Rate of Autism Diagnoses Has Climbed, Study Finds - NYTimes.com

The likelihood of a child's being given a diagnosis of autism, Asperger syndrome or a related disorder increased more than 20 percent from 2006 to 2008, according to a report released on Thursday by the Centers for Disease Control and Prevention.

The new report estimates that in 2008 one child in 88 received one of these diagnoses, known as autism spectrum disorders, by age 8, compared with about one in 110 two years earlier. The estimated rate in 2002 was about one in 155.

The frequency of autism spectrum diagnoses has been increasing for decades, but researchers cannot agree on whether the trend is a result of heightened awareness, an expanding definition of the spectrum, an actual increase in incidence or some combination of those factors. Diagnosing the condition is not an exact science. Children "on the spectrum" vary widely in their abilities and symptoms, from mute and intellectually limited at one extreme to socially awkward at the other.

Children with such diagnoses often receive extensive state-financed support services — which some experts believe may have contributed to an increase in the numbers.

Doctors working to update the Diagnostic and Statistical Manual of Mental Disorders have proposed significant changes to the definition of autism, which are due to take effect in 2013. If the changes are carried out, some experts say, they could reduce the number of children being given a diagnosis.

"One thing the data tells us with certainty: There are many children and families who need help," Dr. Thomas R. Frieden, director of the C.D.C., said in a news conference on Thursday.

C.D.C. researchers did not meet any of the children they judged to have an autism spectrum disorder. The team made the decisions based on evaluations of the children, drawn from 14 states. The estimated rates in those states varied widely, from one in 210 children in Alabama to one in 47 in Utah.

"This is a fourfold difference," Dr. Éric Fombonne, a psychiatrist at McGill University and Montreal Children's Hospital, said in an e-mail. "It means that ascertainment is unequal across states. Thus, in the next surveys, as ascertainment will most likely improve where it is currently low, average rates are bound to increase. Is there, in addition to this, a real increase in incidence? It's possible, but cannot be determined from the study design."

Over all, boys were almost five times as likely as girls to get such a diagnosis — at a rate of one in 54, compared with one in 252 for girls.

The sharpest increases appeared among Hispanic and black children, who historically have been less likely to receive an autism spectrum diagnosis than white children.

http://www.nytimes.com/2012/03/30/health/rate-of-autism-diagnoses-has-climbed-study-finds.html?_r=1&pagewanted=print

The Case for Sleep Medicine - NYTimes.com

ACCORDING to a new study in the journal BMJ that has received wide media coverage, people who regularly took sleeping pills were nearly five times more likely to die over a two and a half year period than those who didn't take them.

Oh no, I groaned, reading the headlines, not another scare story about sleeping pills. As a lifelong insomniac who has extensively researched the topic, I find such stories alarming — but not because of the information they present. Rather, I'm afraid that they will cause doctors to stop prescribing these medications to people who need them.

The risks of sleeping pills are real, as I well know, having taken them for three decades. But so are the risks of chronic sleep loss. As the pioneering sleep scientist William Dement has argued, sleep is "the most important predictor of how long you will live — perhaps more important than smoking, exercise or high blood pressure."

Sleep deprivation ratchets up the stress system, leaving you more susceptible to even relatively mild sources of strain. When University of Chicago researchers led by Eve Van Cauter deprived young, healthy people of a few hours of sleep for six nights, they produced in them the hormonal profiles of much older people: higher levels of stress hormones and lower levels of growth hormone(essential to cell repair). The study's participants developed hormonal imbalances conducive to weight gain and levels of insulin resistance like those of people with diabetes.

Loss of sleep also compromises immune resistance and leaves you more vulnerable to everything from the common cold to cancer. In a University of Chicago study led by Karine Spiegel, participants whose sleep was restricted to four hours a night for six nights had, when vaccinated for influenza, less than half the immune response of those who had slept well. Michael Irwin and colleagues at the University of California, Los Angeles found that even modest sleep loss — only one night, between 3 and 6 a.m. — significantly reduced white blood cell activity, a crucial line of defense against infection and cancer.

Then there are the ravages of sleep deprivation on the mind and mood. After a night with four hours sleep or less, I can't think, can't work, can barely string words together to make a sentence. Sleep deprivation undermines focus, creativity, motivation and judgment, and leads to a wide range of emotional disturbances including volatility, impulsivity and depression. Studies show that insomniacs have a hard time getting jobs, performing at jobs and holding on to jobs, let alone building careers. No wonder so many people make the trade-off that I've made: medication for functionality.

The recent study in BMJ about the dangers of sleep medications had methodological shortcomings: It compared a large group of people who had been prescribed sleep medication with a large group that had not, matching them in terms of age, sex, ethnicity, body mass index, smoking and drinking — but not in terms of how well they slept. Given that those taking the medications had more hypertension, heart failure, obesity, asthma and other health problems associated with poor sleep to begin with, it's not surprising they had higher mortality rates.

Which is not to say that the drawbacks to sleep medication aren't real; they are. These medications alter sleep cycles, so that the sleep they provide may not have the deep restorative benefits of natural sleep. They adversely affect memory and coordination, which can be bad news for the elderly, the group that takes them most. And you can develop a tolerance to them, causing you to take larger and larger doses to get the same effect. But the sleep they provide may make the difference between having a life or not.

The study in BMJ alludes to "the meager benefits" of sleep medications and the greater success of behavioral methods of dealing with insomnia, which include things like going to bed and getting up at set times and using the bed only for sleep. But such strategies are not as effective as is sometimes claimed: studies that demonstrate their efficacy tend to look at small numbers of carefully screened, self-selected and highly motivated subjects. Face it, if behavioral modification were that simple, there wouldn't be so many of us taking medications.

It's not fun to rely on medications that carry risks. Nor is it fun to rely on doctors who are often not very sympathetic or knowledgeable about sleep, whose medical training is a hazing in sleep deprivation, and who often pride themselves on how little sleep they need. Insomniacs need doctors who will work with us to troubleshoot our condition; we do not need doctors who have been scared into a one-size-fits-all solution, when one size so obviously does not fit all.

We need to be allowed to work out our own terms with sleep and balance one set of risks against the other, so we can get on with our lives.

Gayle Greene, a professor of English at Scripps College, is the author of "Insomniac."

http://www.nytimes.com/2012/03/25/opinion/sunday/the-case-for-sleep-medicine.html?_r=1&hp=&pagewanted=print

Psychiatry debates whether the pain of loss is really depression - Los Angeles Times

The pain of losing a loved one can be a searing, gut-wrenching hurt and a long-lasting blow to a person's mood, concentration and ability to function. But is grief the same as depression?

That's a lively debate right now, as the psychiatric profession considers a key change in the forthcoming rewrite of its diagnostic "Bible." That proposed modification -- one of many -- would allow mental health providers to label the psychic pain of bereavement a mood disorder and act quickly to treat it, in some cases, with medication. With the Diagnostic and Statistical Manual's fifth edition set for completion by the end of this year, the editors of the British journal The Lancet have come out in strong opposition to the new language, calling grief a natural and healthy response to loss, not a pathological state.

"Grief is not an illness. It is more usefully thought of as part of being human, and a normal response to the death of a loved one," writes the editor of The Lancet. "Most people who experience the death of someone  they love do not need treatment by a psychiatrist or indeed by any doctor. For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills."

The change under consideration would expunge any reference to the passage of time since a loved one's death before a diagnosis of depression could be considered. The current edition of the diagnostic manual states that if a patient's low mood and energy, sleep difficulties and appetite changes persist for more than two months following bereavement, a diagnosis of depression might be considered. An earlier edition of the manual had established a year as the period during which mourning should not be confused with depression.

"Putting a time frame on grief is inappropriate," The Lancet's lead editorial states simply. And in a "Perspectives" essay also published Thursday in Lancet, Harvard University medical anthropologist Dr. Arthur Kleinman agrees, eloquently exploring what's at stake.

"Is grief something we can or should no longer tolerate?" asks Kleinman, who describes his own grief after his wife of 46 years died last March from Alzheimer's Disease. "Is this existential source of suffering like any dental or back pain unwanted and unneeded?"

Kleinman calls the current two-month time period allowed for grief a "shockingly short expectation" that no religion or society would support. To allow grief to be redefined as depression with no allowance at all for the passage of time not only spells "the loss of grief": it risks redefining vast numbers of Americans who are taking their time to adjust to the loss of a loved one as sick, he writes. And it powerfully rewrites cultural values about how we understand and mark the loss of a fellow human being.

Proponents of the change have argued that it would allow the bereaved to seek help for their suffering. And they add that it would not define all who grieve as depressed. They argue there is often no difference, but for the recent death of a loved one, between the behaviors that define depression and those that define grief.

The Lancet's editors note there is no evidence that antidepressant medications improve the moods of people who are healthy to begin with. Citing fellow critics of the proposed move, Kleinman suggests that it might have been inevitable once the financial interests of pharmaceutical manufacturers collided with psychiatry's loose definitions of mental illness and the profession's tendency to expand its patient base.

"Its ubiquity makes grief a potential profit centre for the business of psychiatry," writes Kleinman.

http://articles.latimes.com/2012/feb/16/news/la-heb-grief-or-bad-grief-depression-psychiatry-20120216

Colonoscopies often come with costly, unnecessary sedation - HealthPop - CBS News

Dread getting a colonoscopy? You're not alone - which is why lots of people are sedated before the procedure. But a new study suggests too many people are getting extra, unnecessary sedation, racking up nearly $1 billion annually in health care costs.

What's more, most of the patients utilizing anesthesiologists to monitor sedation are considered low-risk patients who don't need the extra help, the study authors said.

"These services are not harming patients. They're basically giving them a luxury that is not strictly necessary," said study author, Dr. Soeren Mattke, a senior Rand Corp. scientist. That matters because policymakers are trying to rein in rising medical costs, the authors said.

Patients usually are briefly sedated for a colonoscopy, and some kinds of sedation require monitoring by specialists. That includes use of propofol, a powerful drug that's injected to cause deep sedation and was implicated in pop star Michael Jackson's death. Anesthesiologist-monitored sedation, with or without propofol, is recommended for high-risk patients, including those who are old or sick or previously had complications with anesthesia.

While propofol sedation is also sometimes given to low-risk colonoscopy patients, the study authors say that's often unnecessary. Drugs usually recommended for these patients typically cause lighter sedation, though most patients don't remember anything about the exams afterward. These drugs can be given by the doctor doing the exam, but the study suggests they're often being given and monitored by anesthesiologists, driving up costs.

For the study, published in the March 20 issue of the Journal of the American Medical Association, researchers analyzed insurance claims data on more than 6 million U.S. adults who had the colon exams or imaging scopes of the upper digestive tract between 2003 and 2009. The tests are done to screen for colon cancer, acid reflux and other illnesses.

When the study kicked off, 14 percent of these tests included an anesthesiologist. That climbed to more than 30 percent by 2009. The portion of this extra sedation treatment given to low-risk commercially insured patients remained constant during the study and fell slightly in Medicare fee-for-service patients. But the study authors said far too many low-risk patients are still getting this treatment - more than three-fourths of the commercially insured patients and two-thirds of the Medicare group.

The extra treatment added an average of about $500 to an insured patient's bill in 2009, and $150 to a Medicare bill. In 2009, about 3 million colonoscopies and other digestive scoping tests were done in low-risk patients but included anesthesia services, amounting to $1 billion in potentially unnecessary costs, the study authors estimated.

While some insurance policies exclude coverage for anesthesiologist monitoring for low-risk patients undergoing these exams, insurers sometimes pay for it, Mattke said.

Because of doctor backlash, Aetna, one of the nation's largest health insurers, has indefinitely delayed a policy it tried to implement in 2008 that would have excluded this coverage for low-risk patients, said Dr. James Cross, Aetna's chief of national medical policy and operations.

Reasons for the frequent use of anesthesiologists during these exams vary. Sometimes low-risk patients undergoing colonoscopies and other digestive scoping exams request propofol because they want to be totally unconscious and have heard that it wears off quickly and doesn't cause grogginess, unlike other sedatives, said Dr. John Vargo, a spokesman for the American Society for Gastrointestinal Endoscopy and a digestive specialist at the Cleveland Clinic.

Propofol requires careful monitoring because it has "a narrow window between providing deep sedation and making people stop breathing," and unlike other sedatives, there's no rescue drug to reverse its effects, said Dr. Norm Cohen, vice president for professional affairs at the American Society of Anesthesiologists.

The rising use of anesthesiologists may partly reflect more obese patients and users of Vicodin and other opiate-based prescription drugs, Cohen said. Both may be missed under coding used in the study, but they should be considered at risk because sleep apnea that often accompanies obesity makes sedation trickier, and users of opiate painkillers often require higher than usual doses of sedation, he said.

Vargo said doctors who do the exams can be trained to use propofol in healthy patients, but a journal editorial said some prefer anesthesiologist assistance because it allows them to focus on the colon exam, and if something goes wrong with the sedation, they may not be held legally accountable.

A recent study found the tests actually do what they're supposed to do, HealthPop reported. It found people who underwent a colonoscopy were 53 percent less likely to die from colon cancer, compared with people who didn't get the procedure.

"Sure, it's a pain in the neck. People complain to me all the time, 'It's horrible. It's terrible,'" the study's author Dr. Sidney Winawer, a gastroenterologist at Memorial Sloan-Kettering Cancer Center in New York, said at the time. "But look at the alternative."

http://www.cbsnews.com/8301-504763_162-57401162-10391704/colonoscopies-often-come-with-costly-unnecessary-sedation/

Justices Reject Patents for Medical Tests Relying on Drug Dosages - NYTimes.com

The Supreme Court unanimously ruled on Tuesday that medical tests that rely on correlations between drug dosages and treatment are not eligible for patent protection.

Writing for the court, Justice Stephen G. Breyer said natural laws may not be patented standing alone or in connection with processes that involve "well-understood, routine, conventional activity."

The natural law in question was the relationship between thiopurines, which are drugs used to treat gastrointestinal disorders, and metabolites in patients' blood. Relying on its research into that relationship, Prometheus Laboratories patented a method to help doctors find the dose that is large enough to work and small enough to cause no needless harm.

After a unit of the Mayo Clinic developed its own test using slightly different correlations, Prometheus sued for infringement of its two patents for its method. Mayo responded that Prometheus was seeking to protect an abstract idea based on natural phenomena that was not eligible to be patented.

In a statement, Prometheus said Tuesday's decision against it "will, in our view, encourage imitation, not innovation."

"Without the availability of patent protection," the statement went on, "future health care will suffer as companies may opt out of new research and development."  

A lawyer for Mayo, James A. Rogers III, said the decision "is going to be a benefit for patient care, spur innovation in the field and allow access to good quality diagnostic tests."

In his opinion for the court in the case, Mayo Collaborative Services v. Prometheus Laboratories, No. 10-1150, Justice Breyer started with first principles.

"Einstein could not patent his celebrated law that E = mc2; nor could Newton have patented the law of gravity," he wrote.

The basis for Prometheus's invention, Justice Breyer said, was also a law of nature — "namely, relationships between concentrations of certain metabolites in the blood and the likelihood that a dosage of a thiopurine drug will prove ineffective or cause harm."

The question for the court was whether the use that Prometheus made of this relationship was eligible for patent protection. In general, Justice Breyer wrote, an inventor must do more than "recite a law of nature and then add the instruction 'apply the law.' "

"Einstein, we assume, could not have patented his famous law by claiming a process consisting of simply telling linear accelerator operators to refer to the law to determine how much energy an amount of mass has produced (or vice versa)," he wrote.

Justice Breyer said Prometheus had done essentially the same thing. The company's instructions, he wrote, "simply tell doctors to gather data from which they may draw an inference in light of the correlations."

In holding Prometheus's process ineligible for patent protection, the court struck a balance, Justice Breyer wrote.

"On the one hand, the promise of exclusive rights provides monetary incentives that lead to creation, invention and discovery," he wrote. "On the other hand, that very exclusivity can impede the flow of information that might permit, indeed spur, invention."

Justice Breyer rejected a proposed middle ground that had been offered by the federal government. It had urged the court to rule that the Prometheus method was eligible to be patented as an initial matter but could then probably be challenged as invalid because it was obvious and insufficiently novel.

Justice Breyer said that approach would make "a dead letter" of the exception to patent eligibility for laws of nature.

Just before the argument in the case in December, Prometheus told the court that it had been bought by Nestlé in July. Justice Breyer's wife owned stock in Nestlé, and that would have required his disqualification.

She sold the stock on the morning of the argument, allowing Justice Breyer to sit and to write the court's opinion in the case.

http://www.nytimes.com/2012/03/21/business/justices-reject-patents-for-medical-tests-relying-on-drug-dosages.html?hpw=&pagewanted=print

Generic Drugs Prove Resistant to Damage Claims - NYTimes.com

Debbie Schork, a deli worker at a supermarket in Indiana, had to have her hand amputated after an emergency room nurse injected her with an anti-nausea drug, causing gangrene. She sued the manufacturer named in the hospital's records for failing to warn about the risks of injecting it. Her case was quietly thrown out of court last fall.

That result stands in sharp contrast to the highly publicized case of Diana Levine, a professional musician from Vermont. Her hand and forearm were amputated because of gangrene after a physician assistant at a health clinic injected her with the same drug. She sued the drug maker, Wyeth, and won $6.8 million.

The financial outcomes were radically different for one reason: Ms. Schork had received the generic version of the drug, known as promethazine, while Ms. Levine had been given the brand name, Phenergan.

"Explain the difference between the generic and the real one — it's just a different company making the same thing," Ms. Schork said.

Across the country, dozens of lawsuits against generic pharmaceutical companies are being dismissed because of a Supreme Court decision last year that said the companies did not have control over what their labels said and therefore could not be sued for failing to alert patients about the risks of taking their drugs.

Now, what once seemed like a trivial detail — whether to take a generic or brand-name drug — has become the deciding factor in whether a patient can seek legal recourse from a drug company. The cases range from that of Ms. Schork, who wasn't told which type of drug she had been given when she visited the hospital, to people like Camille Baruch, who developed a gastrointestinal disease after taking a generic form of the drug Accutane, as required by her health care plan.

"Your pharmacists aren't telling you, hey, when we fill this with your generic, you are giving up all of your legal remedies," said Michael Johnson, a lawyer who represented Gladys Mensing, one of the patients who sued generic drug companies in last year's Supreme Court case, Pliva v. Mensing. "You have a disparate impact between one class of people and another."

The Supreme Court ruling affects potentially millions of people: nearly 80 percent of prescriptions in the United States are filled by a generic, and most states permit pharmacists to dispense a generic in place of a brand name. More than 40 judges have dismissed cases against generic manufacturers since the Supreme Court ruled last June, including some who dismissed dozens of cases consolidated under one judge.

Public Citizen, a consumer advocacy group, has petitioned the Food and Drug Administration to give generic companies greater control over their labels, a rule change that could allow users of generic drugs to sue, but the agency said earlier this month that it needed more time to decide. "Congress can make this problem go away, and the F.D.A. could, too," said Allison Zieve, the director of Public Citizen Litigation Group. "But we haven't seen signs that either of them is paying much attention." A spokeswoman for the F.D.A. declined to comment.

The Supreme Court's ruling, which was split 5 to 4 on ideological lines, has its roots in the Hatch-Waxman Act, the 1984 law that opened the floodgates to generic drugs. That law allowed companies to skip the lengthy process required to approve new drugs if they could prove that the generic drug was equivalent to its brand-name counterpart.

With few exceptions, it also required generic manufacturers to use the same labels — the lengthy list of a drug's uses, dosages and risks — used by the brand names.

If a problem develops, the brand-name companies are responsible for changing the label, and the generic companies must follow their lead. As a result, the court's majority ruled, generic companies cannot be held responsible for failing to alert patients to problems with their drug. The dissent, which was written by Justice Sonia Sotomayor, argued that generic companies nevertheless have a responsibility to report problems to the F.D.A. and should be held liable for failing to warn patients.

The ruling came just two years after the Supreme Court established — in Ms. Levine's case — that, by contrast, brand-name companies can be sued for failing to adequately warn patients.

Ms. Levine was given an injection of Phenergan in 2000 during a visit to a clinic to treat a migraine headache. Her hand and forearm turned black and eventually had to be amputated. Reports had shown that the drug can cause gangrene if it enters an artery, especially if it is placed directly into the vein rather than injected into the muscle or through a diluted intravenous drip. Although the label warned that gangrene could occur if the drug came into contact with arterial blood, Levine argued that the warning did not go far enough.

She sued Wyeth and a Vermont jury awarded her $6.8 million. Wyeth appealed and the Supreme Court sided with Ms. Levine, agreeing that the company could be held liable for failing to adequately warn about the risks of a drug.

Ms. Schork, 52, was given the generic version of Phenergan when she visited the hospital in 2007 with a stomachache and nausea related to her diagnosis of Crohn's disease.

When a nurse injected the drug into her arm, it entered her artery, and Ms. Schork's right hand developed gangrene. In asking that the case be dismissed, lawyers for Baxter Healthcare Corporation, which then was one of several companies that made the drug but has since sold its injectable generics to another company, argued that Ms. Schork could not conclusively prove that Baxter had made the drug she took.

The judge agreed that the question could be debated at trial but said it was irrelevant because of the Supreme Court's ruling.

Ms. Schork filed a malpractice claim against the hospital with the Indiana Department of Insurance, and received what her lawyer described as a limited award; the amount was confidential. She said she could not continue to work at her supermarket job and is now unemployed.

Soon after Ms. Levine won her case, Ms. Schork wrote to congratulate her and to share her own story. At the bottom of the letter, Ms. Levine recalled, Ms. Schork apologized for her handwriting because she was writing with her left hand. "The fact that it had happened to her and she had this same struggle — and then to hear now that it's getting dismissed — is just beyond me," said Ms. Levine.

Ms. Schork said she and Ms. Levine later spoke on the telephone. "I'm glad for her," she said, "but it didn't help me any."

Lawyers for generic drug companies say their clients are able to provide low-cost drugs because their primary task is replicating drugs. If the companies were expected to take responsibility for updating their labels, "we would effectively start to turn generic companies into brand companies, and of course the tremendous cost savings that American consumers have benefitted from would start to wane," said Jay Lefkowitz, who served as the lead attorney representing generic companies before the Supreme Court.

The Supreme Court recognized that its decision must make "little sense" to plaintiffs who sue generic drug companies. However, Justice Clarence Thomas wrote for the court, "Congress and the F.D.A. retain the authority to change the law and regulations if they so desire."

Some attorneys who follow the issue have speculated that Congress and the F.D.A. are reluctant to deal a blow to generic companies, which are responsible for providing cheap drugs to millions of American consumers, especially in an election year when health care is a hot issue.

In a statement last week, Representative Henry A. Waxman, Democrat of California, who co-wrote the Hatch-Waxman Act, said he was exploring ways to address the issue, either through legislation or a rule change.

Mr. Waxman argued in a brief opposing the generic companies in the Supreme Court case last year that Congress had never intended for generic companies to be freed of all responsibility. "Congress did not intend for consumers' rights to be categorically eliminated simply because they purchased a generic rather than a brand-name drug," he wrote.

Camille Baruch, 18, and her family say that is precisely what happened to her. When she was 12, Camille, of Rockville, Md., began taking the generic version of the antiacne drug Accutane and developed severe gastrointestinal pain several months later. Her diagnosis was ulcerative colitis, a type of inflammatory bowel disease, and she had to have her large intestine removed.

Six years and eight operations later, doctors have not been able to stabilize her condition. Her parents said the disease transformed their daughter from a talented basketball and softball athlete to someone who will struggle with debilitating physical challenges for the rest of her life.

Thousands of patients have sued Roche, the maker of Accutane, claiming that it caused their inflammatory bowel disease, and several have won multimillion-dollar verdicts against the company. In 2009, citing litigation costs and competition from generics, Roche removed Accutane from the market. In 2010, Camille sued the makers of the three generic versions of Accutane she took. Her lawyer, Tayjes Shah, said lawyers for the companies have told him they intend to ask for a dismissal. "I have very little optimism," Mr. Shah said.

Camille, who was in the hospital this month recovering from another operation, said she had heard the arguments that the generic companies had made. "It makes me almost want to cry every time that I think that I took something that is nearly identical" to Accutane, yet she cannot sue, she said. "I lost everything. That is not a reason enough that these people aren't to blame."

http://www.nytimes.com/2012/03/21/business/drug-lawsuits-hinge-on-the-detail-of-a-label.html?_r=1&pagewanted=print

Dr. Cheeseburger will see you now - National Post

Early in my career, I was a junior doctor at a clinic where one of the senior doctors would go on smoke breaks with his patients. He had the look of a lifelong smoker - lots of wrinkles, hoarse voice and yellowed fingers. I would leave the building where we both worked and there he'd be, a little distance from the door, mid-smoke. At the time, I was still working out my own take on the responsibilities doctors have to act like role models for their patients. The sight of a senior physician engaging in health-harmful behaviour, and with a patient, no less, provoked all sorts of questions for me.

Should doctors smoke with their patients? More to the point, what responsibilities does a doctor have to act as a role model? To what extent does a physician's personal behaviour affect the care that physician provides? Such questions sprang to mind again when I saw the study published earlier this year in Obesity by researchers at the Johns Hopkins Bloomberg School of Public Health. The study authors claimed it was the first to examine whether a physician's weight affected the doc's care of obese patients.

As the study noted, remarkable parallels exist between academic studies conducted years ago on smoking physicians, and more contemporary work on obese physicians. Older studies on smoking physicians suggest that a doctor's personal behaviour does affect the medical care that doctor provides. For example, studies suggest that MDs who smoked were less likely to raise smoking as a health issue with their patients. They were also less likely to encourage patients to quit smoking, and less likely to make stopping smoking a high priority for patients.

Such findings bring to mind a British Medical Journal editorial from 1995, which wondered whether medical students who smoked should be channelled away from working as general practitioners. "An apocryphal tale in public health, said to have originated from a candid tobacco industry executive, is that each doctor who smokes is worth hundreds of thousands of dollars to the [tobacco] industry," went an opening line in the editorial by Simon Chapman, then an associate professor at the University of Sydney.

If overeating is today's equivalent to smoking as an epidemic behaviour that poses severe and underacknowledged health risks, then should we be asking whether overweight medical students should also be channelled away from primary care?

A physician's weight is an attribute that is both a part of an MD's appearance, and a suggestion of his or her behaviour. The issue of doctor appearance is something that's been studied a lot by academia. For example, numerous studies suggest that a work uniform of a white lab coat and formal attire "may favourably influence trust and confidence-building in the medical encounter." At the clinic where I manage the medical team, we encourage our doctors to dress professionally with lab coats - and I tend to wear a tie and white lab coat when meeting with patients.

However, we don't have any guidelines concerning the weight of our physicians. Which brings us back to that study from the Johns Hopkins Bloomberg School of Public Health. A U.S.-wide survey of the behaviour of 500 primarycare physicians revealed tendencies that were similar to the older smoking studies. Obese doctors were less likely to diagnose for obesity, for example, and heavier doctors also were less likely to bring up obesity as a health issue for their patients. Meanwhile, normal-weighted physicians were a lot more likely to believe that MDs had a responsibility to act as role models for patients by maintaining a healthy weight and exercising regularly.

Nevertheless, I agree with the study authors when they counsel against "isolating heavier physicians for intervention" because it "may increase obesity stigma." As a profession we all have a duty to combat obesity - regardless of our weight, or any other attributes. To really combat the growing health problem of obesity, we should train all doctors on the risks, regardless of their own weights, and encourage doctors to engage in regular exercise and healthy eating habits. At my own clinic, employees are offered fitness boot camps and discounts for personal training appointments. They also receive newsletters on healthy nutrition. Among our physicians are serious runners and cyclists, and many recreational athletes who work out regularly at the gym.

So, should a patient avoid overweight doctors, doctors who smoke, or any medical professionals who engage in health-harmful behaviour? Not necessarily. People seeking a primary care practitioner who is a perfect role model for healthy behaviour would find themselves selecting from a very short list. Medical professionals are as flawed as anyone else. The doctor-patient relationship must include rapport and trust. While many of us may prefer our physicians to be trim and professionally dressed, others may prefer a doctor who is as flawed and as human as they are. The bottom line? The MD should always encourage healthy behaviour regardless of personal biases - but action speaks louder than words.

Dr. James Aw is the medical director of the Medcan Clinic, a leading private health clinic in Toronto. 

http://www.financialpost.com/todays-paper/Cheeseburger+will/6327761/story.html

Doctor and Patient: Getting Doctors to Think About Costs - NYTimes.com

My first formal lesson on health care costs occurred one afternoon on the wards when I was a medical student. The senior doctor in charge, a silver-haired specialist known for his thoughtful approach to patient care, had assembled several students and doctors-in-training to discuss a theoretical patient with belly pain. After describing the patient's history and physical exam, he asked what tests we might order.

One doctor-in-training proposed blood work. A fellow student suggested a urine test. Another classmate asked for abdominal X-rays.

My hand shot up. "A CAT scan," I crowed with confidence. "I'd get a CAT scan!"

There was complete silence. Everyone turned to stare at me.

The senior doctor coughed. "That's an awfully expensive test," he said, a grimace appearing on his face. Another student asked him just how much a CT scan cost, and he shifted uncomfortably in his seat and shrugged. "I don't really know," he said, "but I do know that we can't just think about the patient anymore." He took a deep breath before continuing, "We are now being forced to consider costs."

That was 20 years ago, when the managed care movement was first in the headlines. Today his lesson still rings true, as doctors continue to struggle to reconcile cost consciousness with quality care. And doctors-to-be are not getting much help in learning how to do so.

But one nonprofit organization, Costs of Care, and the young doctor who created it are determined to change that.

Over the last two years, Dr. Neel Shah, a senior resident in obstetrics and gynecology at Brigham and Women's Hospital in Boston, has been collaborating with medical educators and health care economists at Harvard Medical School and at the Pritzker School of Medicine at the University of Chicago to create a series of videos and educational materials designed to help medical students and doctors-in-training learn to make clinical decisions that optimize both quality of care and cost. With support from the American Board of Internal Medicine, these educational modules, called the Teaching Value Project, could represent a significant breakthrough in how medical students learn to be conscious of costs.

The patchwork of payment patterns that mark the American medical system makes it particularly difficult to teach young doctors. Net costs for treatments and medications vary depending on region, payer and even specific hospitals, so medical students and trainees often end up learning what is relevant only to their particular workplace. They might learn to prescribe a certain drug for diabetes because it is cheaper in their hospital formulary, only to discover later that the reverse is true in a different hospital or after policies have changed.

"When learning is haphazard like this, it's hard for young doctors to see the entire picture," said Dr. Vineet Arora, an assistant dean at Pritzker who is working on the Teaching Value Project.

Cost variations aside, it can also be a challenge simply to get hold of precise costs for patients. Dr. Shah recalls one woman who refused to get a potentially lifesaving ultrasound until she knew how much it would cost her. Her doctors and nurses "sweated out every minute," concerned she would collapse at any moment, said Dr. Shah, before finally hunting down a figure later that afternoon, and the patient consented to paying the $600 cost.

The Teaching Value Project uses a rough pricing hierarchy rather than exact dollar figures to gauge costs, similar to the approach at well-known restaurant or travel search sites, which helps young doctors avoid getting mired in price variations and hairsplitting details. When combined with the project's lessons on common cost errors that doctors make, the pricing hierarchy can bring clarity to clinical decisions.

For example, a young doctor might plan on ordering an ultrasound of the heart, or an echocardiogram, for an otherwise stable patient in the hospital because the wait for inpatients is shorter. But if that doctor also knows that echocardiograms are much less expensive when administered to outpatients, he or she might instead decide to wait and order it after discharge.

Similarly, a team of trainees might believe they are being cost-conscious by debating whether to get a battery of moderately expensive tests for a patient in the intensive care unit. But then they might learn that the time they are devoting to the debate is actually costing more than the tests themselves because of the expense of keeping the patient in an I.C.U. bed even a few extra hours.

"Zagat has figured it out," Dr. Shah said. "Knowing whether it's one, two or three dollar signs can be enough to influence behavior."

The group recently posted an introductory video, a tongue-in-cheek look at what hotels would be like if they were run like hospitals. At the "Hotel Hôpital," prices are never listed; concierges order expensive cabs pre-emptively, or "prophylactically," even if you don't need one; and no one working in the back office can decipher your surprise $20,000 hotel bill.

The group expects to complete its first full Teaching Value module this summer, with more planned over the next few years. It also hopes to collaborate with professional medical organizations to help raise cost consciousness among more established practicing physicians.

All involved are quick to acknowledge that as appealing as the approach may be, the Teaching Value Project represents only a beginning for medical students and trainees. "Our goal isn't for them to master the entire topic before graduating," Dr. Arora said. "It's to get them thinking about how to integrate cost consciousness into practice."

Dr. Shah added: "At the end of the day, what we are talking about is spending our patients' money in a way that is both ethical and pragmatic. To do that, we will all need to create a culture where it becomes awkward not to think about cost."

http://well.blogs.nytimes.com/2012/03/15/getting-doctors-to-think-about-costs/?pagemode=print

Hospitals Aren’t Hotels - NYTimes.com

You should never do this procedure without pain medicine," the senior surgeon told a resident. "This is one of the most painful things we do."

She wasn't scolding, just firm, and she was telling the truth. The patient needed pleurodesis, a treatment that involves abrading the lining of the lungs in an attempt to stop fluid from collecting there. A tube inserted between the two layers of protective lung tissue drains the liquid, and then an irritant is slowly injected back into the tube. The tissue becomes inflamed and sticks together, the idea being that fluid cannot accumulate where there's no space.

I have watched patients go through pleurodesis, and even with pain medication, they suffer. We injure them in this controlled, short-term way to prevent long-term recurrence of a much more serious problem: fluid around the lungs makes it very hard to breathe.

A lot of what we do in medicine, and especially in modern hospital care, adheres to this same formulation. We hurt people because it's the only way we know to make them better. This is the nature of our work, which is why the growing focus on measuring "patient satisfaction" as a way to judge the quality of a hospital's care is worrisomely off the mark.

For several years now, hospitals around the country have been independently collecting data in different categories of patient satisfaction. More recently, the Centers for Medicare and Medicaid Services developed the Hospital Consumer Assessment of Healthcare Providers and Systems survey and announced that by October 2012, Medicare reimbursements and bonuses were going to be linked in part to scores on the survey.

The survey evaluates behaviors that are integral to quality care: How good was the communication in the hospital? Were patients educated about all new medications? On discharge, were the instructions the patient received clear?

These are important questions. But implied in the proposal is a troubling misapprehension of how unpleasant a lot of actual health care is. The survey measures the "patient experience of care" to generate information important to "consumers." Put colloquially, it evaluates hospital patients' level of satisfaction.

The problem with this metric is that a lot of hospital care is, like pleurodesis, invasive, painful and even dehumanizing. Surgery leaves incisional pain as well as internal hurts from the removal of a gallbladder or tumor, or the repair of a broken bone. Chemotherapy weakens the immune system. We might like to say it shouldn't be, but physical pain, and its concomitant emotional suffering, tend to be inseparable from standard care.

What's more, recent research suggests that judging care in terms of desirable customer experiences could be expensive and may even be dangerous. A new paper by Joshua Fenton, an assistant professor at the University of California, Davis, and colleagues found that higher satisfaction scores correlated with greater use of hospital services (driving up costs), but also with increased mortality.

The paper examined patient satisfaction only with physicians, rather than hospitals, and the link between satisfaction and death is obviously uncertain. Still, the results suggest that focusing on what patients want — a certain test, a specific drug — may mean they get less of what they actually need.

In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can't, at the expense of what it should.

To evaluate the patient experience in a way that can be meaningfully translated to the public, we need to ask deeper questions, about whether our procedures accomplished what they were supposed to and whether patients did get better despite the suffering imposed by our care.

We also need to honestly assess our treatment of patients for whom curative care is no longer an option.

I had such a patient. He was an octogenarian, but spry, and he looked astoundingly healthy. He'd been sent to us with a newly diagnosed blood cancer, along with a promise from the referring hospital that we could make him well.

But we couldn't. He was too old to tolerate the standard chemotherapy, the medical fellow on duty told him. When I came into his room a little later he said to me, with a stunned and yearning look, "Well, he made it sound like I don't have a lot of options." The depth of alienation, hopelessness and terror that he was feeling must have been unbearable.

The final questions on the survey ask patients to rate the hospital on a scale from worst to best, and whether they would recommend the hospital to family and friends. How would my octogenarian patient have answered? A physician in our hospital had just told him that he would die sooner than expected. Did that make us the best hospital he'd ever been in, or the worst?

Hospitals are not hotels, and although hospital patients may in some ways be informed consumers, they're predominantly sick, needy people, depending on us, the nurses and doctors, to get them through a very tough physical time. They do not come to us for vacation, but because they need the specialized, often painful help that only we can provide. Sadly, sometimes we cannot give them the kind of help they need.

If the Centers for Medicare and Medicaid is to evaluate the patient experience and link the results to reimbursement, it needs to incorporate questions that address the complete and expected hospital experience. It's fair and even valuable to compare hospitals on the basis of how well they maintain standards of patient engagement. But a survey focused on "satisfaction" elides the true nature of the work that hospitals do. In order to heal, we must first hurt.

Theresa Brown, an oncology nurse, is a contributor to The New York Times's Well blog and the author of "Critical Care: A New Nurse Faces Death, Life and Everything in Between."

http://www.nytimes.com/2012/03/15/opinion/hospitals-must-first-hurt-to-heal.html?_r=1&nl=todaysheadlines&emc=edit_th_20120315&pagewanted=print