Category Archives: U.S.

Autism—Another Epidemic?

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Does your 6-month old make eye contact?  Does your 8-month old follow your gaze? Does he mimic your facial expression if you show fear, anger or pleasure?

If you answered “no” to these questions, the American Academy of Pediatricians (AAP) wants you to know that your child might be suffering from Autism Spectrum Disorder (ASD). Just two weeks ago the Academy sounded the alarm in a report calling for screening of children under two, listing signs of autism which pediatricians and parents should watch for. The report appeared in the November issue of the journal Pediatrics and on the group’s website.

At one time, autism was considered a rare disease. When I hear the word, I think of Dustin Hoffman’s brilliant performance in “Rain Man,” where he acts the part of an obsessive-compulsive idiot savant, imprisoned in his own tiny world of repetitive behavior. Rain Man is almost incapable of social interaction; it seems clear that he is afflicted with an uncommon disorder. But the Academy’s report begins by warning that, today, autism is not rare. One out of 150 children suffers from ASD, we are told. That’s why it is important to begin screening for the disease at an early age.

According to the AAP, doctors and parents should keep an eye on even the youngest children. For example, the report explains that “turning consistently to respond to one’s own name is an early skill that parents should expect to see in an 8 to 10-month old.”  The absence of this skill is said to be an autism warning sign. Other signs of trouble include “lack of warm, joyful expressions” when the parent points to an object and the baby gazes at it.  And by 9 months, says the report, the baby should be babbling—otherwise parents should be worried.

The AAP offers a brochure, entitled “Is Your One-Year-Old Communicating
with You?”, developed to help raise parent and physician awareness and
to promote recognition of ASD symptoms before 18 months of age. (The
AAP advises that pediatricians give the brochure all parents at the
child’s 9 or 12-month visit.) Different children “present” differently,
the report observes, but some particularly vigilant parents may still
be able to “perceive that their child is ‘different’ during the first
few months of life.”

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Your Yearly Physical Is a Waste of Time

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…or at least that’s what some experts have increasingly been suggesting. According to the American College of Physicians (ACP), instead of having 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.”

So what does that mean, exactly? According to the U.S. Preventive Services Task Force, doctors should focus on “interventions that help patients change health-impairing habits or that spotlight emerging illnesses for which reliable and effective treatments exist.”  These include “Pap smears, mammograms, cholesterol tests, blood-pressure checks, and counseling to stop smoking, lose weight, get more exercise and eat a healthier diet.” In other words, rather than just checking for everything, doctors should focus on interventions that can be substantively linked to treatments we know work. Currently, most check-ups are comprehensive run-throughs that seem to be administered  just for their own sake, regardless of how, or even if, they relate to meaningful treatments.

For many of us, the annual physical is a fixture of our health care
experience, something we assume to be both necessary and desirable.
Indeed, a study released last month found that 64 million Americans a
year get a physical or gynecological exam, costing a total of $7.8
billion.  Regular gynecological exams are important—they include Pap
smears that have made cervical cancer a rare disease. But the point of
the general physical is less clear.  More people get annual check ups
than visit doctors for respiratory conditions or high blood pressure,
and the price tag for yearly physicals closes in on the $8.1 billion
spent on breast cancer care.

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The Truth about the Politics of National Health Reform

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For the past year, progressives have begun to talk about health care reform as if it is inevitable. Listen to the Democratic Party’s presidential candidates, and it seems just a question of what form the health care revolution will take, how quickly it will happen, and how we’ll finance it. After all, the polls show that the majority of taxpayers, employers and even most doctors want to see a major change.  Moreover, health care research shows that if we cut the waste in our system, we could fund universal coverage. What, then, is stopping us?

As regular readers know, I recently attended a Massachusetts Medical Society Leadership Forum where what I heard about the Massachusetts plan made my heart sink. While everyone in Massachusetts wants health care reform, no one wants to pay for it. Those who are receiving state subsidies to buy insurance are enthusiastic. But uninsured citizens earning more than 300% of the poverty level are expected to purchase their own insurance. The state hoped that 228,000 of its uninsured citizens would sign up; as of last month, just 15,000 had enrolled. Many have decided that they would rather pay the penalty than buy health insurance.

At the forum, Robert Blendon, professor of health policy and political analysis at Harvard’s Kennedy School of Government, talked about what Massachusetts’ experience might mean for the national health care debate: “Massachusetts is the canary in the coal mine,” Blendon, who is also a professor at Harvard’s School of Public Health, declared bluntly. “If it’s not breathing in 2009, people won’t go in that mine.”  If the Massachusetts plan unravels, he suggested, Washington’s politicians will say “If they can’t do it in a liberal state like Massachusetts, how can we do it here?” 

I’m not writing Massachusetts off. The state’s leaders are behind the plan and they may be able to persuade the Commonwealth’s citizens to come on board. But it won’t be easy. 

In the meantime, this week I decided to ask Blendon some follow-up questions: Just what would it take, politically, to achieve national health care reform sometime in the next two to four years?  How many seats would reformers have to capture in Congress?  Is this likely?   Some observers say that if a reform-minded president hopes to succeed, he or she will have to ram a plan through Congress sometime in 2009. But health care is complicated; wouldn’t it make more sense for a new administration to take its time and explain what it is doing to the public, while trying to create a sustainable, affordable, high quality health care system?

Finally, what are the biggest barriers to reform?  If major change proves impossible, what more modest back-up plans should a new president have in mind? What other health care legislation could he or she hope to pass?

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Online Doctors, Privacy, and the Almighty Dollar

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Last month a
slew of media outlets caught wind of Jay Parkinson, a 31 year old
Brooklyn-based M.D. who provides care for his patients through the Internet.
Here’s how it works: you get an initial in-person consultation at your home or
office. After that, you can ask Parkinson questions online through instant
message or video chat; e-mail him digital images of minor wounds, rashes, etc.,
that he can then diagnose; have him help contact, call ahead, and inform
specialists when you need their help; and generally fulfill most basic medical
consultation functions online.

Parkinson’s work raises a lot of questions, but first among them may be
this: how come my doctor isn’t
utilizing virtual communication to its fullest potential?

Part of doctors’ technophobia stems from their lack of incentives to engage
with the virtual world: they’re not reimbursed for virtual consultations that
may be deemed “self-management support activities,” or good old fashioned advice
about do-it-yourself care. As little as eight
percent of patients communicate with their doctors via e-mail—a shame,
considering in the latest issue of JAMA, Tom Delbanco from Harvard Medical
School estimated that 50 percent of visits to the physician are unnecessary and
could probably be dealt with online.

But there are other reasons why doctors are reluctant to take their practice
online. For most doctors, communicating sensitive patient information without
special, government-approved secure platforms is illegal under the Health
Insurance Portability and Accountability Act (HIPAA). HIPAA, originally passed
in 1996, was revised in 2002 by the Bush Administration to incorporate a
privacy rule that came into effect in 2003. The privacy rule regulates the use
and disclosure of private health information (PHI),
which is information about “health status, provision of health care, or payment
for health care that can be linked to an individual.” It’s this privacy rule
that makes so many doctors computer-shy.

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Human Growth Hormone and The Business of Immortality

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Last week, James Forsythe, a prominent doctor in Reno, Nevada was acquitted by a federal jury after going to trial on allegations that he trafficked in human growth hormone (HGH). The decision came as a relief to the American Academy of Anti-Aging Medicine (A4M), because among other allegations, the doctor was accused of selling HGH as an anti-aging treatment, which is illegal in the U.S. A4M has a history of pushing for HGH-driven anti-aging treatments.

So what’s so special about HGH when it comes to aging? Beginning in your 40s, the pituitary gland slowly reduces the amount of hormone it produces, a fact that some feel is both responsible for the frailty of age and reversible through the introduction of synthetic growth hormones.

But there is little, if any, reliable scientific evidence about the anti-aging benefits of HGH. In fact, there are no double-blind placebo-controlled studies for most of the anti-aging miracle cures out there. Yet we do know for a fact that HGH can increase the risk of cancer—not to mention edema (retention of fluids), arthralgia (joint pain), carpal tunnel syndrome, diabetes, and gynecomastia (enlarged mammary glands in males).  Oh, and it might actually shorten life.

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When the Government Does What Drug-Makers Won’t Do

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Today, Bloomberg News reported that “Deadly Staph Germs May Be Cured by Old, $1-a-Day Antibiotics.” It turns out that generic, World War II-era antibiotics are becoming “the newest weapon of choice in the fight against deadly, drug-resistant staph germs.”

Physicians have discovered that drugs costing less than $1 a day can be very effective when treating methicillin-resistant Staphylococcus aureus, known as MRSA. The bacteria, once found only in hospitals and nursing homes, recently made news by showing up in schools and gyms. Last month, MRSA was linked to the deaths of a student in New York and one in Virginia.  Annually, more than 18,000 Americans are killed by MRSA.

The physicians who mounted the studies of the older drugs were funded by the federal government. Meanwhile, in the for-profit private sector, Bloomberg observes, “drug-makers are spending hundreds of millions developing medicines that cost more than $100 a day to treat advanced cases.”

But physicians know the older, cheaper drugs work. “We have used these
older drugs with success for years,” says Gregory Moran, one of the
study leaders. He is a professor of emergency medicine at the Olive
View-UCLA Medical Center in Sylmar, California, affiliated with the
University of California at Los Angeles.

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The Genetic Effects of Loneliness

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In September, a UCLA study took the long-recognized connection between loneliness and poor health to a new level by uncovering the genetic consequences of loneliness (see the full text of the study here). Its results are compelling, both on their own and as an opening salvo in medicine’s new campaign to understand how perception, feelings, and interaction with others determines health. 

Measuring loneliness (referred to in the study as “social isolation”) through the UCLA loneliness scale, researchers found that “feelings of social isolation are linked to alterations in the activity of genes that drive inflammation, the first response of the immune system.” At the same time, “key gene sets were under-expressed”—in other words, were not as functional as you’d expect them to be–in lonely individuals, “including those involved in antiviral responses and antibody production.”

In other words, loneliness fundamentally alters our immune system. As one author put it, “…the biological impact of social isolation reaches down into some of our most basic internal processes …the activity of our genes; changes in immune cell gene expression  in [ways that are] specifically linked to the subjective experience of social distance.” This is important: it’s feeling alone that matters. 

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What Rudy–and Most Americans–Still Don’t Understand about Prostate Cancer

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Presidential candidate Rudy Giuliani recently made the mistake of trying to turn his brush with prostate cancer into a campaign issue: “I had prostate cancer, five, six years ago. My chance of surviving prostate cancer, and thank God I was cured of it, in the United States, [is] 82 percent. My chances of surviving prostate cancer in England, [is] only 44 percent under socialized medicine,” Giuliani declared.

Rudy, of course, was wrong.

Merrill Goozner has done the best job that I’ve see of cutting through to the truth of the matter. In a Nov. 2  post titled “Columnists Miss Chance to Educate on PSA Testing,” he points out that “Paul Krugman’s column in the New York Times and Eugene Robinson’s column in the Washington Post justifiably attack Rudy Giuliani’s misuse of prostate cancer stats, all but accusing him of lying.

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Why Aren’t More Students Applying To Medical School?

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Did you know that there are only two applicants for every place in U.S. medical schools?

In Canada, surprisingly, close to four students apply for each opening. The training in the two countries is very similar; indeed, the Association of American Medical Colleges (AAMC) accredits medical schools in both countries.  And, in the U.S., at the high-end, physicians  can hope to earn far more than Canadian doctors.

Why then do so few Americans apply to medical school?

The answer is that we have priced a medical education well beyond the reach of most middle-class students.  In 2004, tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to a 2005 study published in The New England Journal of Medicine. 

The author, Dr. Gail Morrison, Vice Dean for Education at University of Pennsylvania School of Medicine, tacks on $20,000 to $25,000 a year for living expenses, books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools.  I’d add that, in many American cities, students would be hard-pressed to cover rent, food, clothing, utilities and transportation for $20,000 a year—let alone books and equipment.

This helps explain why 60 percent of all medical students come from the wealthiest one-fifth of all U.S. families. Another 20 percent come from families lucky enough to be on the fourth step of a five step ladder.

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We Need to Begin A Conversation About “Cost Effectiveness”

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As any policy-maker knows, catering to public opinion, ensuring the public interest, and managing costs can seem an impossible task–especially when what the public thinks it wants is at loggerheads with what it needs. But in the case of health care, there may be an opportunity to do all three at once according to a proposal in the September/October Health Affairs.

The proposal argues for cost-effectiveness analysis (CEA) “to set priorities for Medicare coverage of new or costly interventions” through a citizens’ council made up of “a cross-section of users” who can provide leadership with “well-considered social-value judgments.” This citizens’ council model is borrowed from the UK, where a group of 30 men and women advise the National Institute for Health and Clinical Excellence (NICE) on behalf of the public.

The British experience shows that there are likely to be practical complications with implementing a citizens’ council, but it’s still an idea that’s on the right track. We need to turn “cost-effectiveness” from a bad word into a public interest issue in the US.

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