Impending doctor shortage?

Courtesy of Reuters comes an article that discusses the coming retirement and career changes of physicians between the ages of 50 and 65. That group represents about 1/3 of all doctors in this country, and according to a survey conducted a fourth are planning on leaving the profession in the next few years:

Specifically, 14 percent said they were planning on retiring, 7 percent said they were looking for a medical job in a non-patient care setting, and 3 percent said they were seeking a job in a non-medical field.

It’s not really news to see that 14% of older physicians are planning to retire – a lot of people in that age range are nearing their retirement. The survey finding I did find interesting was this:

When asked about the work ethic of physicians entering practice today, 68 percent of the respondents said that these younger doctors are not as dedicated or as hard working as physicians who entered practice 20 to 30 years ago.

Ha! Granted I’m only a medical student and not a physician, but it’s quite funny to me that they don’t think I’m as hard-working as they are. Many people don’t know what it’s like to be in medical school, but it pretty much takes up you’re entire life. We study all the time, and when I say all the time I don’t mean a 40-50 hour week. I mean you wake up, go to class, maybe take a break for lunch, study, take a break for dinner, and study more. Weekends are usually filled with some degree of more studying. We don’t study this much because we want to, but because that’s what it takes to pass exams, and more importantly, prepare to pass the licensing exams (USMLE). I’m not as bad as some of my classmates, but I definitely have a few friends who literally study from 8 am to 10 or 11 pm, and then spend almost their entire weekend in the library. Medical students don’t really go out and party (at least at my school), unless it’s the day after an exam when we get a brief break. It’s just funny to me that older docs don’t think we work as hard, especially given that a lot of the material we have to learn now was not taught when they were in medical school because the medications didn’t exist or the disease mechanism wasn’t well understood. Our professors have to update their lectures every year to reflect all of the advances made in medicine. I will say that I doubt this generational view is specific to physicians – I’d bet that if you surveyed any older professionals about their younger peers, they would say the youngsters don’t work as hard. Another finding of the survey, which was a bit sad to me, is this:

Fifty-seven percent of older physicians said they would not recommend medicine as a career to their own children. Similarly, 44 percent said they would not select medicine as career if they were starting out today.

I understand that sentiment – it’s not that they don’t like treating patients, but is likely due to the fact that the medical field has significantly changed from when they started out. Paperwork is a nightmare, and you really don’t get to spend a lot of time with each patient. Patient’s definitely don’t like this, but neither do a lot of doctors! They want to spend more time with each patient, but if you saw all of the paperwork that must be filled out and all of the phone calls that must be made (regardless of whether it is private insurance or through a government system like the VA), you’d see that a huge chunk of their day is taken up in those less-than-desirable activities. Plus reimbursement is always an issue. Obviously they make a good living, but payment incentives tend to lie more with performing procedures rather than talking with the patient to understand all of the factors that are contributing to their illness.

The major concern, with older physicians leaving the profession, is whether the country will face a doctor shortage. The truth is, who knows? A lot of studies now point to both a doctor and nursing shortage in the near future. But, not too long ago a lot of studies predicted a surplus, to which the industry responded by restricting entry into the profession. The problem with the surplus studies is that they were made based on the assumption that our entire country would be under managed-care by now…a prediction that has since proved false. I think there is a good chance that there will be a doctor/nurse shortage – fortunately some actions are being taken to alleviate this, but unfortunately some are contributing further to the problem. First, the good – many medical and nursing schools are adding positions to their classes, and new schools are opening up. This is great, and in the next 5-10 years we should (hopefully) see a noticeable increase in health care providers. The bad news, is that lobbying groups and regulatory agencies continue to put restrictions in place to limit supply. Mostly this is done to ensure that these groups’ constituents continue to earn high wages (supply vs. demand), though they lobby under the pretense that they’re “ensuring quality” or something to that effect. Consider, for instance, that the medical licensing board has continually raised the minimum passing score. An intelligent person would say it’s great if 97-99% of medical students pass their licensing exam – it means that the schools are preparing them and covering all of the important material, and that the students are really working hard. But this group wants to maintain the pass rate at around 94% – so every time it starts to creep up, they raise the minimum pass score or make the exam harder (I don’t pay $40,000 a year and work my ass off to fail an exam). It’s great to increase the overall quality of the profession, but do those measures actually increase quality in the areas patients most desire? Doubtful – the best way to increase quality in areas that are important is to let the patient decide, not a licensing board or lobbying group. All they manage to accomplish is a further increase in their wages, which makes the medical care they provide expensive and unattainable for a significant portion of our population.

If we’re really serious about health-care – and given all of the attention it gets during election time I’m assuming we are – then we should deregulate some of this stuff. Lessen the licensing requirements and let the market pick quality physicians (they’d probably be less socially-inept bookworm and more warm-caring physician). Remove restrictions that physician-lobbying groups place on other health care providers – let nurses, physician-assistants, optometrists, physical therapists, etc occupy their rightful place in our health-care system. They’re capable of a lot more than we’re allowing, and it’s insulting and stupid to waste all of that talent and manpower (seriously…be skeptical every time you hear these lobbying groups tout “quality” as their motivation to place further restrictions on another group). Not only would this lower prices of care, it would open up the system to people who are currently shut-out. These regulations don’t ensure quality as much as they ensure that an increasingly larger share of people cannot afford the most basic care. That’s tragic, and completely unnecessary…it really doesn’t have to be this way, and there are better solutions to increase access that don’t involve a Hillary Clinton-styled single-payer system.

~ Lily


Praying to ace an exam

I’m a medical student, and my classmates and I have an exam coming up. It’s not uncommon for students to send out study guides, flashcards, mistakes in lecture notes, etc to the entire class via our listserv – we’re generally a cooperative bunch and like to help out fellow classmates and save each other time. There are also occasions in which different school organizations send emails to the class advertising meetings, events, etc. Some of these organizations are strictly medical (interest groups related to every medical specialty imaginable), and others are religious or political in nature – “Catholic Medical Students Association”, “Med Students for Choice”, “Jewish Medical Students Association” – you name it, we’ve probably got a group for it. I’m an atheist, but generally am not bothered when these religious groups advertise to the entire class. They’re an organization, and it’s the easiest way to reach everyone until you have your first few meetings and narrow down your list of interested individuals.

But the most recent email I received was different. It was from a few of my Christian classmates who were advertising an hour long “prayer session.” I’m not sure how to explain it, but the email felt weird. They weren’t trying to be exclusive – indeed they specifically mentioned it didn’t matter whether you were “Christian or not” – but it still came across that way. It still made me feel like an outsider – a reminder that the majority of this country (some of my family members included) think I’m destined for hell, or that I’m the equivalent of a murderer or rapist. Maybe it wasn’t the tone of the email, but the fact that these classmates in particular like to conspicuously “advertise” themselves as Christian – one frequently has the word “Jesus” displayed quite prominently when he comes to class. When I see that, I can’t help but think he doesn’t want to pray with anyone “Christian or not”, but rather for them – to save their soul. Is this true? Maybe I’m wrong. They’re very nice people, but I still feel like they are judging me for my (lack of) beliefs.

Moving on from my initial impression, what also bothered me was what they wanted to gather and pray about. We’re in the middle of an infectious disease course, learning about all of these viruses and bacteria that cause death and destruction around the world. We learned about rotavirus, which kills around 650,000 children every year. Were they praying that children in developing countries could have access to sanitary water or a vaccine to prevent this infection? No! Part of our local patient population includes many poor and homeless people. Were they praying that these families would not have to worry about paying their next bill? No! Were they praying that the homeless man on the corner could get access to mental health-care and a safe place to sleep? No! They were praying so they could do well on our upcoming exam. That may reflect more on their personalities or the fact that they’re medical students rather than their religious background, but it came across as incredibly selfish.

I don’t even believe in the power of prayer to change outcomes (most recent evidence here), but I do think it can be beneficial for the person praying (as a form of meditation) or a person who knows that loved ones are praying for them (as a form of emotional support). However, regardless of whether it works or not, I must ask my classmates – seriously? Out of all the things you pray for, and you choose an exam?! Are you an idiot?! Do you not care about other people in the world?! Are you really that selfish?! And now, until they prove otherwise, my answer is…yes. They are that selfish. They would rather pray for a good grade then for a decrease in human suffering around the world. They would rather spend an hour praying to do well on an exam, than an hour studying (which is guaranteed to help them on the test). They would rather pray for an hour than spend an hour volunteering at a local homeless shelter and making a tangible difference in the life of a person. Maybe I’m crazy…but it seems like they’ve got their priorities wrong.


~ Lily

Self-fulfilling anti-Philanthropy Prophecy

Ezra Klein has a post up over at his blog criticizing the “conservative” view that many “liberal” government programs are misguided efforts to substitute the State in place of private charity. He claims that this is not true and that charity is different from social policy because one is “a way to demonstrate virtue or compassion” while the other is “at least in theory…a way to try and fix a structural problem.” He advances as evidence of this divergence the observation that “very little philanthropy actually goes into the areas that social policy focuses on.”

I see at least two problems with Klein’s views. First, he basically short circuits the entire debate with his casual dismissal of the divergence between the theory and practice of social policy. Regardless of what social policy should do “in theory” it very often ends up functioning as forced charity. What, precisely, are the structural problems meant to be solved by the National Endowment for the Arts? Second, I believe there is something called the “crowding out effect” that might help explain why we don’t observe private individuals contributing vast sums to areas the government has effectively claimed as its own prerogative. Why, after all, should I be donating my money to pay for health care for the elderly when the government is already taking 3% of everything I earn for that purpose?

If Klein’s discussion was meant to clarify and exonerate the “liberal” in contrast to the “conservative” he did a very poor job. The whole of his post consists of question begging and circular argumentation.


Archbishop hasn’t read recent abortion study

Or at least that’s the impression the Archbishop of Canterbury gives in his recent writings. He thinks that people see abortion as an “easy” option, rather than using it only in extreme cases:

“But the rapidly spiralling statistics – nearly 200,000 abortions a year in England and Wales – tell their own story. We are not now dealing with a relatively small number of extreme cases (and clinical advances have in fact reduced the number of strictly medical dilemmas envisaged in 1967 act’s supporters). When we hear, as in a recent survey reported in the Lancet, that one-third of pregnancies in Europe end in abortion, we may well ask what has happened.”

Ok, so he has read the Lancet article in question (or at least is aware of the journal issue). Why then, does he think abortion rates are “spiralling” simply because they are legal? I was under the impression that the study showed it didn’t matter whether abortion was legal or not – people still sought them at the same rate. I also like when people quote statistics such as “one-third of pregnancies in Europe end in abortion.” He means induced abortion, which is fine – but he should state that explicitly. He fails to say that 20-25% of recognized pregnancies result in spontaneous abortion. The percentage is probably even higher, given that many women spontaneously abort without being aware they were ever pregnant (I’ve heard it quoted as high as 40-50% taking that into account). People of God never like to quote that one (surprise, God kills babies too!). My favorite quote of the Archbishop – and by favorite, I mean the one I am most appalled by – is this (emphasis mine):

Recent discussion on making it simpler for women to administer abortion-inducing drugs at home underlines the growing belief that abortion is essentially a matter of individual decision and not the kind of major moral choice that should involve a sharing of perspective and judgment. And that necessarily means that certain presumptions have changed.

Seriously? Is that really what he believes? That there is a “growing belief” – implying a change in previous belief – that abortion is a decision made by an individual? Abortion has always been an individual decision – sure, a woman may consult friends and family members, but she is the one that has to go through with it. You can argue that she should consult the father of the baby (which is debatable), but she should never have to get permission from a complete stranger (archbishop, political figure, etc) in order to proceed. If you don’t want an abortion, don’t get one. If you think abortion is wrong, then try and intelligently communicate to people why you think it is wrong. But you should never get to tell someone what to do with their life, when their actions have no consequence to you. If you think a woman is damned to hell for eternity if she gets an abortion, then fine – that’s your belief. But her decision makes no difference to you and your spiritual quest. I may believe that it’s appalling when people eat meat, but that doesn’t mean I should get to ban you from ordering that hamburger the next time you go to a restaurant. It makes no difference to my life whether you do or do not consume meat. (this said after I just consumed eggs and sausage for breakfast)

I find it hard to believe that this Archbishop has ever met a woman who had an abortion – I doubt it’s an easy decision for most of them. They understand that it’s a baby – their baby, but they get the abortion because in their situation it is the best decision for them. Maybe they don’t have the means to care for the child. Maybe they’re not in a stable relationship, and want to raise the child in an environment with two capable parents. Or maybe they have a medical condition and don’t want to put their body through the stress of pregnancy. It shouldn’t matter. Plus, who wants to have any sort of medical procedure done “just because”? It carries certain risks, which most are aware of – but the benefit to their personal situation outweighs the risk.

I will give the Archbishop credit for acknowledging that there aren’t necessarily “absolutes” when it comes to deciding what is right or wrong:

“There is no escaping the tough decisions where no answer will feel completely right and no option is without cost. But when do we get to the point where accepting the inevitability of tough decisions that may hurt the conscience has become so routine that we stop noticing that there ever was a strain on the conscience, let alone why that strain should be there at all?”

I just disagree that women who get abortions don’t notice a strain on the conscience – they’re human beings after all, not unemotional robots. Perhaps if women had better access to contraceptives then there would be fewer abortions in the first place. I don’t know the Archbishop’s stance on that issue, but a lot of vocal anti-abortion people seem to be against those measures as well.

I also find his discussion on the issue of “fetal rights” interesting – that is, the “paradox” between legislation that would punish women who harm their unborn child (he gives the example of smoking or drinking) versus the legislation that protects a woman’s right to terminate the pregnancy. I don’t know much about those laws, but it makes for interesting debate. One thing I know for sure is that we do not give a fetus the same rights as a woman (at least in the past…perhaps the fetal-rights laws are changing that). This is because our society does not view someone as a “complete” person (with all rights) until they reach a certain age. You can’t drive until you’re 16, you can’t vote or enlist in the military until you’re 18, you can’t drink until you’re 21, and you can’t run for President until you’re 35. By the definitions we’ve put forth in our legislation, a fetus does not have the same rights as an adult. I think it’s harmful to say otherwise – to try and put the rights of an unborn child on the same level (or above, if you are restricting abortion) as the woman is a dangerous path.

As much as I disagree with most of the Archbishop’s opinion, I’m glad he wrote it. It’s helpful to think about these things from time to time, and to see how different each of our views can be. This is why I am a libertarian. We can continue to disagree, but under my political philosophy those disagreements remain personal, rather than public. My views on any issue will never trump yours, just as yours will never trump mine. Live and let live, so long as we don’t infringe upon the rights of each other.

To read the Archbishop’s entire letter, click here.

~ Lily

For those who thought SCHIP was actually about children…

…I would call your attention to the New York Times article discussing the recent vote upholding the President’s veto of the bill. In the article, Rep. Thomas M. Davis III (R-VA), one of the members of Congress who opposed the President’s veto had this to say about his decision:

“He’s not going to get his way on this,” said Mr. Davis, who voted to override the veto and predicted that Mr. Bush would ultimately be forced to sign a measure similar to the one he rejected.

“And he’s jeopardizing people’s careers,” added Mr. Davis, who is contemplating a race for the Senate.

People always complain about not being able to get straight answers from politicians, and there is no doubt that most are highly skilled in the art of circumlocution, but that doesn’t mean they are never honest. In Mr. Davis’s case, his words are plain and his meaning unmistakable, supporting legislation is not about serving the public or upholding the constitution, it is about doing whatever it takes to advance one’s own career.

To me, this is a great argument for why we need term limits…and also why we are likely never to get them.

~ Fox

The American Idea

The current issue of The Atlantic features a compilation of short essays dedicated to the future of the American idea. The authors represent a diverse group of prominent Americans, and I look forward to addressing some of their individual contributions in future posts. For the time being, however, I would simply like to share my own understanding of the American idea as a means of participating in a project I admire.

The American idea is the conviction that freedom works. Countless thinkers from across the world have all expounded upon the nobility and promise of individual liberty, but Americans were the first to implement that philosophy as the foundation of a practical political framework. It was certainly unprecedented, but we should be careful lest we lay too much emphasis on its status as an experiment. No doubt there was trepidation among the Founders—there always is when people confront an unknown future—but America was not put forward as a tentative model to be measured against a predetermined benchmark. Economic prosperity, a unique and flourishing culture, and widespread spiritual improvement are all characteristic of our society, but were they all lacking, it still would not be cause to abandon our original charter. Happily, we need not worry about making such a choice since, as it turns out, high material quality of life and moral dignity are mutually reinforcing rather than exclusive. Call it the American corollary.
A further extension of the idea that freedom works is the idea that free men work. Industriousness, ingenuity, and innovation are all deemed virtues in the American vocabulary. Under the American scheme, life is both laborious and vibrant, evidenced in such Americanisms as “party hard.” There is nothing more likely to imbue a person with endurance and enthusiasm than a valid sense of ownership of his own efforts. Self-reliance in the American sense has nothing to do with being able to support yourself in isolation from the rest of society, rather it is the incorrigible confidence that if left to your own devices you will come out ahead. Freedom is not a theory of which hard work is not a consequence—they are the substance of an American life.

Please feel free to share your own take on the American idea or criticize mine in the comments section.

~ Fox

Beware of MRSA!

That’s the word out of the CDC and a recent report in JAMA. Not really news, since MRSA (methicillin-resistant staphylococcus aureus) is known to be problematic in hospitals. What is news, however, is that the resistant strain is also becoming more prevalent in communities, and by recent estimates has outpaced AIDS in terms of annual US death rates. Formidable, though the other side of this is that HIV is practically a chronic condition for many in this country thanks in large part to multi-drug antiviral regimens that keep the disease in check and prolong the lifespan of those diagnosed. Still, MRSA should not be taken lightly.

Is there anything you can do to protect yourself against MRSA? Don’t get admitted to the hospital, for one (by staying healthy – obviously you shouldn’t avoid going to the hospital if you are very sick). Every time nurses/doctors poke and prod you, you’re at risk (catheters, surgeries, etc). If you don’t see your nurse/doctor wash their hands in front of you before performing an exam, ask them if they washed their hands. Most will wash their hands before and after each patient, sometimes out in a hallway or other room where you might not see them, but it doesn’t hurt to ask and make sure – your health is at risk if they don’t, so you have every right to know. Most hospitals and doctor’s offices also have hand-sanitizer pumps all over the place that should be frequently used. Hospitals in Great Britain recently banned the use of neckties in an attempt to control hospital-acquired infections, since ties are rarely washed and thus are known to harbor germs for a long time. If you’re not in the hospital but get a scratch or other wound, you should always wash it carefully to avoid any infection, staph or other.

Hopefully health care works will be more careful in their use of antibiotics – indeed, several drugs are “use-restricted” at hospitals so they may still be used as a last-ditch effort, reserved for only the most drug-resistant bacteria.  But if a bacteria is resistant to those drugs, quite frankly there’s not much that can be done, and people die as a result of overwhelming infection.  Last but not least, if you are taking a prescription antibiotic you should always finish the entire dose as directed, to avoid breeding your own drug-resistant bugs. Only time will tell whether these measures are enough to limit the dangers of MRSA and other resistant bacteria.


~ Lily

I bet it tastes delicious

Hardee’s has unveiled a new Country breakfast burrito that tops in at 920 calories and 60 grams of fat. To put it in perspective, that’s about half your calories and all of your fat for the day, packaged as a hand-held burrito for the modest price of $2.69. Now, on the one hand, I think if you were poor and could only afford a few bucks worth of food each day you’re getting a decent deal for fat and protein. On the other hand, there is probably no nutritional value beyond that, and if you eat it on a regular basis you are likely to be obese and nutrient deficient (which is an interesting phenomenon if you think about it). You won’t catch me at a Hardee’s anytime soon waiting in line for one of these or their “Monster Thickburger,” but go ahead and enjoy that massive burrito America. Just know that I reserve the right to judge you if I see one in your hand…your heart will thank me for it.



An Introduction and Observations on Politics in Money

This is my first post on this blog. I’ve been following my wife’s writing for awhile now. I’ve enjoyed it and have been quite impressed. Since med school keeps her insanely busy, I asked if I might sign on to help keep things going when she gets a bit overwhelmed. She graciously accepted my proposal so here I am. Hope I don’t muck things up too badly.

I’m a staunch defender of individual freedom, and I truly believe that a limited government dedicated to the protection and preservation of the rights to life, liberty, and property is both the only morally justifiable government and the one most likely to effectively promote peace and prosperity. However, I’m not holding my breath for the dawning of the new age of enlightenment. Recent developments in Washington suggest I’d be sure to suffocate if I tried.

You’ve probably heard people complain that there is too much money in politics. While I certainly agree with the observation, most of the policy prescriptions that follow strike me as naive at best, most likely genuine but misguided, and possibly viciously cynical. As the piece in the Post points out, bureaucrats know bureaucracy. Placing restrictions on the ways in which organizations can spend their money for lobbying purposes is a futile endeavor. It is even possible that it could make things worse by further complicating the regulatory framework and providing more obscure language that can be massaged into loopholes to make even the most blatant malfeasance seem legal (ie. deliberately ignoring the mandate that lawmakers pay charter rates for private jets).

Interests with large amounts of cash have disproportionate political clout. This is usually bad, but the answer is not to try to get the money out of politics; the answer is try to get politics out of our lives. Drastically reduce the scope and power of the federal government to dole out favors (in other words, legitimately apply the Constitution to the current establishment) and I guarantee that a lot less money will be wasted on rent-seeking. By the same argument, leave the current powers in place, and it won’t matter how many hurdles you throw in the way of lobbyists–they will leap over, scramble under, dodge around, or just plain break though every last one. When your life is on the line, people become remarkably resourceful.

Trying to reduce the link between the size of an organization’s bankroll and the magnitude of their political clout by restricting the ways in which they can spend their money for lobbying purposes is a futile endeavor more likely to


FDA denies drugs to terminally ill – Part IV

In a follow-up to my previous discussion (part I, part II, part III), regarding the August 6th court decision which said that terminally ill patients do NOT have the right to access experimental treatments, I was able to attend a policy seminar at the Cato Institute in which panelists Michael Cannon (of Cato), Scott Ballenger (lawyer for the Abigail Alliance who argued the case for the terminally ill), and Ezekiel Emmanuel (bioethicist at NIH who agreed with the court decision) battled it out in front of a decent sized crowd. Forgive me for my tardiness in posting about this (…the seminar was 2 weeks ago) – life has been a bit hectic lately. Here’s a summary of each panelists’ main points, and the impression they left:

Scott Ballenger -He was very articulate and came across as the “nice guy” in the debate. Ballenger argued that terminally ill patients should be able to take a risk (which I agree with), and pointed out that they were fighting for access to drugs that were already in the clinical trial phase – specifically phase 2 and 3 – meaning that since we already let others access drugs at that point (people who qualify for a clinical trial) it should then be considered ethical to let the terminally ill also access these meds.

He then spent a good deal of time discussing the “rational basis test” versus “strict scrutiny”, which if I’m being honest, was a bit more lawyerly and over my head. His point with this (if I’m getting this correct) was that the Abigail case should be strict scrutiny because it involved the fundamental right of life/death. He pointed out a few cases where courts have upheld decisions supporting patient autonomy, such as end of life issues in which a person has the right to die – that is, they can choose not to take food or water, and it may not be forced upon them by medical staff or family. Ballenger also mentioned the right to fight regardless of the means and end, giving rape as an example. A rape victim can fight with whatever means necessary, regardless of whether those means will have any effect (so even if will make no difference in the brutality of the attack, they can still fight). I found this analogy compelling, because his argument is that terminally ill patients should be able to fight with whatever means necessary, regardless of whether the outcome will be positive or negative. Finally, he pointed out that the FDA allows “off-label” prescribing of drugs by doctors, despite the lack of approval (and sometimes hard evidence) to support this use – as an example, prescribing aspirin to ward off heart-attacks is considered an off-label, yet widely accepted, practice. This is useful to consider when we understand that the reason many of these terminally ill patients don’t have access to experimental drugs is because they fail to meet the criteria for enrollment into the clinical trials. A trial may be testing the drug for breast cancer, and you have head and neck cancer and thus don’t qualify. However, maybe your doctor knows the biochemical mechanism by which the drug works and thinks it might have even a tiny chance of making an impact on your cancer – should he be allowed to get that trial drug to you in an off-label fashion? I would argue that he should, and I think Ballenger would agree.

Ezekiel Emmanuel – I disagreed with him on almost every point, didn’t find his examples strongly supported his arguments, and in general he came off as a bitter and angry man. Allow me to explain – the first thing he does when he gets up to speak is complain that up on stage it is 2 against 1 (Cannon and Ballenger vs. Emmanuel), and that despite the fact that he is arguing for the opposite position he is only given 1/3 of the time to speak. Ballenger talked for a long time, so I’ll give Emmanuel a slight break, but Cannon barely got a chance to speak, so I think Emmanuel did in fact get almost half of the time to make his point. Me thinks he doth protest too much, and that really set the tone in my opinion (ah…the importance of first impressions). First he pointed out that the FDA certifies drugs based on their safety and efficacy, and said that the Abigail Alliance doesn’t care whether the drugs are effective or not. This seemed to amaze him (actually, almost every quasi libertarian viewpoint seemed so astonishing to him). Personally, I don’t think the FDA should restrict drugs based on efficacy. Why should they decide what’s considered effective? To a terminally ill patient, a few extra weeks of life might be effective, but if the government disagrees they’re not getting the drug. Moving on…Emmanuel thought that the Abigail Alliance asking for drug access after Phase 1 trials makes it less a principled argument and more a regulatory issue. I kind of agree with this, but I think the AA had to be realistic about what they could accomplish.

Emmanuel also argued that just because we have a right doesn’t mean we can exercise it by any means. Well…yeah…but I think a lot of rational people say that a fundamental right can be exercised by any means so long as it does not infringe upon the rights of another. I don’t think allowing terminally ill to fight for their life infringes upon the rights of others, but Emmanuel thinks that it is not in the best interests of cancer patients and society. He argued that by extending access to experimental drugs to patients not enrolled in clinical trials, you make it more difficult for researchers to meet their enrollment quota, and may deter patients from seeking drugs that are proven to be effective. His paternalistic view was that “sometimes your job as a doctor is to say ‘no’ to someone”…and I guess to him it doesn’t matter whether that someone is addict who needs an oxycontin prescription versus a dying patient who wants a chance to fight. This is where some of his examples didn’t strongly support the claims in my opinion. For instance, he gave an example of a bone marrow transplant study for patients with metastatic breast cancer that took place in the 1980’s. The randomized-controlled study took 4 years to get 1000 people enrolled, while 40,000 got it off trial. The study later showed that the drug wasn’t effective. Call me cynical, but if I’m dying of metastatic breast cancer, I don’t give a damn how long it takes a researcher to meet their quota. They still got people enrolled! And they had metastatic cancer for crying out loud. They were going to die without an intervention – would you enroll in a clinical trial and risk being given a placebo? I wouldn’t. His arguments would hold more water if researchers couldn’t get people enrolled because of access outside of the trial, but in each example he gave that wasn’t the case. His argument was that it took too long (usually 3-4 years) to get people enrolled. Boo hoo. Has he forgotten that these are people with families, and not statistics? (did I mention he left a bad impression on me?)

Michael Cannon – He didn’t get much time to talk, but still made a few good points. He said that “all laws must be both necessary and proper” and that this court decision fails on both counts. It robs patients of their right to self-determination and dignity at best, and at worst it prevents their lives from being extended. Cannon pointed out research he had done on economists and the FDA, and found that most/all economists that have written about the issue came to the conclusion that the FDA requires too much testing and commits more type II than type I errors – that is, more people are harmed by the failure of the FDA to approve useful drugs than by their approval of harmful drugs.

Follow-up points included discussions on giving patients incentives to enroll in clinical trials. If you’re going to risk being given a placebo, than you should be compensated for that risk. Both Cannon and Emmanuel agreed on this point, but Emmanuel thought there was no data to support that it increases enrollment. In my opinion, all that says is that they aren’t paying enough for the risk to take the drug versus the risk of taking a placebo. (it’s basic economics, no?) Both also agreed that the FDA has a really tough job, and that there is no magic moment at which a drug is definitively safe and effective. I think the difference is that Cannon doesn’t think the FDA will ever be able to do the best job, so the decisions should rest with patients (a libertarian utopia), while Emmanuel probably thinks that the FDA can be constantly tweaked and regulations reworked until a happy point is found (his utopia). In case it hasn’t been clear up to this point, I most definitely agree with Cannon and not Emmanuel. I don’t think the FDA can ever be sufficiently tweaked. As long as they are the sole group that determines whether you or I have access to drugs, they will never be able to meet our individual needs. I think it’s important that drugs be safe so people aren’t unnecessarily harmed, and I think it’s important that drugs be effective so people aren’t taken advantage of, but I don’t think the decision of safety/efficacy can be properly done through an agency like the FDA.

Is the media against Ron Paul?

So I watched the Republican economic debate tonight on CNBC, after which there was an online poll to vote for who won the debate, who gave the best answers, etc. So I went online to vote, at which point there were about 8,000 votes total – Ron Paul won by a landslide in all 3 categories with a whopping 75%. I believe John McCain and Fred Thompson were the next pair with around 5% (Romney might have been in there too…I didn’t look too closely). So I went to check back with the poll about 20 minutes later to see how it would change once more votes were in, and CNBC took the poll down. I’m not a big “conspiracy theorist” type person, but it seems a bit fishy. After all, the poll they put up during the debate asking “What is the most important economic issue the next president should focus on?” is still in place. I know it’s an online poll and not scientific, but I see no reason why they should have taken the poll down.

What’s the deal CNBC? Don’t like seeing a “long shot” gaining support? They never seem to have a problem publicizing poll results done by phone survey showing a particular candidate in the lead – I find it interesting that this type is still considered “scientific” considering a lot of younger voters are excluded because we don’t own a land-line phone (I include myself in this category – most of my friends live on cell phones and an internet connection and will never be included in such a poll). Anyway, I think it’s ridiculous that they took the poll down considering they told people during the broadcast to go to their website and vote after the debate. It’s just an online survey – what are they so afraid of?

The magically non-existent poll was here.

The link for the still-existing poll is here.

Via, you can still vote on the MSNBC poll…though it doesn’t ask who “won”

To see video highlights of the debate including discussions on unions, trade, and going to war without Congressional approval, click here.

Flying First-class at the taxpayer’s expense

Have you ever flown first class (or ever flown at all)? I’ve never traveled first-class, and I don’t plan to in the near future because it’s expensive and not worth the extra money in my opinion….which is why it is particularly irritating to me that Federal employees are upgrading their seats with our tax dollars, resulting in $146 million extra spent on their travel. This comes courtesy of a report from the Government Accountability Office. From the first page of the report there are 4 examples of improper travel that was found:

  • USDA – $163,000 – “Executive had subordinate authorize 25 premium class flights”
  • DOD – $105,000 – “Executive flew premium class 15 times claiming a medical condition. Medical condition was documentation with a note signed by a DOD employee, not a physician as required by DOD regulations”
  • State – $46,000 – “Family of 8 flew premium class to relocate from Washington, D.C. to Eastern Europe. Coach tickets would have cost $12,000”
  • USPS – $2,200 – “A member of the board flew first class round trip from Washington, D.C., to Los Angeles. Comparable coach price was $400.”

Several things come to mind – would these people have flown first class if they were the ones footing the bill? My guess for most is “no.” But let’s say they would have flown first-class anyway, because they’re special and that’s the only way they know how to fly. Considering the tax payers are the people funding their travel, and that taxation is more or less theft (be honest, even if you think taxes are necessary, you have no choice whether or not to pay), these workers are stealing from YOU to pay for their luxurious travel. They’re taking money from rich, middle class, and poor workers to fund their upgrade – $146 million worth of pure waste! (sigh) When will we ever learn? This is just one example, from one report, of how much waste a MASSIVE government is capable of. It doesn’t matter whether it is Republican or Democrat dominated – waste is waste. I mean, $146 million? I could think of a lot more useful things to spend that amount on…makes you wonder where else our money is being frivolously spent without our knowledge.


GEICO Caveman pokes fun at The View’s Sherri Shepherd

The caveman that is now part of a network sitcom (which I refuse to watch) made fun of Sherri Shepherd yesterday on “The View.” If you’ll remember, Sherri is the co-host who doesn’t believe in evolution and who isn’t sure whether the earth is round or flat. Even though I think she’s pretty dumb (at least based on the comments that have given her such notoriety), I have to give her credit for being a good sport.

To see my original post on the topic from a few weeks ago click here.

Source: Bad Astronomy Blog

Shingles – to vaccinate or not to vaccinate (and my experience)

That’s what’s being discussed by a NY Times article today, titled “A Vaccine as an Option to Keep Shingles at Bay.” Unfortunately the vaccine is new, so a lot of the effects are unknown – that is, no one really knows how long the immunity lasts, and if there are any long-term side effects. Still, it’s something to consider if you’re worried about suffering from shingles.

If you don’t know what “shingles” is, consider yourself lucky. It’s a reactivation of the Varicella Zoster Virus – the same virus that causes chickenpox. But when it reactivates (usually in older people with weakened immune systems) instead of breaking out in those characteristic red blisters all over, shingles usually results in a more localized blister. It’s localized because after suffering from chickenpox, the virus retreats to a nerve, and upon reactivation will generally effect only that nerve. The area of skin supplied by these nerves is called a “dermatome”, and if you look at the picture below you can see how these are distributed across the body (borrowed from the website, which I’m pretty sure was borrowed from Frank Netter’s Atlas of Human Anatomy):
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So the virus hangs out in a nerve root near the spine, and upon reactivation affects a strip of skin that correlates to the strips in that picture. If it presents classically like this, it’s probably pretty easy to identify by a doctor or nurse, although the NY Times article describes a woman who had to make a few trips to the ER and Urgent Care clinic before getting diagnosed and treated.

I can say from personal experience that you do not want to suffer from shingles. I had an outbreak at 23, which I’m assuming is pretty rare. It’s associated with old and immunocompromised patients, but it can also erupt because of extreme stress, which is what I believe happened in my case. I had just moved across the country, started medical school, and ‘came out’ to my very Christian parents about my atheism – there was definitely a significant amount of stress in my life at the time, though I was trying to manage it by exercising and eating relatively healthy (obviously it wasn’t enough!).

I had what I assumed to be multiple bug bites or poison ivy (I’m an outdoorsy person), and decided to go to the doctor after the ‘bites’ wouldn’t heal and appeared to get worse. Fortunately my primary care doctor identified it immediately as shingles (literally, she took less than one second) and put me on retroviral therapy for a week to put the virus in check, but I’m not sure whether other doctors would be so quick to catch it in a younger patient, which I believe was part of the problem with the woman in the article who was repeatedly misdiagnosed (plus it was on her scalp which probably made it more difficult to see). The next few weeks were miserable, to put it mildly, as the blisters crusted over and went from causing a minor tingling sensation to spontaneous severe, sharp pain. Even after the spots healed and disappeared, I would still get random tingling or brief pain for months. Fortunately this disappeared, but in some individuals (the article says about 20%) this pain never goes away and is referred to as ‘postherpetic neuralgia’ (PHN). I feel very sorry for anyone who suffers from PHN – I think I would go crazy if I had to live with those sensations for the rest of my life.

So would I get a shingles vaccine? I think it’s sort of a moot point for me – having suffered from shingles already the odds of a second incident are small. Still, if I were older and in a risk group for an attack, I would probably get the vaccine. It’s worth the $200-300 not to experience the weeks of weird sensations and pain, and definitely worth it to avoid experiencing PHN.

Ron Paul – the candidate they keep trying to ignore

Ron Paul, onetime Libertarian presidential nominee and current Republican presidential candidate, raised over $1 million for his campaign in the past week (the end of the third quarter). He may not get the press that some of the other candidates do, but he’s certainly not about to give up. There’s something about an underdog I find fascinating – whether or not you agree with their position, you can’t help but cheer them on a bit (maybe that’s just me, though – I always enjoy rooting for the underdog in sports…upsets are fun).

To read a letter from Ron Paul thanking people for the fundraising success click here.

Also, an article from “The Hill” titled “Pay Pals – Paul supporters reach into their pockets

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