While there may be more thoroughly-investigated and references books on the topic of understanding health statistics, I find this one the most accessible. At a very light 130 pages (lots of tables, pictures and charts) it’s an extremely quick read and gets to the heart of the matter. That heart is “Don’t get flummoxed by misleading health ads.”

The very patiently and cogently explains the difference between absolute risk (Zocor reduces the chance of death from heart attack by 42%) and relative risk (Zocor reduces the chance of death from heart attack from 8.5% to 5%).
Of course, this could be applied to well-meaning public service announcements meant to scare us into action as well.

The authors have been taking the lead to get the US FDA to require a “Drug Facts Box” for all direct-to-consumer print advertising. Such a box would not just include the most favorable way of describing clinical results (see above) it would also require the maker to list the common side effects and their likelihood as well. It would be a big step in the right direction. To get background on their work, take a look these two reports:

• The drug facts box: providing consumers with simple tabular data on drug benefit and harm. Med Decis Making. 2007 Sep-Oct;27(5):655-62.
• Using a drug facts box to communicate drug benefits and harms: two randomized trials. Ann Intern Med. 2009 Apr 21;150(8):516-27.

Highly recommended due to it’s ‘punch per page.’
(2/10)

On Sunday 2/7, I attended a forum at Temple Beth Am (Seattle’s  Ravenna neighborhood) organized by the Healthy Washington Coalition. The forum featured Rep. Jim McDermott (D), who represents my district in congress. He was there to provide an update on the state of the national legislation and answer broader questions on health reform. Also at the forum was David Hanig who is a Senior Health Care Policy Analyst for the WA
State Senate Democratic Caucus.

The crux of the message Rep. McDermott brought with him was that he’s convinced there will be a bill this session just because there are the votes to get something done and to come away completely empty-handed would be too big a mistake to make. He also recounted the story of the ‘winner’ of the healthcare battle in the ‘90’s, Newt Gingrich. He paraphrased Newt in saying that the Republicans had to oppose the health care bill because to fail to do so would be to hand over the legislative branch to the Dems for another 40 years (like what happened after social security was passed in the 30’s). While no one wants to slap the ‘obstructionist’ label on every Republican. It is notable that they have put forth no comprehensive plans (yes, they have ideas around the margins, but no plan that strikes at the fundamental issues of universal coverage, perverse incentives and control of costs). So it looks like it’s the same tack all over again: make sure nothing gets done so the Dems can’t take credit for taking on any big challenges.

You don’t really ‘win’ in politics by just making sure the other guy can’t do the right thing for the country, can you? Of course you can, who am I kidding?

Waiting with great anticipation to see if any Republicans will show up at the televised healthcare debate.

While all the particulars may not yet be clear to us, what is clear is that Haiti needs our help. There are many organizations helping to ease the suffering there. Here are just a few of the places where you can help:

There are numerous ways to help groups already on the ground in Haiti. One of the best, Partners In Health, founded by Dr. Paul Farmer and several others, has been operating in the country since 1987. PIH operates clinics in Port au Prince and other major Haitian cities. With hospitals and a highly trained medical staff in place, Partners In Health is already bringing medical assistance and supplies to areas that have been hardest hit. Donations to PIH to help earthquake relief efforts will be quickly routed to the disaster.

You can donate online to the Partners in Health effort via this link:
http://www.pih.org/home.html

or send your contribution to:
Partners In Health,
P.O. Box 845578
Boston, MA 02284-5578

Mercy Corps

https://donate.mercycorps.org/donation.htm?DonorIntent=Haiti+Earthquake

There’s a relief fund called Yele Haiti http://www.yele.org which puts 100% of its donations toward disaster relief in Haiti. (The Yele organization was founded in 2005 by musician and Haitian native Wyclef Jean.)

You can make a fast donation of $5 via your cell phone by texting the word "Yele" to 501-501. The donation will show up on your cell phone bill. (You will receive a text back from them asking you to confirm the charge by texting back "YES.")
Or, if you’d like to donate more than $5, use this link to make a secure donation by credit card for any amount:
https://co.clickandpledge.com/advanced/default.aspx?wid=23093

There is also a well-endowed list of organizations that are providing direct relief to Haiti on the University of Washington web site:

http://www.washington.edu/provost/globalaffairs/helphaiti.html

From barackobama.com

http://my.barackobama.com/Haiti

Please join the Healthy Washington Coalition for a meeting
on Federal Health Care Reform and its likely impact on
Washington State featuring:

• Congressman Jim McDermott
• State Senator Karen Keiser: Chair of the Senate Health & Human Services Committee
• State Representative Eileen Cody: Chair House Health Care & Wellness Committee

This event will be an opportunity to catch up on the latest in the
Federal Health Care Reform negotiations from those closest to the
debate.

Sunday, January 17 2:00—4:00 pm

5030 1st Ave S
Seattle, WA

United Food and Commercial Workers International Union Offices

For more information, contact:
Rachel Berkson: rberkson@seiuwa.org

He’s now trained his sights on a very specific, and uncommon issue: that of the use of checklists during surgical procedures.

The Checklist Manifesto: How to Get Things Right

Seems like an odd thing for a surgeon of international renown to spend his time on: the lowly checklist. But the results speak for themselves. In a controlled trial involving eight hospitals all around the globe (from rural Tanzania, to Amman, Jordan to Seattle, Washington) they observed double-digit reductions in major surgical complications and in deaths. He correctly notes that if there were a pharmaceutical drug or medical device that could produce these results, every newspaper around the world would be blaring the headlines. But, in this case, there’s no big payday – only improved outcomes for patients.

As it happens, Seattle was one of the first stops in the obligatory book tour that ensues, so I got a chance to meet and speak with him. In his talks, he provides some greater context to the work in the book. For example, the impetus for exploring the approach of using checklists during surgery (his study focuses exclusively on surgery) was engendered by the success of checklists in aviation. It may come as a surprise that there are checklists for pilots even in emergency cases like the plane landing on the Hudson last year.

Truth be told, the pioneer of using checklists in medical procedures is Dr. Peter Pronovost of Johns Hopkins. By creating a brief (must take no longer than 90 sec), simple checklist of the most crucial items needed to ensure central line catheters are applied safely, his checklist resulted in Johns Hopkins eliminating (as in reducing to –0-) infections for these procedures. He went on to do a pilot for all the hospitals in Michigan which led to those hospitals becoming the exemplar for patient safety for central line catheterization. But he doesn’t write for the New Yorker. Nor did he take on the massive effort of organizing a controlled study in hospitals all over the globe (that’s massive) and organize the team to produce the results of those efforts.

One additional thing to note about these checklists (in addition to their brevity) is that they need to be very carefully crafted to ensure that only the most critical items that are likely to be missed/overlooked are covered. It’s common to think of a checklist as being exhaustive, detailed and cumbersome. Obviously, that wouldn’t work in this context. Further, as you can’t set foot in the OR unless you know what you’re doing, the checklist is not a READ-DO checklist (like a recipe), but a DO-CONFIRM checklist where you’re pausing before each critical juncture to confirm that everyone is on the same page and has completed all the crucial activities for the safety of the patient and the increased success of the surgery.

One final insight that occurs to me is that this idea could have legs with patients. This is because once this issue becomes common knowledge, it could be one of those things that patients begin demanding of their providers. It’s something any patient can easily grok (Do you have a checklist, or don’t you?) without having to know anything about the intricacies of care.

Here are a couple of media links you might find interesting as well:

Doctor Saved Michigan $100 Million (Pronovost)http://www.npr.org/templates/story/story.php?storyId=17060374

Atul Gawande on Charlie Rose
http://www.charlierose.com/view/interview/10792

University of California Television (uctv.tv) has an entire video series on the topic: Vitamin D Deficiency: Treatment and Diagnosis. You may watch it streamed directly from the site, or download the individual audio or video files for playback locally. I find that even though there are often presentations that go along with the talk, the audio by itself is quite useful in most cases.

There are two talks that bear particular note:

Vitamin D Prevents Cancer: Is It True?
First Aired: 09/28/2009
In a new study, researchers at the UCSD School of Medicine and Moores Cancer Center used a complex computer prediction model to determine that intake of vitamin D3 and calcium would prevent 58,000 new cases of breast cancer and 49,000 new cases of colorectal cancer annually in the US and Canada. The researchers’ model also predicted that 75% of deaths from these cancers could be prevented with adequate intake of vitamin D3 and calcium. Join Carole Baggerly with GrassrootsHealth as she discusses this new research.

D-Lightful Vitamin D: Bone and Muscle Health and Prevention of Autoimmune and Chronic Diseases
First Aired: 03/11/2009
Can vitamin D help prevent certain cancers and other diseases such as type 1 diabetes, cardiovascular disease, and certain autoimmune and chronic diseases? To answer these questions and more, UCSD School of Medicine and GrassrootsHealth bring you this innovative series on vitamin D deficiency. Join nationally recognized experts as they discuss the latest research and its implications. In this program, Michael Holick, MD, discusses vitamin D relating to bone and muscle health and the prevention of autoimmune and chronic diseases.

There are also a raft of resources at the GrassrootsHealth site.

One picture says many, many volumes on this topic. It’s entitled Disease Incidence Prevention by Serum 25(OH)D Level. The story it tells is that there are clinically-verified correlations between the incidence of specific conditions and levels of circulating Vitamin D. Based on this large (and growing) body of evidence, it is reasonable to infer that by increasing our serum Vitamin D levels into the optimal range of between 40 and 60 ng/ml, the following conditions could be reduced at the indicated rates:

• Breast Cancer: down by 83%
• Ovarian Cancer: down by 17%
• Colon Cancer: down by 60%
• Non-Hodgkins Lymphoma: down by 18%
• Type-1 Diabetes: down by 66%
• Fractures (all combined): down by 50%
• Falls (women): down by 72%
• Multiple Sclerosis: down by 54%
• Heart Attack (men): down by 30%
• Kidney Cancer: down by 49%
• Endometrial Cancer: down by 37%

This topic is especially relevant to me and my family. As an African-American who lived his entire life above the 38th parallel (Chicago, Minneapolis, Washington, DC and Seattle, to be precise), the absence of adequate sun exposure during most months of the year had a profound effect on my health (primarily in the very early onset of severe periodontal disorders, seasonal allergies, lower bone density). This is a message that literally needs to be trumpeted from the rooftops for everyone – especially anyone who skin has a lot of melanin (like mine).

The optimal range (40-60 ng/ml) must be put into context: In A recent NHANES study (2001-2004), only 3% of black folks were in the ‘sufficiency’ range of >30 ng/ml. That is not a typo: three percent – and remember, the optimal range begins at 40 nl/ml. Of even greater concern is that prevalence of deficiency (<10 ng/ml) is at 29%.

This is the real pandemic.

The kicker here is that vitamin D is about the least expensive dietary supplement available. At about $.05 (that’s FIVE CENTS) a day, most of us can, over time, get our levels in the optimal range.

So, what is a person to do? Obviously, I am not your physician, so I cannot give you medical advice. However, I have it on extremely good authority that it is safe practically everyone to take 1,000 IU (international units) of oral vitamin D daily (you want the D3 form, not the D2 form). If you do not know your vitamin D levels, make a beeline to your doctor’s office to get tested. Please do not simply accept the ‘normal/not normal’ pronouncement from your doctor. Obtain the actual test results and read it for yourself to determine your levels. Ideally, you will want to test at least twice a year (once at the end of the winter, and again at the end of summer) to make sure you’re staying in range. Just so your expectations are appropriately set, it took me about two years to get my levels stabilized in the optimal range.

Please, please, PLEASE, do what you can to raise awareness of this inexpensive and powerful way to improve our health.

p.s. I have been alerted by one of my readers – who is also a physician – that I should take care to warn people who have kidney problems (renal disease, renal failure) or elevated creatinine levels (which is an indicator of diminished kidney function)that they should always check with their physician before taking any dietary supplements.

I will be attending the meeting of “United for Single Payer” in Seattle on Wednesday 1/6/10. While my health reform manifesto didn’t make it crystal clear, I am a very vocal skeptic of the entire single payer idea. A recent private correspondence pretty well sums it up:

When I speak to supporters of ‘single payer’ approaches, I don’t find their arguments persuasive because they are rarely able to successfully contrast single payer with other options for universal coverage (a la Switzerland, Denmark, etc.). In speaking with many proponents of single-payer, I have yet to get an answer to my crucial question: we’ve seen the firepower the for-profit insurers pulled out against proposals that were not direct, existential threats to them. How would any practical approach for single payer be able to survive the political and economic onslaught that would inevitably ensue?

Seems to me the best approach is to focus on goals that are (mostly) shared: universal coverage, radically greater transparency (on several dimensions), much more tightly regulated medical insurance, a sensible ‘floor’ of medical coverage, etc. Only then can the appropriate pressure be placed against for-profit insurers to meet the new bar. That’s the way to equitable universal coverage – long-term strategic approach.

My other problem with ’single-payer’ is more ethereal and probably less defensible. I just have an aversion to mono-culture. That’s not the way nature works – and it seems to me that we need an approach that is not just functional for now, but also sustainable and adaptable over the long term. A diversity of approaches is needed in order to achieve that end. I just have a gut reaction to the idea that a single approach to funding the entire system would give us that adaptability. We will still need to innovate as time moves forward.

That said, I’ll be going to the meeting tomorrow to learn and be open to new ideas. Stay tuned, if you will.

That’s about to change. In addition to having done my homework on the areas of nutrition, supplements, exercise and longevity, I have also spent a fair amount of time learning about how health care services are provided in the US. It should be no surprise to you that I have formed very clear perspectives on these matters as well.

After considering starting up a separate blog to cover those issues, I have decided to begin covering those issues in this blog – in addition to providing even more info on how to keep yourself healthy. I hope to persuade you that one of the necessary elements for improving the way health care is provided is to have more of us managing our personal health in a way that aligns better with the bodies we’ve been given.

Given the attention this issue has been receiving as of late I expect it will be broadly engaging (although, it is fair to say I’m on the wonk side of things so prepare to wade in the deep water).

So, by way of introduction, here’s my brief manifesto regarding the health care issues of the day:

• We need to change the narrative on healthcare
  • Access to suitable healthcare services should be considered a right in this country – as it now is in every other industrialized country in the world
  • There should be a ‘floor’ below which no one would be allowed to go below and a ‘ceiling’ above which individuals would have to pay for their own services
  • One’s access to these services should not differ based on one’s financial means (you can pay more for the guiding, but the core medical services should be equitable)
  • No person should be rendered financially bankrupt solely due to medical bills
  • All persons should be required to financially participate in the system (with suitable subsidies for those who truly cannot afford to pay in)
• It is imperative that we reform the way for which services are paid
  • universal coverage without respect to pre-existing conditions
  • ending policy rescission practices
  • ensure portability (i.e. remove ‘work lock-in’ and ‘spouse lock-in’)
  • radically alter the business of health insurance that mandates the MEMBERS are the priority, not profit or equity investors (again, like every other industrialized country, by the way)
• It is equally important that we simultaneously revamp way care is delivered
• radically alter payment incentives to focus on outcomes as opposed to solely paying fees for services
• Explicitly emphasize primary care as a means to enable better primary prevention
• Explicitly pay for care coordination services (“medical home” model or the like) to provide higher-quality, more cost-effective secondary prevention (focusing in on the most costly chronic conditions: diabetes, congestive heart failure, coronary artery disease, hypertension, cancer), with the explicit goal to reduce costly hospitalizations that arise from acute events due to poorly-managed chronic conditions

We must create an equitable and sustainable healthcare system in the US (notice I said ‘create’ – since we do not have a health care system today, doesn’t make sense to talk about changing the existing system).

To get a sense of the perspectives I’ve considered in coming to this point of view, here is a very brief list of books I consider most valuable in becoming knowledgeable on these issues:

Healthcare, Guaranteed: A Simple, Secure Solution for America

Health Care Will Not Reform Itself: A User’s Guide to Refocusing and Reforming American Health Care

A Second Opinion: Rescuing America’s Health Care

The Innovator’s Prescription: A Disruptive Solution for Health Care

The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

Chaos and Organization in Health Care

Money-Driven Medicine: The Real Reason Health Care Costs So Much

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer

In the weeks and months to come, I will provide more background on additional books and other resources that will help you become better informed citizen and more empowered consumer of health care.

[Dr. Lustig] explores the damage caused by sugary foods. He argues that fructose (too much) and fiber (not enough) appear to be cornerstones of the obesity epidemic through their effects on insulin

I’m always keen to get complete agreement from another perspective. The major item that makes this talk unique is that he explains the biochemistry in, perhaps to some, excruciating detail, but it’s necessary to make the point.

To watch the original in its entirety, go to the University of California Television site: Sugar: The Bitter Truth. is also available on YouTube in full form, and is available in nine YouTube-sized bites courtesy of our decidedly eccentric (and I say that in the fondest way possible) Dr. Joseph Mercola.

Let’s dig a little deeper, shall we

First off, I’m not convinced that this new set of recommendations in any way could be considered a substantive ‘cost saving’ measure. These primary prevention tests are an infinitesimal portion of the overall healthcare dollar. I don’t think there’s enough crack on the planet which, if smoked, would lead one to conclude this recommendation would bend anybody’s ‘cost curve.’

To the issue of some ‘impersonal commission’ who, pray tell, *should* make these guidelines? The patients themselves? Each individual physician? Surprisingly (at least to me) your reaction to this is very anti-science. Who better to make recommendations than professionals who have actually looked at the data and have made a professional determination based on that data. What’s your alternative?

You seem to forget how women came to expect the annual mammogram at 40 and routine self-exams as the way to go. It was likely this same body (or one very similar). So you’re put in a position now of essentially saying "don’t bother me with any new facts – just keep telling me the same thing you told me 20 years ago."

What this recommendation highlights (and, very coincidentally, the recommendation from the ACOG {American Congress of Obstetricians and Gynecologists} regarding cervical cancer screening) is that we *do* need to be continually evaluating care guidelines and adjust them based on the actual clinical outcomes. The reaction to this update (and the accompanying political whiplash) is another reminder of how out of whack our sensibilities are about the delivery of health care. We seem to operate under the assumption that more care is always better. The facts are that the data show that this is not universally the case (see the Dartmouth Atlas of Health Care for clues). Uninformed (bordering on petulant) reactions don’t help us here. Let’s at least try to think things through whenever possible.

As I re-read the thing, I don’t see a whole lot more I’d add to the post (without making it completely unwieldy by diving into the changes in recommendations point-by-point).

And … yes, I know I do not have a cervix. If you think that disqualifies me from opining on this topic, you are free to make that judgment. Know that it’s not likely to keep me quiet.