Choosing Contraception

The study below provides more evidence on the most effective form of birth control is Long Acting Reversible Contraception (LARC).  LARC includes Intrauterine Devices (a small device that is inserted into the cervix during an office visit) and Implantable Contraception (a small device inserted under the skin).  The advantage of these is that one procedure lasts 3-10 years.  No pills to take, things to insert, shots or anything else for the duration of the implant.  And, if you decide to get pregnant, they can easily be taken out.

Effectiveness of Long-Acting Reversible Contraception — NEJM

This research as others shows that they are more effective than other types of contraception (pills, patches, vaginal rings, etc.).  Here are some visual pictures to help everyone understand.  The numbers are approximate based on the data they show.  Each face below represents one woman over a year.  In the thousand women below, about 2 will have a pregnancy while on a LARC:

For women on a pill, patch or ring, about 48 more (smiley faces with the X's) will have a pregnancy:

LARCs also save money for the patient and the health care system.  There also have minimal side effects.  For instance, some women get increased bleeding with the IUD, but most get less or the same amount of monthly bleeding.

I talk to a lot of women about contraception, but many still choose a pill.  Why?  I'm interested in hearing the perspectives of women.  I think we all have the goal of reducing pregnancies that are not desired.

(Thanks to NNTonline.com for help creating the graphs.)

Gay Marriage: An Economist's Perspective

I'm not an economist, but I like to listen to economists.  They are usually pretty smart.

Today Obama stated that he supports gay marriage.  I support his decision to not take away rights from any individual in this country.  (I'm not going to discuss whether this was the right political decision, as I'm not a political scientist.)

This issue is clearly a wedge issue that divides many Americans.  However, there is an interesting solution from the economists Thaler and Sunstein, who wrote the bestseller book, Nudge:

"Under our approach, the only legal status states would confer on couples would be a civil union, which would be a domestic partnership agreement between any two people.  Marriages would be strictly private matters, performed by religious and other private organizations.  Within broad limits, marriage-granting organizations would be free to choose whatever rules they like for a marriage conducted under their auspices. ....  Instead of channeling every partnership into the same one-size-fits-all arrangement of state marriage, couples could choose the marriage-granting organization that best suits their needs and desires.  Government would not be asked to endorse any particular relationships by conferring on them the term marriage."

There's a solution that should not be as divisive.  Make marriage a private institution, while the government support equality by granting civil unions.  

Can you look at this growth on my back?

Dermatologists often do not like to admit that they look at skin growths all day.  Because the next thing they know, there is someone at a cocktail party asking them to look at a mole on their backside.  (And yes, all Dermatologists regularly attend cocktail parties.)

Should physicians diagnose or treat their friends and family members?  It is a tough issue.  Once you complete medical school (or sometimes even before), you are immediately seen as the know-it-all of everything medicine related.  Physicians want to be helpful to friends and family.  But how far should we go?

Let me start with diagnosis.  This is the most common thing I'm asked by friends and family.  "What do you think is wrong?  Could he have cancer? Why is my pee green?"  The process of diagnosis is probably the most complicated thing most physicians do.  Diagnosis is not as simple as looking in a book at the causes of green pee.  We spend hours in medical school learning how to arrange a proper diagnostic encounter, including how to look at the patient, what tone to use, what words to use, and even which way to cross our legs.  (Crossing your legs away from the patient signals that you are closed to hearing what they have to say.)

When I see a patient in my office, I start by asking open ended questions and letting the patient talk.  Based on what the patient is saying and how they are saying it, I continue down a path until I think I have a diagnosis.  I am also cuing into patients non-verbal responses, which can lead me to new and important questions.  This whole process is disrupted when a family member calls and asks, "Why is my pee green?"  Without the rhythm of the normal diagnostic encounter, the correct diagnosis could be missed.  

There is another reason diagnosis with friends and family members is difficult: some questions are off limits.  If my friend calls me and asks me why she is fatigued, I don't want to ask her if she could be pregnant, how heavy her periods are, or if she has any blood in her stool.  (Weird and awkward, but all causes of anemia.) If my friend asks me about some new joint pain, I don't want to ask him if he's a new sexual encounter, especially if I'm friends with his wife!

Finally, the hardest part of diagnosing friends and family is giving bad news.  What if I think my family member has cancer?  Is it right for me to have to give them that information?  It's unfair to both the physician and the patient.  Giving this type of news is something that only an unbiased physician should do.

Are there diagnostic questions that are ok to ask? Yes.  If I'm riding bikes with you and you fall off your bike, I'm happy to help you decide if you need an ambulance, or if you have a broken bone.  Why?  There's not much of a story to tell.  There are no questions about your sex life involved in broken bones (usually), and it's not likely we will have to address prognosis.  So most urgent situations are fine.

Treatment.  "So my doctor says I have high cholesterol.  Do you think I should take medicine?"  Most of you that know me would probably guess that I would say, "No. Eat more vegetables and ride a bike."  But, that's not fair, because that's my opinion.  Treatment decisions are another complicated interaction between a physician and a patient.  The dyad needs to account for the values of the patient and the long term implications of taking a medication.

But what can I ask you about treatment?  I'm actually much more open to talk about treatment with a family or friend, as long as the decision is made with the treating physician.  I'm happy to give you my opinion if it's in area I know about or can look up.  It actually can be helpful for me to arm you with some questions that you would want to ask your doctor.  But you should always make the final decision with your physician.

Summary: Being a physician that's asked questions by a family or friend is a tough situation. We always want to help, but do not want to hurt.  It's always ok to ask me about my opinion on something, but do not be offended if I suggest you talk to your doctor.  I'm not being rude.  I'm just trying to help.  

Older Is Better, even with oral contraceptives

New stories, including this one,

Bayer Withheld Yasmin Data From U.S., Former Agency Chief Tells Court - Bloomberg

highlight the elevated risks with the new oral contraceptives. The one under major scrutiny is drospirenone, also known as Yaz or Yasmin.

First, the most important thing: The increased risk of blood clots is small. Your risk of blood clots is probably still higher if you are pregnant. Yes. Your risk of blood clots is higher being pregnant, than being on Yaz or Yasmin. So, patients: Please do not suddenly stop your OCP suddenly. Talk to your doctor first.

When you do talk to your doctor, consider switching to an older contraceptive. One of my mantras in prescribing is that older drugs are usually better, as we know more about their safety. One of my mentors told me, "Never be the first or last to prescribe a new drug." I tend to use norethindone, but any older oral contraceptive will do.

I never understood the hype of Yaz and Yazmin. The drug companies just did a good job marketing it as an acne drug. The truth is, most OCPs work for acne. It appears that Bayer also did a good job of hiding drospirenone's side effects. How many times will we hear this story?

McDonald's: Doing it Wrong

San Francisco's ordinance on free give away toys at fast food restaurants was intended to nudge restaurants to improve the health of their kids meals. The ordinance requires meals that have free toys to meet certain nutritional requirements. The ordinance is a great idea, as the toys are just marketing gimmicks, designed to create brand loyalty with McDonald's.

As this article states, McDonald's, instead of improving their meals, will charge 10 cents for each toy. This will get them around the ordinance and allow them to change meals on their own terms. Still, the pressure from this law got McDonald's to make some changes to the kids meals, such as reducing the portion of fries. But, they are still not healthy. The extra charge will also likely prevent some from buying the toy, as it's not included with that meal.

So it's time to put more pressure on McDonald's, and we have more legal tools that we can use. I want to know why McDonald's has to sell toys. Aren't they in the business of selling food? Why should food establishments sell toys? Why not create a law that states that restaurants cannot sell toys? I'm not yet sure if this is legal, but I would like to find out.

Do Kids Need 3-4 servings of Milk a Day?

Many of you know that I have long said that the benefits of milk were overstated. The article below does a good job of reviewing the evidence why:

Wisconsin milk board overstates dairy’s benefits to children, some experts say | WisconsinWatch.org

The key statements are this:

“The so-called calcium requirement in the United States is based on very short-term studies (that are) irrelevant to long-term calcium needs,”

-Dr. Walter Willett, who chairs the nutrition department at the Harvard School of Public Health

“We know that those individuals who avoid milk and animal products that contain calcium do just fine in terms of their growth, their development, and their bone health,” - Jennifer Nelson, director of clinical dietetics at the Mayo Clinic

“I wonder how the marketing board explains why the highest rates of osteoporosis are found in countries that drink the most milk, or how cows manage to make huge bones that support their weight while eating mostly grass?”- Marion Nestle, Chair of Nutrition at NYU

“It’s hard not to be sarcastic about this kind of marketing,” Nestle added. “Milk is a fine food if you like it, but it is not an essential nutrient.”

Healthy Checkout At Walmart

This video is a great example of a couple of things:

1. Creating healthy checkout aisle shows that behavioral economics works: kids want fruit when it's in their check out aisle.

2. Walmart is doing some more great things in encouraging healthy eating. This was however, a local store initiative. Big Walmart is not yet doing this. Let's how they do.

3. Federal money can work for good. The reason these changes happened was because West Virginia got a grant from the CDC, likely as part of the Affordable Care Act. Federal Money -> States -> Promoting Healthy Changes and Increased Sales.

WATCH IT HERE:

Life in the health lane - News - The Charleston Gazette - West Virginia News and Sports -

Is the Food Industry a Partner in Battling Obesity?

Check out this debate about whether the food industry can be a partner in fighting obesity.  Our study is featured about half way through.



Food Industry Friend or Foe Debate: Yoni's opening arguments from Yoni Freedhoff on Vimeo.

This is just the first in a series of videos by Yoni.  For more, see his blog.

Every day is Medicine Day. But, today is Food Day.

Every day is Medicine Day.  Every time a family doctor like me sees a patient who struggles with weight gain, diabetes, or high blood pressure, I give them medicine.  But today is different.  Today is Food Day.

To be honest, I have long tried to emphasize the importance of food choices in preventing and treating disease.  I high-five my patients when they lose weight or cut out sugar-loaded beverages from their diet.  When people pick a food to eat, they are making one of the most important health decisions of their day.  The vast majority of problems I see in primary care are related to what people eat.  Our food system and our health system are closely linked.  It's no surprise that the faults or our food system contribute to the problems of our health system.  

Our general taxes fund massive giveaways to large agribusinesses, so that they can grow corn (for sugar) and soy.  This makes the major ingredients for most processed foods and beverages cheap, allowing the big food companies to spend billions of dollars a year getting Americans to eat a lot of junk.  And it works. Obesity and diabetes rates are skyrocketing, leading to increased patient suffering and corresponding health care costs.  Guess who pays for those costs?  The same taxes that fund agricultural subsidies help our seniors buy the medications to treat the conditions the subsidies helped cause.

There is a very simple way to break this cycle.  And we don't have to rely on politicians to do it.  All we have to do is know where our food comes from.  Then we just vote with our fork and start eating food that is not part of the industrial food system.

This is the idea behind the first annual Food Day, today, October 24^th (www.foodday.org).  Food Day was founded on six national priorities: reduce diet-related disease by promoting healthy foods, support sustainable farms & cut subsidies to big agribusiness, expand access to food and alleviate hunger, protect the environment & animals by reforming factory farms, promote health by curbing junk-food marketing to kids, and obtain fair wages for all workers in the food system.

One of the best ways to do this is to visit a farmer’s market.  At farmer’s markets we can directly ask the food producer: Where does this strawberry come from?  Did you spray it with pesticide?  Is there any chance it is infected with bacteria from a nearby animal slaughterhouse?  How much do you pay your farm workers?  So visit your farmer's market this week, ask these questions, buy some fruits and vegetables, and provide your family with a few healthy meals.

For those of you who want to celebrate food day in other ways, you can celebrate Meatless Monday by not eating any meat or poultry today (and every Monday).  You can turn your child's television (and internet) off so they do not see all the junk food ads.  Stand outside McDonald's or Taco Bell and warn people about the dangerous food they are planning to eat.  Celebrate water by joining the "Life is Sweeter" campaign and get sugar-loaded beverages out of the buildings where you work.  Or grow a tomato plant on your porch.  You can involve your family in any of these activities, while teaching your children where food comes from.  

While I'm hoping that the 2012 Farm Bill will fix some of the problems with our food system, I'm not optimistic.  However, I am optimistic that many of our food issues can be solved without relying on politicians. By choosing to eat non-industrial food, we can start our own food movement.  

So when I see patients tonight, instead of picking up my pen and writing a prescription for a new medicine, I'm going to write a food prescription for my patients.  I'll give my patients three choices of what I can write: "Eat seven vegetables a day," "Don't Drink Sugar-loaded beverages," or "Give up meat on Mondays."  I hope other doctors follow my lead, and that my patients do too.

Protecting your Prostate and your Package

According to reports out today, the United States Preventive Services Task Force will give a D rating to prostate cancer screening. This means they recommend men should not get the test.

Physicians who have watched the data on prostate cancer screening for awhile could have seen this coming. When I counsel men on PSA (the antigen that screens for prostate cancer) screening, I tell them that the test more likely to harm them then help them. Most prostate cancers are slow growing and never cause problems. How can this be? Cancer is a growth of abnormal cells in your body. The body is always fighting off abnormal growths. It often suppresses early cancers through the immune system and other mechanisms. Even if a cancer continues to grow, it may take years and years to cause something bad. Most people die of a heart attack before the prostate cancer does anything bad.

Now there are a very small amount of people where prostate cancer kills people. The problem is that medicine does not have a way to detect these people. So as in breast cancer, universal screening of women under 40 will result in a lot of people getting mastectomies to prevent one "bad" cancer in women. In prostate cancer, if we screen everyone, we will make millions of men unable to get an erection or be able to hold on to their urine while trying to prevent one prostate cancer.

Screening is not the best way to stop cancer deaths. The best way to prevent them is to stop them in the first place. According to the World Cancer Research Report, you can prevent prostate cancer by eating a lot of fruits, vegetables, and whole grains; and by avoiding a high calcium diet. And that doesn't involve becoming impotent or incontinent.

A Contagious Blog

Having loved the movie "Outbreak," I had to go see Contagion. I was hoping it was going to bring as much intensity as "Traffic." It didn't reach that level. This is not to say it was a bad movie. It was a fairly realistic portrayal of what could happen with an outbreak of a global pandemic.

I felt the most compelling pieces were about who gets what first. We will surely have to ration in a situation like this. Who should get the vaccine or treatment first? Of course, we don't think about rationing in our current health system, even though we do it all the time. Who gets cancer treatment first? Probably the rich insured patients. But not many people are up in arms over this. Things will be different when massive amounts of people are dying daily.

Another lesson of the movie is that most of these emerging viruses are likely to come from humans being close to dead animals. We can do a lot to assure a non-infectious animal. However, even the USDA does not have enough animal inspectors, and Republicans are currently trying to cut food safety initiatives. Compare this to other countries, where there are even less regulations in food preparation. Animal agriculture will continue to create risks for humans in many ways. Kind of makes me want to continue to the call for more people to eat less meat. If you do eat meat, know exactly where it came from. (I.e. buy it yourself from a local farmer.)

The movie also remind us about preparation. Everyone procrastinates this. If we were actually prepared, there would be no rush to the grocery stores last minute. Ready.gov has some good examples of what you need. If you are a camper, you might have many of the supplies already: a stove, freeze-dried food, and a lantern. If you are not a camper, get started! Everyone should remember to get a few jugs of water and leave them in a closet.

The biggest thing we can do to get prepared for these things, is to get vaccinated for things we know about. Influenza kills people. Last year it killed young people. I see too many patients that are afraid of getting the flu shot. I've heard, "It gives you the flu," over and over again. It does not give you the flu. It can't. Some people get an immune response to the vaccine which makes them feel under the weather for a day. For most people, this is tolerable. Consider the other option: dying. It happens. Get your flu shot!!

Most of all, this movie reminds us how critical our public health departments are to our health. We forget about them. But everyday they are investigating new viruses, food poisonings, and poor sanitary conditions. The current climate talks about defunding all governments institutions. This is clearly not the smart thing to do.

Why I Race Bikes

A few weeks ago I participated in the Leesville Gap Road Race. It was my hardest race of the season: 64 miles, horrible roads, climbing, headwinds, with temperatures near 38 Celsius. (That is 100 Farenheit. One thing I learned this year is that to be a cool cyclist, everything has to be Euro.) I almost didn’t finish due to the heat and dehydration, despite drinking over 3 liters of fluid and consuming 1000 calories while riding. After the race my Mom asked me, “Why are you doing this? What are you trying to prove?” I’ve been thinking a lot about that question.

I started cycling with the UCLA cycling team last fall. I joined them to have a group of people to ride with. I never thought I would race. I don’t remember what changed my mind, but I wanted to race. It’s been an amazing year, where I thought I’d stop racing at least twice. Yet I continued on and finished my last (13th) race of the year yesterday.

I sacrificed a lot this year: Thousands of dollars in bike equipment, sports massages, and energy foods; not skiing at all this year so I could keep up with my training and racing (despite a great snow season); weekends with my friends and girlfriend; and SLEEP (especially on those mornings I wanted to stay in bed).

So why sacrifice all this?

Maybe it was all the friends I was making in the cycling community. Maybe it was that I like gear, and cycling has a lot of it. Maybe it was I just wanted a regular way to stay active and in shape.

But I could have been in good shape just riding my bike a few times a week, and not pushing myself with an aggressive training plan. I could have trained for charity/century rides. I could have just exercised on my bike and not taken the risks of racing, which sometimes includes crashes and broken bones. (I’ve been in a few of them this year, but got out with only a few scrapes.)

So why race?
I like winning.

Whether it is in academics, sports, or a debate over some issue, I like to win. There is no winner in exercising. There is no winner in charity rides. (Not that I think charity rides are a bad idea. I may do one this fall.) I know life isn’t all about winning. But winning is what propels humans. It gives us a sense of our ability and purpose.

I just finished watching the Tour de France, which I believe is one of the hardest sporting events in the world to win. (Maybe only second to the Stanley Cup.) If you look a the faces on the winners as they cross the finish line, you will see the excitement in bike racing. While I haven’t won a race, nor done heroin, I think the two probably give a similar feeling.

I almost won a race. I was in the #6 position at the Stanford Road Race with 200 meters to go. But there was a crash from the front and I didn’t get the chance. But that feeling of almost winning is still with me. It was so close and felt so good.

But, as I started in my first non-collegiate races, I realized that winning would be tough. While I still believed, I wasn’t sure I’d win one in my first season. Still, I wanted to race, despite the pain of pushing my legs to their limit in 2-3 hour races. Why?

What else would I be doing? Spending time on facebook? Cleaning my apartment? Watching TV? Reading? Writing a research grant? So many people just sit on their bums all day. Our bodies are not built for that. Pushing myself hard on a bike reminds me what my body was built for: to push, to endure, to work hard.

As Peter Flax said, “We spend our so-called modern lives coddled-breezing through airports on people movers, accepting meeting requests nestled in Aeron chairs, engaging in cruise control to avoid the demands of the gas pedal. Our amazing muscles and capillaries and neural pathways are built to do something far more profound if we put them to the test.” My day job requires me to test my mind. Bike racing allows me to test my body and forget about my day job for a few hours.

There is something primal about racing. One human against another, with a prize at the end. Humans were meant to battle and to pursue speed. Cycling combines the two.

I feel alive on my bike. And I’m having fun. What I’ve described above may not sound like fun to some of you. But, remember that first time you were able to ride a bike? Remember the freedom to push your body into the wind? Remember racing your friend down the street? Remember the feeling of triumph?

Bike racing is fun. I don’t think I need another reason to continue. Except for the fact that I still want to win.

(This post is dedicated to all my team members and my Koach who pushed me beyond my limits this year. I’ll wait for you all at the top of Latigo.)

It's time to stop marketing junk food to kids

(cross post from the NPA Blog)

I’m often faced with parents who want to know what do do with their kids who are overweight. There are a lot of causes of obesity, but the major causes are soda and junk food. The increase in consumption is due to the food industry’s aggressive marketing of junk food to kids.

In 2009, the fast-food industry spent $4.9 billion on marketing. How are parents supposed to fight with an industry that is telling kids to eat more junk food at school, while watching tv, and while on the internet? It’s time to make parenting easier. It’s time for the food industry to stop marketing to kids.

A bi-partisan bill in Congress asked a group of government organizations to come up with VOLUNTARY standards for the food industry on what products it’s ok to market to kids. They came up with very good guidelines. But, they are under big pressure from big food to be weakened, even though they are VOLUNTARY. The government group (the Interagency Work Group- IWG) needs to hear from you on why these standards are really important. They will provide a blueprint on where we should start in stopping marketing junk food to kids.

Please click here to add your comments. Parents around the country will thank you.

Marijuana and Terrorism

Recently, I've turned on some of those Border Patrol tv shows and tv documentaries. They are usually trying to catch marijuana smugglers and growers. It seems marijuana smoking is booming in California, and the cross border trade is feeding this demand. Now I do not have a big problem with people smoking small amounts of marijuana, especially for medical purposes. But, I do have a problem with where the marijuana is coming from.

If you grow your own marijuana, fine. But as some of these programs show, Mexicans are being forced to smuggle or grow marijuana to feed American's desires. In one recent documentary I saw, there were Mexicans who snuck over the border to grow massive amounts of marijuana in forests in California. It's hidden and hard to find, but they have whole camps in rural California growing the stuff. According to the officials most of the men are forced to live in these camps and protect the crop. If they lose the crop, they are threatened with the killing of their families back home. This is terrorism.

Everyone has heard about the Mexican drug crime going on. Is it possible that this is America's fault? Is our greed for drugs forcing families into the drug trade, with no way out. (I also recently saw the great (fictional) movie, Sin Nobre, about what it's like to live in one of the drug gangs.) Think about it: Do you want your weed smoking to be responsible for the rape or murder of families in Mexico?

I spoke to a source in the marijuana business who told me that even if you buy your pot at a legal shop, it's in no way guaranteed that it was grown legally. I think if we want to legalize marijuana, we have to do it fully, and put all operations under supervision. Anyone that sells marijuana should have to verify that it is from a legal growing source.

In the meantime, know where your weed comes from. Just think about the families in Mexico, and the power the drug rings have right now. And if that does not move you, remember that Afganistan is now a prime drug exporting country.

Slowing Down Cars to Speed up Cycling Growth

Another one of my friends was hit while riding her bike this week. She has significant injuries, but is going to be ok. After the shock wore off I started thinking about my new favorite hobby. Most cities, like Los Angeles, are designed for cars, not people or bikes. This is despite the fact that I think biking can save the world, as I mentioned on a previous blog.

New research out describes how separate bike transit ways can reduce bike deaths. (Read the full news coverage here.) Some striking statistics from this story:

• about 51,000 American cyclists suffered injuries as a result of encounters with motor vehicles in 2009, with such accidents accounting for two percent of all traffic fatalities in the United States (according to 2008 figures).
• In the U.S, bike lanes typically consist of merely a painted stripe on the pavement delineating cyclists' portion of the road. In contrast, the Netherlands -- a country half the size of South Carolina, with just under 17 million residents -- is home to about 18,000 miles of separate cycle tracks.

• While more than a quarter of all Dutch commuters get around by bike and 55 percent of Dutch cyclists are women, in the U.S. less than one-half of 1 percent of Americans ride a bike to work and fewer than one-quarter of those riders are women.
• Cycle injury rates are at least 26 times higher in the U.S. than in the Netherlands, the researchers noted.
• The research team pegged the overall relative risk of injury as 28 percent lower on the separated tracks versus biking on a street in traffic.

While I think we need to reconstruct our cities around biking, public transportation, and walking (again see my previous post), I don't think this will happen tomorrow. In the meantime, everyone PLEASE SLOW DOWN WHILE DRIVING. I mentioned the city of Davis, CA as a great biking city, where speed limits are 25mph to make it safer for bikers. Here are some great tips for driving safe around cyclists: please read them. Just slowing down and being extra careful may make you 5 minutes late for a meeting, but could prevent another one of my friends (or me) from having a serious, life-changing injury.

Guideline Experts Fail Again: and this time it costs us

One of the buzz-phrases of health reform and cutting costs has been, "We are going to pay physicians for quality, rather than quality." This sounds good. I would agree with this method.

The question becomes: What is quality health care? For hospital care, one can get pretty good measures of things that happen acutely. Some examples:

-Paying less to a hospital when a patient gets a hospital-acquired illness (e.g. a fall or infection due to lack of sanitary conditions)

-Pay more when a hospital discharges patient with a complete plan for post-hospital care

But for outpatient care, the measures are much harder. Here are some candidates for diabetes care:

1. Pay doctors for how much their patients like them

2. Pay doctors for how long their patients live or what their quality of life is

3. Pay doctors for what their patient's lab values are

Each of these choices has its problem. Option #1 seems like a pretty good option. But you could be a really bad, friendly doctor. (That's not me.) Option #2 seems the best measure, because this is what patients care about. But you can imagine the problems: patients switch doctors, some patients do things that a doctor cannot control, etc.

So we are left with #3, which is how the current proposals urge to pay doctors. The following article reveals how this process has gone terribly wrong:

Sudden Acceleration of Diabetes Quality Measures, February 16, 2011, Pogach and Aron 305 (7): 709 — JAMA

Basically we are using measures that have little research behind them. We are using lab values that do not matter much to patients. Why do we use them? Because the quality experts messed up. They jumped the gun and made quality standards before the research was finished that would give them the answers. I do not think this problem will end. I think we should not rely on paying doctors based on lab values, or intermediate tests that don't have a big effect.

My solution: a mixed payer model. Pay primary care doctors a set fee to take care of patients for a year. Based on a person's age and some other factors, a doctor would get a set amount for the year. The doctor could do whatever they want for that patient. But, if the costs goes above this amount, it's on the doctor's shoulders.

Next: pay doctors like all other professionals, by the hour. Some patient visits take 5 minutes (a cold). Others take an hour (a cancer diagnosis). Fairly simple.

Finally: Pay a group of doctors based on the community's health. So if one city's overall health is increasing more than another's, increase their pay a little bit.

Any of these options is better than paying doctors for lab tests that patients do not care about, and that may not even indicate how good a doctor is.

Which animals should we kill?

Save a Turkey. Eat a Bean.

That's my new facebook/twitter status. It's pretty simple. But the issue of Eating Animals is a lot more complicated than that.

I recently saw the Oscar-winning documentary The Cove. The movie documents the slaughter of 20,000 dolphins each year on the shore of a Japanese town. (The Japanese also slaughter lots of whales every year. Sea Shepard is trying to stop this.) Any American watching the bloody beating of these dolphins is likely to cringe. We are likely to ask why they do this. How could they be so cruel?

Yet we have to be careful not to be ethnocentric. I imagine if we put cameras in the places where we slaughter chickens, turkeys, and cows, people from other countries would cringe. Actually, I think Americans would be disgusted too. No wonder these places are off limits to cameras. (Although sometimes PETA sneaks cameras in. Warning: This is graphic. But it's where your food comes from.)

Now, I do not think that it is always unethical to eat animals. In full disclosure, I eat environmentally friendly fish about once a month. So how should we decide what living beings are ok to eat? Are dolphins ok to eat? Cows? Chickens? Dogs? The answer probably depends on where you live and which animals you were brought up eating.

Everyone has to decide what they are comfortable with. There are many food rules that people go by, whether they be religious or cultural. Both Jewish (Kosher) and Islamic (Halal) rules specify that an animal must be killed instantly, with minimal pain, by a slit through the throat. Others have written that you should buy your meat/fish from a local farm, so you can ask how it was raised and killed. Some even say that if you want to eat meat, the most humane way is to kill it yourself. This way you know how it was treated and you know that it fits with your values.

Whichever food rules you choose, I think most of us can agree that large scale slaughter, such as the dolphins in the cove, or the turkeys in a factory farm, is not the way to get our meat. All I ask is that you think about this during this Thanksgiving. Use some of the links above to learn more and get involved. (Be Active!)

Maybe it's not as simple as "Save a Turkey. Eat a Bean." Maybe it's more like, "Eat less factory slaughtered turkeys. Eat more veggies from your garden." Whatever the correct phrase is, we need to think more about what we eat and where it comes from.

Happy Turkey Day!

P.S. For the guys out there, that need a little inspiration to go vegetarian: Check this out.

My First Conversation with a Tea Partier

I was just at the barber shop and the talk became politics. The man I was speaking with believed in the tea party. Most of his anger was over the requirement that every American purchase health insurance. He believed that that took away the freedom of Americans.

Me: We take care of people when they come in to the hospital and our sick anyway. Shouldn't they have insurance so they pay for their own care, instead of us footing the bill?

Him: That's not freedom.

Me: Universal mandatory coverage was championed by Mitt Romney (a Republican) in the MA Health Insurance Plan.

Him: It was a mistake. He's not a leader in the Republican party.

Me: Should all kids have insurance? Should we leave kids dying on the streets because they have no health care?

Him: That is up to their parents. If their parents are taking care of the kid, their are other ways to take care of that. You can call the authorities. You cannot tell a parent to purchase health insurance for their child. That is not freedom.

Me: I'm a doctor and and worry about my patients. I just want everyone to be able to have good health care.

Him: What you liberals don't get is that socialism didn't work. The Nazis and Russians failed because they didn't allow Freedom. [Note: the Nazis were not socialists and the Russians were communists.]

So I guess he's calling me a Jewish Nazi? He was so angry, and just kept repeating, "Freedom." Is there a conversation to be had about shared American values, or should progressives just talk to the majority of Americans that believe in health for our communities and families?

He shook my hand at the end and said he had no hard feelings against me. I told him I believed in Freedom too.

Hi, I'm a Tea-Partier Video

This video is funny and a good reminder of us of the facts. But it also demonstrates the classic problem of the Democrats: focusing on facts. The Democrat gets better toward the end with values-based messaging.

Remember to vote and keep the Democrats in power, so we can keep moving forward on improving the lives of families in our country.

A Few Nudges Might Help

I just finished reading: Nudge: Improving Decisions about Health, Wealth, and Happiness

It was named one of the best books of the year by the Economist. The basic premise is that classical economic thinking is misguided. In classic economic thinking we all make choices by weighing the benefits and risks of each decision. But most humans do not act like economists.

This book shows that in decisions about health, wealth, and other areas, the maxim of "Give as many choices as possible," does not work. Choices are determined by a lot of subconscious factors that we are unaware of. The liberalistic paternalism the authors speak of is a nonpartisan way of designing choice architecture.

I suggest you read it and think about where you could make simple nudges for you, your family, and your community. Every time you hear a policy maker talk about how great their plan is just because it gives citizens lots of choices (i.e. Medicare Drug Benefit, school choice, retirement savings), tell them to read this book.