of Multiple Sclerosis and an MRI to evaluate the progression of her disease. Her post is called “Surfing the Magnetic Tube.”
Dr. A from Doctor Anonymous wonders if peace and contentment come from accepting one’s lot in life. His post is called, “With Age Comes Happiness?”
Infuriating
ER Nursey relays the tragic story of a baby that died of a preventable illness. His mom decided not to vaccinate him against pertussis and was trying to treat the infection with “natural methods.” Her post is entitled simply: “Whooping Cough.”
[:-/] Abel Pharmboy at Terra Sigillata explains that since 1994, dietary supplements cannot be removed from the market until there is evidence for lack of safety, meaning that consumers must first be harmed before FDA is authorized to intervene. His post is called, “Must People Die Before DSHEA is Repealed?”
[:-/] David Gorski at Science Based Medicine takes a critical look at the claims of a popular alternative medicine practice: colon cleansing. His post is called, “Would You Like a Liver Flush with that Colon Cleanse?”
[:-)] John Crippen from NHS Blog Doctor explores the difference between a young doctor’s “gallows humor” and a senior physician’s deep and abiding concern for patients in this reflection on death certificates in Britain. The post is called “Ash Cash.”
A Canadian Medical Student and author of Vitum Medicinus tells the story of how a patient asked her doctor a question that she already knew the answer to, just to see if he was current in his knowledge of recent health news. The post is “What Trickery Is This?”
David Williams of The Health Business Blog points out the fallacies inherent in one writer’s attempt to vilify the health insurance industry. His post is called, “There is no Health Insurance Mafia.”
Enlightening
This large group of posts may be further organized by the topic of enlightenment. First up we have practical health tips.
Health Tips
[{] We begin this section with an anonymous psychiatrist blogger at How to Cope with Pain. She has captured my little Rehabilitation Medicine heart with her three-part series describing office ergonomics, therapeutic exercises, and how to avoid computer-induced postural strain. Her very practical post (that will be very useful to you readers) is called: “How to Sit at Your Computer to Avoid Pain.”
Ramona Bates at Suture for a Living explains what to do if you’re bitten by a cat – she does a wonderful job describing the treatment options and possible infections that can result. Her post is aptly named, “Cat Bites.”
Paul Auerbach at Medicine for the Outdoors teaches us everything we need to know about preventing and treating foot blisters caused by hiking/walking. His post has the shortest name of this Grand Rounds: “Blisters.”
Jeff Benabio at The Derm Blog offers a comprehensive analysis of the dangers of tanning salons with some tips for safe sun exposure. His post is called, “Is The Tanning Industry The New Big Tobacco?”
Nancy Brown at Teen Health 411 warns that outdoor tanning is also not safe. Her post is called “Sun Safety.”
Jolie Bookspan, The Fitness Fixer, tells the story of how a woman living in the Yukon learned that “doing exercises” doesn’t heal an injury if you go back to bad movement habits the rest of the day. The post is called, “Fixing Herniated Disk and Reclaiming Active Life.”
[:-/] TBTAM at The Blog That Ate Manhattan has practical tips for patients preparing for a new patient visit with an Ob/Gyn. Her post is called: “TBTAM’s Healthcare Team Tips for New Players.”
[:-/] Dr. David at Musings of a Pediatric Oncologist teaches us that HPV can predispose people to oral and throat cancers as well as cervical cancer. All the more reason to vaccinate boys as well as girls. His post: “HPV and Cancer Revisited.”
Kenneth Trofatter, at Fruit of the Womb offers a detailed analysis of when it might be appropriate to use Fondaparinux to reduce the risk of clotting in pregnant women. His post: “Use of Fondaparinux During Pregnancy.”
Joshua Schwimmer at Tech Medicine offers some tips for doctors. Practice makes perfect, and this new teaching mannequin has some nifty bells and whistles. His post is: “The iStan Medical Mannequin: it Sweats, Bleeds, and Breathes.”
More healthcare for dummies is offered by Jan Gurley of Doc Gurley Blog. Her post is called: “Playing Surgeon.”
Next up, a series of posts about Web 2.0 principles.
Web 2.0
Allergy Notes describes a small study in the BMJ demonstrating that text message reminders can improve compliance with asthma medication regimens. The post is called, “Text Messaging Can Help Young People Manage Asthma.”
[{] Sam Solomon of Canadian Medicine describes a new trend in Canadian medical research – using blog tools to analyze public opinion. His post is called, “Putting Clinical Depression under the Microscope and on the Blogosphere.”
Mic Agbayani at GeekyDoc, suggests that patient privacy is violated by YouTube when a video is posted of healthcare professionals laughing during a surgical procedure to remove a foreign body from the rectum. His post is called, “Patient privacy and YouTube.”
[:-/] Richard Reece at Med Innovation Blog explains that doctors get a bad rap when it comes to EMRs and IT in general. See his post: “Bad Rap on Physician IT Use Not Deserved.”
[:-/] A counter-point argument for the mandatory use of EMRs (at his hospital) is made by John Halamka at Geek Doctor. His post is called: “Accelerating Electronic Health Record Adoption.”
Health Policy and Medical Ethics
This is our largest and final subgroup of enlightening posts. You’ll find some great reasoning here (and Dr. Val is partial to reason).
First up we have the inimitable Sandy Szwarc of Junk Food Science. She takes a close look at the numbers and shows that the current Student Nutrition Policy Initiative is failing to stem the tide of childhood obesity and poor eating habits. Her post is called, “JFS Special Report: Major Findings on Childhood Obesity Programs.”
Amy Tenderich at Diabetes Mine has a terrific post about the need to revise the Americans With Disabilities Act. As a physiatrist, I cheer her on. Her post: “Disability and Diabetes Revisited.”
[:-/] Dr. Rich at The Covert Rationing Blog explains the financial incentives behind Medicare’s new “never event” initiative and how it will impact care for the elderly, obese, and those with bleeding disorders. His post is called, “Never Events? Never Mind.”
Bob Coffield at Health Care Law Blog writes that some argue that preventing disease does not decrease health costs. Bob disagrees, but isn’t sure if he can prove his case. His post: “Is prevention cheaper than treatment?”
[:-/] #1 Dinosaur of Musings of a Dinosaur explains that reducing expenditures in a patient’s last year of life requires perfect foresight into his or her life expectancy. His post: “End of Life Care Costs: A Logical Fallacy.”
Maurice Bernstein at the Bioethics Discussion Blog argues that, over the past 50 years, the ethics of medicine has changed more than any other aspect of it. Technological advances and the advent of medical consumerism have changed the way medicine is practiced. His post is: “50 Years of Medical Practice: Changes, Benefits, Costs, Dilemmas.”
Louise Norris at the Colorado Health Insurance Insider would rather be treated by a salaried physician who has no incentive to order additional and perhaps unnecessary tests and treatments. Her post: “More Care Does Not Mean Better Care.”
[:-/] Charlie Baker at Let’s Talk Healthcare offers a nice summary of a recent NEJM article about how to cut healthcare costs in the US. See his post: “Partners HealthCare Weighs In On Health Care Costs.”
[:-/] Kevin Pho at KevinMD has a series of posts called “My Take.” This one on legitimate malpractice lawsuits and anti-aging is very interesting.
Kerri Morrone at Six Until Me raises her voice for Type 1 Diabetes awareness. Her post: “My Raised Voice.”
[{] Ian Furst from Wait Time and Delayed Care wonders if visual cues could be developed to reduce patient wait times. His post is called, “Clutter of the Brain.”
And finally, an anonymous medical student at a blog called From Medskool argues that there is no primary care shortage, that incomes are fine, and that PCPs won’t abandon Medicare. Anyone wish to debate this with him? His post: “Four Myths of the Primary Care Crisis.”
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And here’s a special message from next week’s Grand Rounds hostess, Jan Gurley:
Grand Rounds in medicine often means a morgue-cold auditorium, a sea of starched white coats, and staccato squeaks from irritable chairs. Doc Gurley is hosting April 29th’s Grand Rounds of the medical blogosphere with a more WWF-type approach: Grand Rounds Smack Down Week. Do you want to take on a behemoth topic with some chest-beating frenzy? Or just climb into the Internet ring wearing your most outrageous verbal-costume? Here’s your chance to go for it.
Thanks to all who sent me submissions, and many thanks to Nick Genes our fearless leader. Let me know how this Grand Rounds made you FEEL!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
