HealthLawProf Blog

Responses to Medical Mistakes

The New England Journal of Medicine published a commentary recently concerning the emotional toll of medical mistakes - both on family members of the loved ones injured by the mistake and by the doctors.  The New York Times ran a brief piece on the commentary and an upcoming documentary about medical mistakes this past weekend. 

The New England Journal of Medicine tackled the [emotional toll of medical mistakes] issue yesterday in a moving commentary called “Guilty, Afraid and Alone: Struggling with Medical Error.’’ The writers, Dr. Tom Delbanco and Dr. Sigall K. Bell of the Harvard Medical School, note that while the medical community has focused largely on reducing error rates, hospitals also need to address the “human dimensions” of treatment blunders and to assist in the emotional recovery of patients and families.

The doctors, who are making a documentary film on the subject, talked to numerous patients and families affected by medical errors. The authors found that family members often feel guilty for not having protected loved ones from the caregivers’ mistakes and that many feared retribution if they did complain. And Dr. Delbanco and Dr. Bell note that physicians who err often shut out patients and their families, “isolating them just when they are most in need.’’

When mistakes happen, relatives often berate themselves for not keeping close watch on their loved ones. In one case cited in the commentary, the family of a man with sickle cell anemia repeatedly warned health care workers not to administer morphine. But somehow it happened anyway, sending the man into kidney failure and a coma. “The feeling was impotence, because you can’t stay with a patient 24 hours a day,’’ said his sister. “That’s why you rely on hospitals — you rely on nurses. You feel like you failed your family in terms of ‘I should have been there.’ That’s a guilt that everyone shares.” . . . .

Several family members said that they simply wanted their doctors to talk to them and to explain how the mistake had happened. “What we needed was for someone to reach out and connect with us in human terms,” said one. “The sense that somebody could empathize and know what I was feeling . . . that was almost totally lacking.”

The authors note that honest and direct communication are often the “best antidote” to flawed treatment. Patients and families also want to know that some good has come out of these mistakes, and that the event has taught both caregivers and their institutions.

Psychiatric Advanced Directives (PADs)

The Wall Street Journal's Health Blog reports on a recent development in the area of advanced directives:

Psychiatric advance directives, or PADs, are legal documents that patients can prepare to state in advance of an acute psychiatric crisis what medications, hospitals and other treatments they would prefer or like to avoid.

Twenty-five states have laws allowing PADs. In North Carolina, a sample form includes such items as preferences about electroconvulsive therapy, or ECT, and tips for medical personnel on how to minimize the use of restraints or seclusion. A model form in Texas lays out details on a patient’s consent, or lack of it, for specific medications. A Michigan form guides a patient in legally designating a personal advocate in case of crisis.

But how are PADs actually used? And what happens if, in the breach, a doctor’s judgment clashes with the stated wishes of the patient? The Health Blog asked medical sociologist Jeff Swanson (pictured) from Duke University, who’s been active in research on mental health policy and treatment options for people with serious mental illness.

First, Swanson laid out a key difference between the advance directives for psychiatry and those typical for medical care. A living will focuses primarily on “forgoing unwanted treatment,” Swanson said. “The goal of the psychiatric advanced directive is to [help you] recover. You’re trying, in a way, to protect yourself from decisions you might make when you’re ill.” . . . .

Though PADs are legal documents, most state laws on the subject contain override clauses, Swanson said. In a crisis, a doctor can invoke his or her clinical judgment to act in the best interest of the patient, essentially ignoring the PAD. Empirical data are hard to come by. But “clinical experience and anecdotal reports suggest that overrides occur with some frequency,” according to a commentary Swanson published last year in the Journal of the American Academy of Psychiatry and Law.

Surgeon General Recess Appointment?

ThinkProgress reports that President Bush's surgeon general nominee, Dr. James Holsinger may receive his position through a recess appointment. 

President Bush’s Surgeon General nominee James Holsinger appeared before the Senate health committee on July 12, forced to defend his controversial positions on homosexuality. Yet three months later, Holsinger is “no closer to becoming the nation’s next surgeon general.”

ThinkProgress today spoke with a spokesperson for chairman Edward Kennedy (D-MA) who said the committee still has not received a response to a follow-up questionnaire it sent Holsinger three months ago:

We sent out the questions on 7/26 and requested that they be returned by COB on 8/10. We have not received the answers and there is no Committee action scheduled at this time.

Holsinger’s lengthy delay indicates that Bush may be angling to recess appoint Holsinger. The Louisville Courier-Journal reports:

The committee must vote before the full Senate can consider the nomination, and senators are hoping to adjourn for the year by mid-November.

The delay leaves open the possibility that Holsinger will either have to wait until next year for a confirmation vote or get the job through a “recess appointment” by Bush. […]

A recess appointment would allow Holsinger to serve as surgeon general until the end of the current Congress late next year. . . . .

****

Holsinger has come under intense criticism for his long history of prejudice toward gays and lesbians. He founded a church that “ministers to people who no longer wish to be gay or lesbian” and “opposed a decision to allow a practicing lesbian to be an associate pastor” in the United Methodist Church. In 1991, he also authored a graphic document arguing that gay sex is “intuitively” unnatural and can lead to “lacerations, perforations and deaths.”

Autism Screening Recommended

The Associated Press reports that the American Academy of Pediatrics is recommending that all children be screened for autism twice by age 2.  The AP reports,

The advice is meant to help both parents and doctors spot autism sooner. There is no cure for the disorder, but experts say that early therapy can lessen its severity.

Symptoms to watch for and the call for early screening come in two new reports. They are being released by the American Academy of Pediatrics on Monday at its annual meeting in San Francisco and will appear in the November issue of the journal Pediatrics and on the group’s Web site.  . . . .

The academy’s renewed effort reflects growing awareness since its first autism guidelines in 2001. A 2006 policy statement urged autism screening for all children at their regular doctor visits at age 18 months and 24 months.  . . . .

“With awareness comes concern when there doesn’t always need to be,” he said. “These resources will help educate the reader as to which things you really need to be concerned about.”

Another educational tool, a Web site that debuted in mid-October, offers dozens of video clips of autistic kids contrasted with unaffected children’s behavior. That Web site is sponsored by two nonprofit advocacy groups: Autism Speaks and First Signs. They hope the site will promote early diagnosis and treatment to help children with autism lead more normal lives.

The two new reports say children with suspected autism should start treatment even before a formal diagnosis. They also warn parents about the special diets and alternative treatments endorsed by celebrities, saying there’s no proof those work.

Interview and Job Talk Advice

Concurring Opinions' Daniel Solove has a great piece on how to prepare and give a terrific job talk.  Here is some of his advice: 

The first thing is to understand your audience. Here's my perspective as a member of your audience. Your job talk is taking place during the middle of my day. I'm busy. I've got a ton of things to do, classes to teach, papers to work on, emails to respond to. I'm not coming in eager and excited to give my valuable hour to some unknown person plucked off the street after a 30-minute interview at the meat market. So you've got to work to get my interest and make that hour an interesting part of my day. That involves getting out your thesis quickly, making an interesting argument, and then having a good discussion with the faculty.

Sounds easy, right? You wouldn't believe how many fail at doing these basic things. I've seen countless candidates crash and burn during their job talk. It's like reading a Kafka novel -- things start out bad, and then they get much worse, and then you die.

Here is what I'm looking for in a job talk:
1. Were you able to articulate a coherent thesis? Your talk must have a point, and the point of your talk should be stated towards the beginning.
2. Was the thesis of your talk original and not an obvious point? I should not be saying "duh" to myself throughout your talk.
3. Were you able to defend your thesis?
4. Did you recognize the arguments on the other side of your thesis?
5. Was your talk interesting and engaging?
6. Were you articulate and clear? If not, I might have doubts about the clarity of your thinking as well as about your ability to explain concepts to students in a class.
7. In the Q&A, did you respond well to the faculty's questions?
8. If a question posed a severe challenge to your thesis, were you prepared to address it?
9. Did you demonstrate adequate command of your topic? I expect you to be familiar with the literature and cases on your topic.

Professor Solove provides further helpful tips as well. 

Greenwall Fellowship

GREENWALL FELLOWSHIP PROGRAM IN BIOETHICS AND HEALTH POLICY Johns Hopkins and Georgetown Universities Fellowships The Greenwall Fellowship Program in Bioethics and Health Policy, an interdisciplinary program sponsored jointly by Johns Hopkins and Georgetown Universities, is offering interdisciplinary, two-year Fellowships for early-career legal scholars with outstanding potential. Appointments will begin in September 2008.

FELLOWSHIP DESCRIPTION: The Greenwall Fellowship in Law uniquely combines opportunities for in-depth, mentored research and high- impact public service. Each Fellow will undertake an individualized program of independent research and writing, complemented by a public-service experience in a health policy setting of the Fellow's choosing. Fellows will also enjoy ample opportunity for scholarly interaction (including participation in faculty research workshops) with a broad range of faculty at Georgetown (in the Law Center, the Kennedy Institute of Ethics, and the Philosophy Department) and at Johns Hopkins (in the Berman Institute of Bioethics, the Philosophy Department, the School of Medicine, and the Bloomberg School of Public Health), as well as with scholars at leading Washington "think tanks." Past Fellows have moved on to faculty appointments at leading law schools, as well as high-profile positions in government (including a White House Fellowship and Congressional staff positions). The stipend will be approximately $57,000 per year. No prior health law or bioethics experience is required.

APPLICATION PROCEDURE: For consideration, please send a curriculum vitae, three letters of reference, a writing sample, undergraduate and graduate transcripts, and a personal statement to:

CONTACT: Dr. Ruth Faden Greenwall Fellowship Program c/o Berman Institute of Bioethics Johns Hopkins University 100 N. Charles St., Suite 740 Baltimore, MD 21201 The personal statement should include a proposed agenda for scholarship or research (this need not be detailed, but you should articulate the core idea you would like to develop or the research question you want to investigate). It should also address: (1) unique dimensions of your background, (2) the evolution of your research and other professional interests, and (3) how the Greenwall Fellowship might contribute to your ability to fulfill your career aspirations. The deadline for receipt of applications is December 14, 2007.

For further information, please visit the Academic Training section of: http://www.bioethicsinstitute.org Additional questions may be addressed to: Email: MAILTO:fellows@jhsph.edu

Revised SCHIP Passes House but not by a Veto-Proof Majority

ThinkProgress reports on the House passage of a revised SCHIP bill.  It reports on yesterday's vote:

The House just voted 265-142 to approve revised SCHIP expansion legislation, but fell short of the two-thirds needed to uphold a veto by President Bush. Twenty-seven members didn’t vote. The bill would “add $35 billionto the State Children’s Health Insurance Program” and “addressed critics’ concerns about participation by adults, illegal immigrants and families able to afford health insurance.”

NPR's Morning Edition has further commentary.

Revised SCHIP Vote Today

Firedoglake has the news on the revised SCHIP vote occurring in the House:

Last night Speaker Pelosi announced she would bring a slightly revised SCHIP funding bill to the House floor for a vote — today. The revised bill still provides $35 billion in additional funds and health coverage for 10 million children, but it makes a few changes to counter the Bush Administration’s misrepresentations and opponent’s alleged concerns.

As Pelosi promised last week, the plan is to enact the full SCHIP funding again, and if the President is foolish and heartless enough to veto it again, attempt another override, with the opposition having even fewer excuses to vote no. This type of strategy is exactly what many progressives have been hoping from the Democratic leadership when they know the public is solidly behind them against an out-of-touch, unpopular President. It’s not just good politics; it’s good public policy, because this program deserves passage and has the overwhelming support of the American people.

The changes include clarification that coverage does not extend to families with annual incomes at $83,000 (a confusion left over from New York’s request that the Administration had already denied); it apparently won’t cover those not legally in the US for five years; and it further limits coverage for adults who do not have covered children.

Job Opportunity: Assistant or Associate Professor of Law and Public Health

Harvard School of Public Health Department of Health Policy and Management seeks

Assistant or Associate Professor of Law and Public Health

The Department of Health Policy and Management at the Harvard School of Public Health seeks candidates for the position of assistant or associate professor of law and public health.  This is a tenure-ladder position, with the academic rank to be determined in accordance with the successful candidate’s experience and productivity.  The successful candidate will play a central role in the department’s program of teaching and research.

Candidates should possess the following qualifications:  a law degree and a doctoral degree in health policy (or a related social science discipline) preferred, but candidates with an MD or MPH and evidence of advanced quantitative research skills will be considered; a broad knowledge of legal issues in health care and public health policy and of ethics; and experience in conducting empirical research employing statistical and econometric methods.  Additional qualifications include evidence of the ability or the potential to manage national and international projects, to collaborate with professionals in other disciplines, and to teach health law at the graduate level.

Please send a letter of application, including a statement of current and future research interests, curriculum vitae, sample publications, and the names of three referees to the following address.  Applicants should ask their three referees to write independently to this address.

Chair, Search Committee for Law and Public Health

c/o Mindy Starmer, Search Administrator
Department of Health Policy and Management
Harvard School of Public Health
677 Huntington Avenue
Boston, MA 02115

Harvard University is committed to increasing representation of women and minority members among its faculty, and particularly encourages applications from such candidates.

Health Benefits to Global Warming

Thinkprogress provides more information on the administration's response to its censoring of CDC director's Dr. Julie Gerberding's global warming health remarks.  Here is a brief excerpt from the White House Press Secretary Dana Perino:

In her press briefing yesterday, White House Press Secretary Dana Perino responded to reports that the White House “eviscerated” Center for Disease Control director Dr. Julie Gerberding’s Senate testimony on the “Human Impacts of Global Warming.” She claimed that “the decision” was “to focus that testimony on public health benefits” of climate change.” “There are public health benefits to climate change,” asserted Perino.

Asked to explain what some of those benefits are, Perino said that climate change “would help those individuals” who die from cold-related deaths every winter“:

Q: And one more. You mentioned that there are health benefits to climate change. Could you describe some of those?

MS. PERINO: Sure. In some cases, there are — look, this is an issue where I’m sure lots of people would love to ridicule me when I say this, but it is true that many people die from cold-related deaths every winter. And there are studies that say that climate change in certain areas of the world would help those individuals. There are also concerns that it would increase tropical diseases and that’s — again, I’m not an expert in that, I’m going to let Julie Gerberding testify in regards to that, but there are many studies about this that you can look into.

Science Progress has the unredacted version of Dr. Gerberding's remarks.

Huckabee on Health Care

TalkLeft gives us the money quote from Presidential candidate Michael Huckabee on Health Care:

During the Republican debate last night, after attacking Hillary, contender Mike Huckabee had this to say:

"We don't have a health care system. We have a health care maze. And we don't have a health care crisis. We have a health crisis. Eighty percent of the $2 trillion we spend on health care in this country is spent on chronic disease. If we don't change the health of this nation by focusing on prevention, we're never going to catch up with the costs no matter what plan we have. ... And we've got a situation with 10,000 baby boomers a day signing up for Social Security, going into the Medicare system. And I just want to remind everybody when all the old hippies find out that they get free drugs, just wait until what that's going to cost out there."

Treatment of the Obese

Pandagon and Echidne have interesting articles exploring the treatment of obese and how that treatment reflects some people's views of ill health in general.  Echidne writes,

Something similar is visible on many discussions about health issues. An illness is seen as “deserved” if the patient ever engaged in any activity which is now known to be correlated with that illness, and the illness itself is now viewed as punishment for evil deeds. Illness becomes a moral condition and the search for its epidemiology becomes a court case where the jury looks for that one decision where the patient went wrong, the one sin for which the current pain and suffering might be a just punishment.

In some ways we have stepped out of the framework where illnesses were caused by demons and into the scientifically medical one. But in other ways we have brought those demons with us, transformed into a different type of an ethical judgment or into a search of a different type of causal explanation, and that little hidden demon is what allows us now to judge other people without feeling any embarrassment over doing so. After all, if medical science tells us that some patients “caused” their own illnesses, then it is simply natural that we, too, point out that causal mechanism in all sorts of daily interactions.

Amanda at Pandagon adds,

This kind of discourse on illness is on the rise lately, because conservatives who are opposed to universal health care are rapidly trying to redefine pretty much all illness as a matter of personal responsibility to avoid taking collective responsibility for the health and well-being of citizens. Even the horrible and surely unintended car accident of the Frost family became an attempt to talk about “responsibility”, as if all misfortune could be attributed to a failure of will. . . . .

This pity-then-acceptance curve puts fat activists in a quandary, because it’s widely accepted that being fat is in fact something you can help and therefore the onus is on the fat people to lose weight and not on the rest of us to treat them with decency. And understanding the arch of pity-to-acceptance, fat activists have put a lot of work into arguing that dieting doesn’t work, and that obesity is genetic. That tactic might work, but then again, it might not. One issue that’s going to keep coming up is that people successfully lose and keep off 10, 15, 20 pounds all the time, and erroneously think that a 20 pound loss for me can means a 150 pound loss for you. If you can disabuse people of that notion, then quite possibly the pity-than-acceptance route might work for fat activists.

Fred Thompson and Right-to-Die

ABC news reports on Senator Fred Thompson's view on the "right-to-die."  He doesn't believe that state or federal government should be involved in the end-of-life decisions that a family may have to make.

In a moving, pointed and rare response to a question about the Terri Schiavo controversy, former Sen. Fred Thompson of Tennessee Monday afternoon described details of the death of his own daughter, Elizabeth "Betsy" Thompson Panici, and said that neither federal nor local governments should play any role in making a family's end-of-life decisions.

"I had to make those decisions with the rest of my family," Thompson said. "And I will assure you one thing: No matter which decision you make, you will never know whether or not you made exactly the right decision."

GOP hopeful Thompson said that "making this into a political football is something that I don't welcome, and this will probably be the last time I ever address it. It should be decided by the family. The federal government -- and the state government too, except for the court system -- should stay out of these matters, as far as I'm concerned."

Health and Homelessness

Ezra Klein has an interesting post on the Washington Post story concerning the number one cause of homelessness - untreated chronic disease.
He writes,

. . . The #1 cause of death among the homeless is untreated chronic disease.  It's also a major cause of homelessness.  The Washington Post tells the story of Vaughn Bell -- he had a solid job at a teen rehab clinic, an apartment, a good life. "The sickness stripped it all away. Everything. Bell fell ill with kidney disease. Because he was sick, he couldn't work and lost the job. Because he lost the job, he lost his apartment and had to go to a homeless shelter. Because he lived in a homeless shelter, he had to take two trains and a bus to get to dialysis treatments. He fell behind, stopped caring for himself, then just stopped caring."

This isn't a policy post, necessarily. I don't know how to holistically end the ravages of chronic disease. A universal health care system could ensure treatment, but it can't keep you from losing your job, or from having to travel too far for care, or from falling into depression and giving up, or from lacking the money to purchase the sort of food your body needs. But it's worth thinking about.

Borgman on Health Care

Our local paper, the Cincinnati Enquirer, is not the best but they carry Jim Borgman's cartoons and they are usually quite funny.  Here is one that ran this weekend in response to the consideration of a new law in Ohio to require that women see an ultra-sound of their fetus before receiving an abortion.  . 

FDA Concludes Many Children Do NOT Need Cold Medicines

MSNBC.com and the Associated Press report, 

Cold and cough medicines don’t work in children and shouldn’t be used in those younger than 6, federal health advisers recommended Friday.

The over-the-counter medicines should be studied further, even after decades in which children have received billions of doses a year, the outside experts told the Food and Drug Administration. The FDA isn’t required to follow the advice of its panels of outside experts but does so most of the time.

“The data that we have now is they don’t seem to work,” said Sean Hennessy, a University of Pennsylvania epidemiologist, one of the FDA experts gathered to examine the medicines sold to treat common cold symptoms. The recommendation applies to medicines containing one or more of the following ingredients: decongestants, expectorants, antihistamines and antitussives.

The nonbinding recommendation is likely to lead to a shake up in how the medicines — which have long escaped much scrutiny — are labeled, marketed and used. Just how and how quickly wasn’t immediately clear.

In two separate votes, the panelists said the medicines shouldn’t be used in children younger than 2 or in those younger than 6. A third vote, to recommend against use in children 6 to 11, failed.

Earlier, the panelists voted unanimously to recommend the medicines be studied in children to determine whether they work. That recommendation would require the FDA to undertake a rule-making process to reclassify the medicines, since the ingredients they include are now generally recognized as safe and effective, which doesn’t require testing. The process could take years, even before any studies themselves get under way.  . . . .

Impotence Drugs Linked to Hearing Loss

Oops - yet another unsettling side effect of impotence drugs - CNN.com reports,

Men taking any of three erectile dysfunction drugs -- Viagra, Levitra or Cialis -- may be at increased risk for sudden hearing loss, prompting Food and Drug Administration officials to require label changes for the medications.

   

The FDA is requiring label changes for drugs that may increase the risk of sudden hearing loss.  The FDA said manufacturers must change the labels "to display more prominently the potential risk of sudden hearing loss," according to the agency's Web site.

Labeling must also be changed for the blood pressure medication Revatio, which has the same active ingredient as the other drugs. Men taking any of the ED drugs and experiencing hearing loss should immediately stop taking the drug and see their physician, the FDA said. . .

   The FDA is requiring the label change for the entire class of drugs -- called Phosphodiesterase Type 5 Inhibitor, or PD-5 inhibitors.

I cannot wait for the new commercials . . .

Congress Fails to Override SCHIP Veto

The House of Representatives failed to obtain the necessary votes to override President Bush's veto of the SCHIP program.  TPM election central reports,

It's over: The House just voted on the SCHIP bill moments ago, and failed to override President Bush's veto.

The vote was 273-156, falling short of the two-thirds vote needed to overturn Bush's veto.

Incredibly, despite polls showing strong majority support for a veto override, and an aggressive ad campaign targeting Republicans on SCHIP, the GOP was remarkably successful in holding the line and sustaining Bush's veto. Only forty-four Republicans voted for the bill -- almost exactly the same as last time, save for GOP Rep. Pete King, a bill supporter who was absent this time. One-hundred and fifty-four GOPers voted against it.

The roll call is here.

NPR.org has more here and ThinkProgress reports on future efforts to revive the SCHIP program here.

Dr. Susan Orr - Acting Ass't Secretary for Population Affairs

President Bush appointed Dr. Susan Orr, formerly Associate Commissioner of the Children's Bureau in the Administration for Children and Families, as the Acting Deputy Assistant Secretary for Population Affairs at the Office of Public Health and Science (OPHS).  There is just one small drawback with her appointments as RHrealitycheck reports

The Office of Population Affairs advises the Secretary and the Assistant Secretary for Health on "a wide range of reproductive health topics, including adolescent pregnancy, family planning, and sterilization, as well as other population issues," says the OPHS website. Sounds like you might want to count contraception as one of your areas of expertise in that post, right? Not Dr. Orr! In 2001, when President Bush proposed eliminating the requirement that federal employees' health insurance offer a range of options for birth control coverage, Dr. Orr, then the senior director for marriage and families at the Family Research Council, told the Washington Post, "We're quite pleased because fertility is not a disease. It's not a medical necessity that you have [contraception]."

Clearly, Dr. Orr's definition of "medical necessity" does not recognize that women in the world over consider controlling their bodies and the number and spacing of their children foundational to their well-being. If that's not a medical necessity, what is?

Mary Jane Gallagher, president of the National Family Planning and Reproductive Health Association, said in a statement that her organization was "appalled" at Orr's appointment and observed that "While her resume suggests a commitment to child welfare and children her professional credentials fail to demonstrate a commitment to comprehensive family planning services for all men and women in need."  . . . .

And ThinkProgress chimes in with some further thoughts from Dr. Orr about the value of contraceptive devices: 

In a 2000 Weekly Standard article, Orr railed against requiring health insurance plans to cover contraceptives. “It’s not about choice,” said Orr. “It’s not about health care. It’s about making everyone collaborators with the culture of death.”

Wow, yet another great appointment - I am sure women everywhere feel better about their reproductive health already.  How did President Bush find someone so outstandingly qualified for this job - well - let us look at her credentials:  According to ThinkProgress, "Before joining HHS, Orr served as senior director for marriage and family care at the conservative Family Research Council and was an adjunct professor at Pat Robertson’s Regent University." 

FDA Hearing on Toddler Cold Medicines

As  you are probably well aware, last week several manufacturers of cold medicines for toddlers recalled their products from the market.  This Thursday, the FDA will hold hearings on the safety of these cold medicines.

On Thursday, the Food and Drug Administration will meet to discuss whether over-the-counter cold medicines are safe and effective in children age 6 and under. Earlier this year, the FDA completed a review that found between 1969 and the fall of 2006 there were 54 reported child deaths from decongestants and 69 from antihistamines. Most of the deaths occurred in children under 2. Baltimore Health Commissioner Dr. Joshua Sharfstein headed the push that led to the FDA hearing. He became alarmed when four Baltimore children died after their parents gave them excessive doses of cold medicines. "I didn't quite realize that it could potentially be a life-and-death issue," says Sharfstein.

In August, federal health officials recommended the "consult your physician" advice to parents on the labels of cold and cough medicines aimed at young children be replaced by a warning not to use the medications in children under 2 unless directed to do so by a health care provider.

   Last week, in advance of the hearings, some of the leading manufacturers of cold and cough medicines announced a voluntary recall of more than a dozen cold medicines for infants. The Consumer Healthcare Products Association said the products were being pulled "out of an abundance of caution."

Potential misuse of the medications, not product safety, is driving the voluntary withdrawal, the group said.  In a written statement, the group's president, Linda Suydam said, "It is important to point out that these medicines are safe and effective when used as directed, and most parents are using them appropriately."  The recall "in no way affects our taking this issue to the advisory committee meeting," said Dr. Joel Schiffenbauer, deputy director for the FDA's Division of Nonprescription Clinical Evaluation, Office of Nonprescription Products, Center for Drug Evaluation and Research. "All potential actions are on the table," he said.

I wonder if some parents will hoard this drugs and continue to use them anyway - as a close friend has predicted.  I am not so sure that I agree about the potential for hoarding but I admit when the doctor informs me that my son, who is coughing and snuffling and quite unhappy, has a virus and all he needs is some TLC, I feel like asking for drugs for myself.

Annual Check-Ups Overrated

It turns out those annual visits to your doctor are actually not that helpful.  According to an article in the Chicago Tribune

 

     Your doctor probably knows it. Medical organizations certainly do. But most  patients have no idea.  The annual physical examination -- that encounter when a physician looks in your throat, listens to your heart, pokes your abdomen, checks your reflexes and tests your blood -- is no longer a generally recommended medical practice. That's because there is scant scientific evidence showing that yearly checkups help prevent disease, death or disability for adults with no symptoms. Many tests and procedures performed during the visits have questionable value, experts say.

Instead of an annual physical, healthy adults should undergo a much-streamlined exam that's focused on prevention every one to five years depending on a person's age, sex and medical profile, the American College of Physicians and other professional groups suggest.

Men and women see physicians more frequently for yearly medical checkups than for any other reason, at a cost of $7.8 billion a year in the U.S., close to the $8.1 billion spent on breast cancer care, according to a recent report in the Archives of Internal Medicine. The figure reflects the strong attachment to this entrenched medical tradition felt by patients and doctors.  "There's a feeling of well-being you get from having your doctor look you over and pronounce you in good health," said Andrew Griffo, 48, a financial adviser who lives in Park Ridge and schedules a physical every year.  Largely out of public sight, however, the medical orthodoxy that all adults should undergo a comprehensive annual medical review to detect potentially significant clinical abnormalities has been under scrutiny since the 1970s. 

Experts' concerns revolve around two components of the traditional checkup: the comprehensive physical exam and an extensive battery of tests checking a person's blood, urine, thyroid and heart. (A third component, an updated patient history, hasn't prompted the same scrutiny.)   . . . .

Some believe that for many patients an annual checkup may not be needed at all. In fact, the new Archives of Internal Medicine study found most patients receive the bulk of recommended preventive care -- such as counseling about weight or blood-pressure checks -- not during physicals but on other occasions, such as when they see doctors about a cold or a chronic condition like diabetes.  The report also estimates that, a third of the time, routine physicals become an occasion for unnecessary tests such as electrocardiograms, boosting medical bills by more than $350 million and contributing to soaring medical expenses.

There's good reason to ask "whether the time and resources being spent are worth it," said Dr. Ateev Mehrotra, the study's lead author and assistant professor at the University of Pittsburgh School of Medicine.

Thanks to Ezra Klein for the link.

Reproductive Health Website

Here is a helpful reproductive health website.

Myths about SCHIP

Here is a nice run-down about some of the truths and myths about the SCHIP program from the folks at Families USA and Firedoglake:

FamiliesUSA has put out a mythbusting fact sheet about SCHIP, a sad and tragic necessity in the wake of the abject lies told by the President of the United States and those who get off licking his shoeleather. To wit:

Claims by the President that this bill raises the CHIP eligibility level to $83,000 (400 percent of the federal of the poverty level) in annual income are unambiguously false. There isn’t a single state in the country with such a high eligibility level. One state, New York, wanted to set the eligibility standard at that level, but its request to do so was denied by the Administration.

I’m also fond of the newfound sense of fiscal responsibility espoused by George Bush, who now says we simply can’t afford that kind of expenditure if it’s kids’ lives on the line instead of, say, nuclear warheads.

Republicans for Health Care Reform

Republicans have moved toward promoting a form of health care reform according to the politico.com: 

Under fierce attack by Democrats over the children’s health insurance plan, House Minority Leader John A. Boehner said Sunday Republicans will unveil their own health care plan over the next few months.

“Republicans are working on a plan that will provide access to all Americans to high quality health insurance, make sure that we increase the quality of insurance that we have in American, and we want to foster a sprit of innovation,” said Boehner on “Fox News Sunday.” “This is a plan we’ll see over the next coming months where we put the patients in charge of their health care.”

Republicans have taken a beating on SCHIP, the $35 billion measure that would expand health insurance for children. The fight quickly turned nasty as Democrats ran campaign ads attacking Republicans who voted against the bill in their home districts.

Should be interesting to see what both parties come up with for health care reform.  Perhaps we might actually see some movement toward more coverage for all.

 

Smaller Class Sizes and Health

Slate.com has an interesting article discussing the impact of class size on elementary school children's health:

This week, Dr. Sydney Spiesel discusses a potential link between smaller elementary school class sizes and better health, a safer way to give painkillers, and treatments for ADHD.

Smaller classes, better health?

Question: An extraordinarily provocative article in this month's American Journal of Public Health ties together two seemingly unrelated phenomena: the size of school classes and the health of students. Could smaller class sizes be a good investment not only for educational reasons but for medical ones?

New study: Peter Muennig of the Columbia University School of Public Health and Stephen Woolf of Virginia Commonwealth University in Richmond drew their data from Project STAR, which began in 1985 and randomly assigned almost 12,000 Tennessee kids to classes of different sizes in kindergarten through third grade. Some of the kids were in classes of 22 to 25 students, and others were in classes of 13 to 17 students. Teachers were also randomly assigned. The children were then tracked to determine the effect of class size on educational attainment.

Model: The educational effects were considerable. Now Muennig and Woolf are making use of the findings in a whole new way. They used Project STAR's statistics about educational attainment to build a computer model of a hypothetical group of 5-year-olds exposed for four years to small classes (of 13 to 17) and then followed until the age of 65. The researchers calculated projected earnings, welfare payments, and crime costs based on what we know about the relationship between these outcomes and educational attainment. They also drew on statistics relating degree of education to quality-of-life scores and age-specific mortality. And they accounted for the cost of maintaining smaller class sizes.

Findings: Based on their model, the authors project that reductions in class size would generate a lifetime net cash return of almost $200,000 (presumably in the form of taxes collected) for each additional low-income student who graduates from high school as a result of early placement in a small class. In addition, they project that four years of small classroom size will lead to improvement in health and longevity. These benefits, they calculated, would on average add up to the equivalent of an additional 1¾ years of life in perfect health.

Conclusion: It's important to point out that these numbers are based heavily on assumptions that might not hold true for the future or for places outside Tennessee (kudos, by the way, to that state for supporting this bold experiment). But these are plausible assumptions, at least. And the numbers they generate are astonishing, because they suggest that investment in reducing elementary school classes is better, in cost-benefit terms, than money spent on antibiotics, or hospital buildings, or even vaccines (long thought to be one of the most cost-effective interventions for health care). Perhaps I would do better for my patients if I gave up pediatrics and became a member of my local school board.

Our Teeth and Our Health Care System

Frank Pasquale at Concurring Opinions has some observations about our teeth and the state of our health care system.  He writes,

What is the future of American health care?  Many believe that we need less reliance on government funding.  The current state of American dentistry suggests the likely consequences of such a move--along with the imbalances caused by "marketization" that focuses on the demand side while neglecting a cartelized supply side.

As social stratification deepens, ever more sophisticated cosmetic dentistry becomes the norm for the wealthy.  Meanwhile,

[M]any poor and lower-middle-class families do not receive adequate care, in part because most dentists want customers who can pay cash or have private insurance, and they do not accept Medicaid patients. As a result, publicly supported dental clinics have months-long waiting lists even for people who need major surgery for decayed teeth.

[E]ven as so many patients go untreated, business is booming for most dentists. They are making more money while working shorter hours, on average, even as the nation’s number of dentists, per person, has declined.

***

Even if more students wanted to enter the profession, states are not moving aggressively to expand dental schools or open new ones. Training dentists is expensive, because dental schools must provide hands-on training — unlike medical schools, which send doctors to hospitals for training after they graduate. Hospitals receive federal subsidies for the training they provide to medical interns and residents, but the equivalent system does not really exist in dentistry. Meanwhile, the A.D.A. does not support opening new dental schools or otherwise increasing the number of dentists. The association says it sees no nationwide shortage of dentists . . . .

So while the doctors' lobby has finally acknowledged the need for more medical schools, the dental lobby is holding a hard line.  One key question: is the problem that Medicaid underpays dentists, or the state's failure to assure the training of enough dentists? Consider the hard line the dental lobby takes against the allied health professions:

Despite the rise in dental problems, state boards of dentists and the American Dental Association, the main lobbying group for dentists, have fought efforts to use dental hygienists and other non-dentists to provide basic care to people who do not have access to dentists.

***

"What we’re extremely uncomfortable with is that they need to drill teeth and sometimes extract teeth,” said . . . the association’s president. Use of therapists would create a two-tier system where some people have access to dentists, while others must settle for less-qualified practitioners, she said.

The entire post is an interesting and thought-provoking read with a number of potential solutions discussed to the problem of physician shortages.

Medicaid Enrollment Drops

ThinkProgress reports on a drop in Medicaid enrollment.   The story states,

Enrollment in Medicaid, the public health insurance program for our most vulnerable population, declined in 2006 for the first time in nearly a decade. A new report by the Kaiser Family Foundation finds that enrollment growth among the elderly and disabled was 40 percent less in 2006 than it was in 2005. Additionally, the number of children and parents enrolled in Medicaid decreased by 113 percent during this same period.

While this decline is in part due to two positive factors — an improved economy and low unemployment — another factor is at play: the conservatives’ cumbersome new regulation requiring proof of citizenship and identity when applying for Medicaid coverage.

This law was enacted in large part to prevent undocumented immigrants from enrolling in public programs such as Medicaid illegally even though evidence showed that illegal enrollment of undocumented immigrants into the program is not a problem.

What the law has done, however, is caused a drop in enrollment of eligible individuals. Reports are showing that the new rules have “contributed to slower enrollment growth in fiscal year 2007 and caused significant delays in processing applications and increased the administrative burdens placed on states” and individuals. . . . .

–

Quality of Children's Health Care

McClatchy News reports on a study in the latest issue of the New England Journal of Medicine discussing the quality of childcare in the United States.  It writes,

In the largest study of its kind, researchers found that America's children received appropriate medical care only 46 percent of the time when they visit health professionals, faring even worse than adults and raising serious questions about the quality of care delivered by the world's most expensive health system.

The study, to be published in the Oct. 11 issue of the New England Journal of Medicine, was conducted by the RAND Corp., the Seattle Children's Hospital Research Institute and the University of Washington School of Medicine.

It followed the health care experiences of 1,536 children from 12 metropolitan areas over a four-year period. By interviewing the youngsters' parents, reviewing the children's medical records and comparing their treatments to established care standards, researchers found that even basic care was a hit-or-miss proposition for children who visit hospitals and pediatricians.

The study found only 19 percent of seriously ill infants with fevers had the right lab tests done, only 44 percent of youngsters with asthma were on the right medications and only 38 percent of youngsters were screened for anemia in their first two years of life.
In addition, only 31 percent of children ages 3-6 have their weight measured at  annual checkups.

Failure to provide proper care makes it harder to reverse illnesses and increases the chance that youngsters will carry health problems into adulthood. "How do we catch a child at risk for obesity if we don't look," said co-author Dr. Rita Mangione-Smith, an associate professor of pediatrics at the University of Washington School of Medicine.

The results are surprising, not least because most of the youngsters in the study were white, middle-class and had health insurance.  "These are the kids who most people assume are getting excellent care in this country, and unfortunately they're not," Mangione-Smith said. 
Ironically, the study's dearth of low-income and ethnically diverse youngsters likely skewed the final data, resulting in an "overly rosy" picture, Mangione-Smith said.

The entire McClatchy piece provides a good overview of the study printed in the NEJM (free full text article available).

Suspensions over Sneaking Peek at Clooney's Medical Records

Oops!  Those darn medical privacy laws - how are people supposed to get good gossip.  Huffington Post reports on recent suspensions at the hospital that treated actor George Clooney after his recent motorcycle accident.  These suspensions result from from allegedly peeking at Mr. Clooney's medical records.  Huffington Post states,

WCBS-TV in New York reported Tuesday night that as many as 40 staffers, including doctors, were suspended without pay, accused of accessing Clooney's medical records and possibly providing information to the media, a violation of federal law.  The Jersey Journal of Jersey City reported that 27 employees, but no doctors, had been disciplined, and only for looking at the records without authorization.

The investigation was not prompted by a complaint from Clooney, who said he only learned of it on Tuesday.  "This is the first I've heard of it," Clooney said in a statement. "And while I very much believe in a patient's right to privacy, I would hope that this could be settled without suspending medical workers."

A spokeswoman for the union representing some of the workers said they had been suspended without pay for four weeks.  "We believe this is a harsh penalty and an overreaction," said Jeanne Oterson, a spokeswoman for the Health Professionals and Allied Employees union, adding that a grievance could be filed pending further investigation.

Eurice Rojas, the hospital's vice president of external affairs, told The Jersey Journal that hospital officials do not believe any employees leaked Clooney's medical information, but some staffers did improperly access his records.  Federal law mandates that only direct caregivers _ including doctors, nurses, technicians and support staff involved in a patient's care _ see such information.

A Day in the Life - Without Government

Ezra Klein points to a website by Douglas J. Amy, Professor of Politics at Mount Holyoke College, which examines how the government provides assistance to individuals everyday.  Here is a brief section from his Government is Good blog: 

Ask yourself this question: “What has government done for me lately?” If you are like most Americans, you will probably answer: “Not much.” Surveys show that 52% of Americans believe that “government programs have not really helped me and my family.”¹ But let’s see if that is really true. Let’s examine a typical day in the life of an average middle-class American and try to identify some of the ways that government improves that person’s life during that 24 hour period.

6:30 a.m. You are awakened by your clock radio and listen for a few minutes to the news before getting up. But you can listen to your favorite station only because the Federal Communications Commission brings organization and coherence to our vast telecommunications system. It ensures, for example, that radio stations do not overlap and that stations signals are not interfered with by the numerous other devices – cell phones, satellite television, wireless computers, etc. – whose signals crowd our nation’s airwaves.

6:35 a.m. Like 17 millions other Americans, you have asthma. But as you get out of bed you notice that you are breathing freely this morning. This is thanks in part to government clean air laws that reduce the air pollution that would otherwise greatly worsen your condition.

6:38 a.m. You go into the kitchen for breakfast. You pour some water into your coffeemaker. You simply take for granted that this water is safe to drink. But in fact you count on your city water department to constantly monitor the quality of your water and to immediately take measures to correct any potential problems with this vital resource.

6:39 a.m. You flip the switch on the coffee maker. There is no short in the outlet or in the electrical line and there is no resulting fire in your house. Why? Because when your house was being built, the electrical system had to be inspected to make sure it was properly installed – a service provided by your local government. And it was installed by an electrician who was licensed by your state government to ensure his competence and your safety.

6:45 a.m. You sit down to breakfast with your family. You are having eggs – a food that brings with it the possibility of salmonella poisoning, a serious food borne illness affecting tens of thousands of Americans every year. But the chance of you getting sick from these eggs has now been greatly reduced by a recently passed series of strict federal rules that apply to egg producers.

7:00 a.m. You go into your newly renovated bathroom – one of a number of amenities that you enjoy in your house. But the fact that you can even own your own house is something made possible by government. Think about this: “ownership” and “private property” are not things that exist in nature. These are legal constructs: things created by laws that are passed and enforced by government. You couldn’t even buy your home without a system of commercial laws concerning contracts and a government that ensures that sales contracts are enforced. So the fact that you live in your own home is, in part, a benefit of government and the rule of law.

Website Accessibility

Last week, a federal judge permitted a class action lawsuit to proceed against Target Corporation that concerns the lack of access by the blind to its website.  Reuters reports,

According to the lawsuit, plaintiff Bruce Sexton, a California resident, uses screen reading software to access the Internet but has been unable to use certain features of Target's site. The software vocalizes text and describes the content of the Web page. The plaintiffs, including the federation, say redesigning the Target site to be readable by blind people would be technologically easy and not economically prohibitive.

Minneapolis-based Target said in a statement that it was disappointed that the judge had granted class-action status to the case, but said the decision was a procedural ruling only.  "We will request an immediate review of the ruling granting class certification and we are confident that we will prevail on the merits of this case," the company said. . . .  In the decision, the judge said that after the lawsuit was filed, Target has made some modifications to its Web site to make it more accessible to the blind. . . .

The case was filed in February 2006. The court threw out a portion of the suit in September 2006, dismissing the plaintiffs' claims to the extent that they are based on Web site features that were unconnected to the physical stores.  Martin Wymer, a partner at law firm Baker & Hostetler LLP who represents companies in litigation matters, said that other retailers are likely taking a hard look at the accessibility of their Web sites.  In addition to trying to avoid lawsuits, "there's a business benefit from opening up your doors to that many more customers," he said.

The case is:  National Federation of the Blind v. Target Corp., 2007 WL 2846462
(N.D.Cal.,October 2, 2007).

Nobel Prize for Medicine Awarded to Gene Researchers

NPR.org discusses the winners for the 2007 Nobel Prize for Medicine:

Two American scientists and a British researcher share this year's Nobel Prize in Medicine or Physiology for devising the tools to figure out what individual genes do and how to fix them.

Mario Capecchi of the University of Utah, Oliver Smithies of the University of North Carolina and Sir Martin Evans of Cardiff University in Wales will share the $1.5 million prize this year.

The Nobel Committee says these scientists laid the groundwork for the main work in biology today: figuring out what each of the 30,000 human genes does. Capecchi invented a way to target single genes and turn them off to see what they do. Smithies used gene targeting to correct defective genes. Evans showed that embryonic stem cells can integrate corrected genes into living animals.  Together, these techniques are a big reason why scientists are so excited about the potential for embryonic stem cell research to cure a wide range of human ailments.

Daily Show on the SCHIP Veto

Ok, I promise to stop always posting on the SCHIP issue after this (at least until we find out what Congress plans to do with the veto) but here is Jon Stewart of the Daily Show discussing the veto.

Law School Musical

Just for fun - here is a creative take on the law school experience.  Unfortunately, I don't think that Disney plans to pick this up and make a full fledged movie/musical.  I am not sure that it would appeal to the masses.  Thanks to Professor Caron at TaxProfBlog for the link.

Medicare Cheats

The New York Times has a front page story about some problems in the administration of the Medicare Part D program.  It reports,