what does this say?

Someone gave this second hand t-shirt to my 10 year old son a few days ago. It's never been worn and still has the tags on it. It's a really nice shirt but we all agree that he can't wear it until we all know what it is he is proclaiming to "love."

We've established that it is Japanese. It came from here but the web site does not offer up any translations.

So - do any of you read Japanese?

Updated: Perhaps it isn't Japanese, despite coming from a Japanese company. A couple of people have suggested it looks like Arabic. I have no idea. Thoughts?

The Downfall of AIG

Those of you outside of Washington, DC likely missed the Washington Post's three-part investigation of the events leading to the downfall of AIG.It makes for good holiday reading. I highly recommend the series to you.Knowing the culture at AIG from many years of activity with the company and its leadership, I can tell you the story certainly has the culture right.While this is not a health care

After One Year, 9944 Hours to Go!

In celebration of its one year birthday, the Disease Management Care Blog resolved to show its pride by DMCBly festooning itself. Devotees of body art will recognize the stenciling that precedes the final step. Readers with a medical background, on the other hand, will recall what health care providers have always known about tattoos: when the lights are bright and the clothes are gone, if you’re hirsute, have unsightly nevi or suffer from any other dysmorphism, tattoos don’t help. Maybe that’s what prompted the DMCB spouse to noisily intervene and put an end to what was otherwise a grand idea. Maybe next year. Maybe she’ll even get one that says ‘DMCB Spouse.’

And speaking of one year, the DMCB has determined that one year results in about 340 postings. Assuming a reader takes an average of 10 minutes to read a post, that 3400 minutes or 56 hours.

For your precious time, the DMCB thanks you. It also says keep it up. After 178 years, we’ll have the 10,000 hours we need to be world class genius disease management experts.

just like dr. doolittle

Overheard:

Son (to Father) - "Do you ever talk to our animals? Really talk to them? Mama has entire conversations with the dogs."

Father - "Do they talk back?"

In my own defense, I come by my craziness when it comes to love of animals honestly. My sister is every bit as bad as I am with her cat, Iggie, and my mother can talk to and play with just about any animal for hours.

My mom came from a family of thirteen kids. When we were growing up, my sister and I loved hearing the stories of the animals that lived in and passed through her family home. We still beg to be told these stories and have begun to share them with my kids.

There was George, the budgie, who used to perch on my Grandfather's head (and who died when he came in for a landing, missed and ended up on a hot element).

There were many, many cats, including Fiona (the beautiful), Fluffy (who lost the tip of his tail) and Kelly (the favourite). There was Nicky, the dog that loved to ride on the my uncle's motorcycle. And there were the various animals my mother's oldest brother brought home (often rumoured to have been gambling winnings) - the rabbit (it arrived on Easter and my mother collected hundreds of little "raisins" that the rabbit kept "laying." Fortunately, she didn't try and eat any.), the monkey (banished after he started swinging from the curtains) and the chicken (that my Grandmother found tied to the table leg in her kitchen).

Really, compared to the way my mother grew up, my house with its dogs and cat is really very quiet.

And yes, I do talk to my animals. They are very sympathetic listeners.

The Partitioning of Boston

Von Ribbentrop: Mein Fuhrer, das Boston Globe has published an article that describes in detail our non-aggression protocol with the Massachusetts Blue Cross Blue Shield Bolsheviks.

Hitler: By das Anschluss! When I met mit mein Generals at the Mass General Bunker and moved those pieces around on das map of Boston, we had the perfect plan to partition the city. Now it is a mess of kraut!

Von Ribbentrop: I hope the wurst is over!

Hitler: We can’t go Bach: we will never retreat. We zpent so much time building the reputation of Mass Gen and Brigham. Why doesn’t the world understand they should pay many pfennig for our spezial quality?

Von Ribbentrop: A teutonic set-back Mein Fuhrer!

Hitler: Those conniving communist swine. Launch the Panzer Divisions! I want Caritas Christi crushed and out of business in 72 hours.

Von Ribbentrop: Errr, Mein Fuhrer, the Federal Trade Commission will certainly declare war and open a second front. More minute clinics in Medford! More MRIs in Sommerville. Perhaps instead we might compromise and open negotiations with….

Hitler: and lower prices for healthcare consumers?! Help the other struggling hospitals? Help Massachusetts with its medical inflation cost problem?!? Ninkompoop! Have you been drinking too many St. Pauli Girls and turned all communist on me!? You actually think we should all be transparently competing on price? Dumkopf!

Von Ribbentrop: I apologize Mein Fuhrer. But may I recommend that we telephone Herr Stalin and let him know that our most favored nation status ist gone kaput.

Hitler: We must re-initiate our media education and propaganda campaigns. Our national socialist strategy for centralized health reform domination cannot be compromised!

Von Ribbentrop: Jawohl Mein Fuhrer.

book review: "no such creature"*

I really like Canadian writer Giles Blunt and enjoy his series set in Northern Ontario. All his books feature interesting storylines and are populated by complex characters. The setting of Algonquin Bay (modeled on North Bay) is itself a character in the book - cold, dark and somewhat remote.

And the books really are dark, even compared to other murder mysteries. By The Time You Read This, the last in the series featuring police detective John Cardinal, opens with the suicide of Cardinal's wife. I found it heart-wrenching and I can understand why the author chose a change of pace for his latest novel.

No Such Creature is in some ways very different from Blunt's police procedurals but despite the injection of humour and the relocation to sunnier climes there are a couple of twists that are no less devastating than the author's previous novels.

"Tooling across the American southwest in their giant Winnebago, Max and his nephew, Owen, seem harmless enough, the actorly old fellow spouting Shakespeare like a faucet while his young charge trots him through select tourist destinations along the road. But appearances, as you might imagine, can be deceiving.

Old Max is actually a master thief, and young Owen's summer vacation is his careful apprenticeship in a life of crime. Pulling heists is scary enough, but ominous signs point to the alarming fact that The Subtractors are on their tail, criminal bogeymen who stop at nothing to steal from other thieves. The road trip soon turns into a chase, by turns comic and horrifying. The most disturbing twist: Owen's slow realization that the person he loves most in the world is the one who can do him the most harm."

The book features snappy dialogue, characters that are larger than life, events that test the "willing suspension of disbelief" and little touches or irony that have the ring of authenticity. I was reminded of both Elmore Leonard and Carl Hiaasen but I never felt like I had read this book somewhere before.

In some ways, Blunt tries to do too many things with this novel. I was never sure if I was reading a caper, coming of age book or a story about fathers and sons. But Blunt mostly succeeds in creating a story that's about all of these things. Certainly, I cared about the characters, laughed out loud several times, felt the mountain tension and found myself turning pages compulsively.

No Such Creature is entertaining, amusing, heart-breaking and surprising. You might be disappointed in the ending but you will never be bored.

And you know, those books where you can see the ending coming a mile away? Even with lots of foreshadowing, I was still wondering what would happen ten pages from the end.

You can read an excerpt here.

*This is book was sent to me via Library Thing's Early Reviewer Program.

Telling Quotes on the Medical Home from Attendees at a Disease Management Conference

The Disease Management Care Blog has discovered that when it’s a moderator for an on-stage panel discussion, it will remember nothing about what was said when the session is over. That’s because being a moderator involves focusing on the next question while everyone else is listening to the latest answer. That’s what happened to it at the DMAA Forum ’08 Conference when it led a session on commonalities between disease management and the medical home. This moderatoring stuff is hard work!

Even if the DMCB was paying better attention to the answers, however, it wouldn’t have been able to divine the audience’s reaction once the session was over. It was too busy recovering from all the stress. That responsibility belonged to Managed Care Magazine, which has a well written report on the audience’s reaction written by Maureen Glabman in its December 2008 issue.

Here are some telling quotes from the article from persons from across the payor and provider spectrum. Decide for yourself if these are the perspectives of insightful experts in population-based health care or competitors stuck on their business model or.... something else.

DMAA CEO Tracey Moorhead: ‘…an entirely new business opportunity…. Doctors may want to outsource [the technology]’

Disease Management Purchasing Consortium Al Lewis: ‘….the most overrated concept. Where are the alleged savings supposed to come from?’

Iowa Chronic Care Consortium’s William Applegate: ‘a Christmas gift to family practice docs from Congress.’

Better Health Technology’s Vince Kuraitis: ‘…it would be difficult for physicians…to develop the analytical tools, the information technology tools and the behavioral techniques that the disease management industry has developed over the past ten years. This could be the next big thing or this could fail. There are no guarantees’

Blue Cross Blue Shield of Massachusetts’ David Brumley: ‘The medical home has the potential to contain health care costs….’

Kaiser Permanente’s Paul Wallace: ‘Paying for the medical home is a zero sum game – there is no cost savings.’

WellPoint’s Lisa Latts: ‘It’s a promising but untested model. Our customers are saying we’re already paying you for disease management; we don’t want to pay twice….. doctors are uncertain how to make their offices into medical home’

Take Care Health Systems’ Sharon Glave Frazee: ‘ …it’s just good primary care.’

An unnamed physician: ‘…don’t know that the medical home has proven itself. We don’t know the costs or limitations. Early adopters are entrepreneurial and willing to try new things. They are not representative of the doctor on the street.’

"A Handshake That Made Health Care History"--A Boston Globe Expose: A "Quiet Deal" Between Mass Blue Cross and Boston's Most Powerful Hospitals

In a lengthy expose entitled, "A Hand Shake That Made Health Care History," the Boston Globe details what it called a "gentleman's agreement that accelerated a health care cost crisis" in Massachusetts. The reported deal was between Partners Health Care, the state's biggest health care provider, and Massachusetts Blue Cross, the largest state insurer.The article charges that the agreement all but

Pod's Point: What Does the Wall Street Journal Health Blog, Baylor and the New England Journal Teach About the Physical Examination?

Look hard down the hospital's hallways, around corners and beyond the doorways and you will begin to find them. Dimly lit rooms filled with flickering computer displays networked into the healthcare information systems. Every mg.% lab test, every mg. of drug, every datum of past medical history, every cc. of urine output, every explained and unexplained x-ray abnormality and everything ever written by any provider on every patient is there. The only thing that is missing?

That’s the topic of an interesting ‘Perspective’ by Abraham Verghese MD in this week’s New England Journal of Medicine. He says what is missing is not the patient, but the doctor: the thinking, breathing hands-on type of physician that personally asks about the symptoms and performs a thorough physical exam. Nowadays, what passes for physicians are really remote rushed informaticians who coordinate instead of care and document instead of treat. He points out that actually seeing the patient and touching one are becoming mere formalities.

Case in point? Check out this tongue in cheek posting in the Wall Street Journal Health Blog. While the aim of the post is to address the tiresome issue of the value of annual checkups, the picture displays an example of what concerns Dr. Verghese. Classic, well-performed checkups are supposed to involve a disrobed patient with a package of separate exams of each organ system including (but not limited to) the heart, the lungs and abdomen. Dr. Sadler of the Baylor University Medical Center, on the other hand, is using the classic “Pod’s Point” approach to the abbreviated pro forma examination.

“Pod’s Point” is an inside joke among many physicians describing a spot to the left and below the sternum (breast bone). When a stethoscope is applied in that area, the time-pressed examiner can simultaneously hear the heart beat, the lung’s breath sounds and the gurgling from the abdominal cavity in a second or two. It is named after orthopedic specialists (orthopods or “pods”) who have a reputation for not bothering with time consuming or detailed physical examinations.

Pod’s Point has several advantages. Not only does it save time, it gives the harried physician a chance to symbolically display the use of the stethoscope, giving the patient the impression that actual healthcare is being rendered. By hearing heart, lung and intestinal sounds, the examiner can honestly document in the chart that the three organ systems are apparently normal. It also fulfills the minimal criteria of the performance of a patient examination. It can be used in any setting including the ICU, the emergency room or clinic and can be applied to any patient in any position (such as sitting up) and with or without any amount of clothing. Finally, it is reimbursed by all insurers. The only disadvantage is that subtle and important findings that could be key to the diagnosis and treatment of patients can be missed.

The Disease Management Care Blog believes “Pod’s Point” is a perfect answer for today’s rushed physicians who need to blow through the perfunctory examination so that they see the next patient and/or return to reading and entering data in the electronic health records. The DMCB salutes the WSJ Blog and Baylor for reminding us about the modern version of today’s practice of medicine.

a traditional holiday

My family is cross-cultural and, at least, when it comes to my spouse and our kids, very secular. We do, however, celebrate both Chanukah and Christmas and, the last few days, I have felt the stress of preparations for familial celebrations acutely.

Most of this was of my own doing. I was feeling inadequate and judging myself for having such a messy house. There are no decorations (except the tree, which we put up on Monday) and I have certainly not done any holiday baking.

Every level surface was covered in layers of clutter. I also found that stuff that doesn't usually bother me so much (the fact that most of the knobs are missing from our kitchen cupboards, our counter tops desperately need replacing, our bathmats and towels are all frayed and, in a number of places, the wallpaper has been torn off the walls) was making me absolutely nuts.

I did manage to put a dent in the mess but not until I had driven everyone in the house crazy, too. By the time afternoon rolled around my spouse was trying to get me to take deep breaths and my oldest son was referring to himself as "S-erella".

Then, when everyone (my parents and sister and brother in law) arrived, I just decided to let it all go (OK, the wine helped). As the evening unfolded and I relaxed, I was reminded that we were all there to enjoy each other, that I am a grow-up now (even if I don't always act like it) and that all expectations around our own particular traditions were being met.



These are the things you can count on during the holidays at my house:

1. We will light the Chanukah candles (we have a felt menorah and the real thing) and, in lieu of a prayer we will sing loudly and off-key. We call Chanukah "the festival of fried things" and we always make sure that we eat lots of them (latkes are a particular favourite and my spouse and his brothers each believe that theirs are the best).

2. On Christmas Eve, everyone will come over in the late afternoon. My spouse will have to run one last errand after the guests arrive and I will excuse myself to go wrap all my presents (careful wrapping is not a priority in my family).

3. My mom will bring chicken pot pie and tourtiere (a French Canadian traditional pork pie). My sister will bring a celiac-friendly, kosher chicken pot pie (my sister and I are both married to Jewish men).

4. We will begin to unwrap all our presents to each other shortly after dinner. Despite the fact that we will all have declared that we planned on restraint, we will open presents for hours.

5. The first present we each get will be socks.

6. My spouse will put out crackers, cheese and pickles that almost no one will eat because we are still full of tourtiere and pot pie.

7. My sister and I and the kids will all get pajamas.

8. My brother-in-law will give my mom a bottle of wine.

9. We will put out a snack for Santa (we tracked his travels on Google Earth). This year, we left him a banana, blueberry, chocolate chip muffin and apple juice).

10. The next morning, D. will wake up first. We will keep him in our bed for a while so that the others can get a bit of sleep (this morning, D. woke me up to say, "Mama! You fell back asleep!" but he also read to himself for more than an hour).

11. The kids will go and wake up my mom in the attic guest room and we will go downstairs.

12. Santa will have come. Euphoria will ensue. This year's haul included DS games, a hot wheels set (for D.) and a big red bean bag chair (for S. but D. has been eyeing it).

13. We will all find chocolate in our stockings (fair trade, except for D. who has a nut allergy. Santa hasn't been able to find a distributor of fair trade chocolate that's safe for him. D. gets a Mars bar).

14. My brother-in-law will bring a bottle of Baileys (one of the many reasons I love my brother-in-law) and most of the grown ups will pour liberal amounts into our breakfast coffee.

15. I'll go for a post-breakfast dog walk with S. and my sister. They will wear their pajamas.

16. We will have a Christmas dinner, consisting of a turkey with all the fixings. T. will roast the turkey and veggies, mom will make the cranberry sauce and my sister makes the stuffing and desserts. We will all eat until we can't move.

Something we did last year, which we are making into a tradition is watch a movie on Christmas day. Last year it was Elf. This year's choice is Get Smart. Going to go do that now.

May you all be enjoying your good traditions, surviving the meshugas and spending time with people you love.

Happy holidays!

The Decreasing Problem of Drug-Drug Interactions Among the Elderly & the Role of PBMs, EHRs & Disease Management. Commentary on JAMA.

The Disease Management Care Blog got a holiday present from JAMA today: an article on the prevalence of major drug-drug interactions among the community dwelling elderly. This was an incredibly detailed and nationally representative study that sent researchers into persons' homes to not only ask what drugs were being taken, but the respondents were asked to go get and show the interviewers the actual drug bottles. In addition, persons were asked about over the counter (OTC) and herbal use.

91% swallowed at least one pill a day. 81% used at least one prescription medication. More than half took more than 5 different pills a day, and about 30% took 5 or more prescription drugs a day.

But what caught the DMCB's eye was the finding that 'one in 25' (or 4%) of study subjects were being exposed to a 'potential' major medication interaction. According to the authors, this corresponds to 2.2 million persons being at risk, which caught the eye of the national media here and here. Sounds like a lot.

The DMCB thinks the real newsworthiness of this report is how low the incidence is. To the DMCB's knowledge, a comparably performed study of outpatients looking specifically at drug-drug interactions doesn't exist. Only half of the drug-drug interactions in this study involved prescription drugs. Contrast that with some representative past studies: drug-drug interactions were more common at 6% in the past among Veteran's Administration outpatients, and among inpatients in Arizona the rate among admissions was 6.4%.

Unfortunately, the authors didn't ask the survey respondents if they received their drugs through an insurance plan, if their prescribing physicians used an eletronic health record (EHRs) or participated in a disease management (DM) program. That's because the data bases of pharmacy benefit managers (PBMs) are being successfully used to identify and prevent interactions. While the DMCB is no fan of EHRs in general, they are good at spotting prescription mishaps. Last but not least, disease management - using registries combined with 'live' person alerts for the prescribing physician - have also been effective in preventing injury.

The DMCB suspects the prevalence of drug-drug interactions nationwide is dropping and it thinks that's because of the market penetration of insurance coverage of medications using PBMs, clinicians' use of EHRs and the activities of DM programs. That's good news.

Post script: This JAMA article also identifies the potential for drug-OTC and drug-herbal problems, which accounted for more than half of the interactions. In the 'real' world of clinical practice, this is very hard to follow because patients (in the opinion of the DMCB) frequently change these agents. While EHRs and the practice of asking patients to tediously list every pill they use at every clinic visit (chewing up precious minutes in a high volume patient 'throughput' setting), a better approach may be covering these agents in pharmacy benefit plans. This is a radical notion, but the coverage doesn't have to be generous. In exchange for the insurance expense, the underlying PBM and DM data bases should be able to spot the other 2% of elderly individuals who are unnecessarily exposing themselves to ills from their pills. While some may be shocked, SHOCKED at the notion of insurance coverage for unproven therapies, the DMCB finds distant public policy parallels here and here.

The Magi and What Their Mathematics Discovered. The Fat Lady is Back

While the role of the Bible in modern American society can be controversial, the Disease Management Care Blog still thinks it’s great literature that gives important insight into the human condition. While it is the nature of popular media to substitute “Happy Holidays” for “Merry Christmas,” Santa for St. Nick and happiness for holiness, the DMCB is reminded by the Fat Lady to look for the lessons from the Season.

That’s why it’s been thinking about the Magi. These are the wise men who made a brief appearance in the second chapter of the Gospel of Matthew. These individuals were probably top learned scientist-astronomers engaged in the full time study of the patterns of the heavens. As the lights circled overhead in precise mathematical patterns, this expert class of professional stargazers constantly sought out new insights and even attempted to link them to human events or predict the future.

The DMCB isn’t too sure that the stargazers of that day are not too dissimilar from today’s vast numbers of professional number crunching pattern watchers. The only difference is that their areas of study are no longer confined to the stars. In addition to breathtaking advances in the physical sciences, modern wise men are gazing at humans and their patterns, likewise seeking to link them to other events and predicting the future.

We’re all familiar with these brainiacs. Facile with incredibly complex mathematics, these data-heads can price risk, assess the strength of statistical associations and assign attribution. Some are better than others. The ones that are really good, really lucky and benefitting from the work of others often go on to make incredibly useful discoveries. Some even win Nobel Prizes. This is the work of turning data into insight and information into inspiration. This is the work of making numbers “sing.”

So who were the greatest mathematicians greatest of all time? The DMCB votes for the Magi. Blessed by the work of generations of predecessors as well as the good fortune of being in the right place at the right time, these brainiacs also applied prodigious (and literal) amounts of leg work in the pursuit of explaining new pattern in the sky. And what a thing they discovered.

Is this an endorsment of mystical numerology? Hardly. But the DMCB finds it interesting that mathematicians feature so prominently in this classic Bible story. Once again, something far greater lies at the center of our logical hard wired dependence on what is seen and what is measurable. The Fat Lady reminds us that this calls to us every Christmas season.

now this is snow

More photos of my snowy backyard on Flickr.

When Primary Care Physicians Go Tone Deaf

By the way, not all physicians are necessarily sympathetic to the plight of primary care. It’s not just a matter of the members of the House of Medicine jostling over who gets a bigger share of the fixed economic pie, but, according to this newsletter, the PCPs losing their way.

With that in mind, it was with some interest that the Disease Management Care Blog – who is a “Fellow” of the American College of Physicians (ACP) - decided to investigate when it found out a letter had been sent to HHS Secretary-designee Daschle on its behalf.

The letter recommends that another ‘stimulus package’ be created that a) assists persons who are newly unemployed to access insurance coverage, b) expands Medicaid and SCHIP, c) increases Medicare payments for primary care physicians (PCPs) including a 10% payment bonus over 18 months and d) provides incentives (grants, interest free loans and tax incentives along with technical support) that increase PCP adoption of health information technology (HIT) as part of a broader effort to promote the Patient Centered Medical Home.

The DMCB understands why its ACP colleagues believe that a key ingredient for health reform is physician payment reform. It’s uncomfortable, however, with the mercenary tone of the letter. While primary care physician income has serious problems, the ACP letter above is muddling the patients’ well being with its physician-members’ economic interests. A cynic would argue that the otherwise laudable advocacy for the unemployed, expansion of government subsidized insurance, bonus payments and incentives are really attempts to preserve their members’ income levels.

The DMCB also thinks the request for a 10% bonus is bordering on nervy. Compared to the pain from the widespread mortgage foreclosures, lay-offs and vaporizing retirement funds, even the worst-off primary care physicians have little to complain about.

Is there no limit to the willingness of those in positions of privilege to seek government hand-outs, based on pleas that it’s really all about the little guy? Maybe the DMCB is being overly sensitive but a word count reveals the word ‘patient’ appears 8 times in the letter, while the word 'physician' appears 15 times and the word 'payment' appears 11 times. Conflict of interest anyone? Or is this just a case of tone deafness?

Maybe there is an element of truth to the notion about losing their way.

CBO to Health Care Reformers: Naive Policy Makers Need Not Apply

The Congressional Budget Office (CBO) has released two comprehensive papers detailing the policy and financial options for health care reform: Key Issues in Analyzing Major Health Insurance Proposals and Budget Options, Volume I: Health Care.I can't overestimate the importance of these documents to health care reform.I recently did a post as sort of an open letter to the CBO: To the Congressional

still recovering from the concussion (and it wasn't even my head).

On Tuesday afternoon, I was at a craft sale doing some holiday shopping with a friend (who had booked the afternoon off to hang out with me). We had only been there about forty-five minutes when my mobile rang.

I was expecting it to be my spouse, wanting to consult about a present but it was one of the administrative staff from my older son's school. She told me that he had fallen and hit his head at recess. Some time later, he had told his teacher that he was "feeling weird" and she had sent him to the office. The woman who called me said she was worried about him but wasn't able to get much out of him, as he was "being very non-verbal."

Anyone who has ever met my son would never ever describe him as "non-verbal." I knew that something was wrong. When I got there a few minutes later, he was sitting there quietly. He didn't react much when he saw me and seemed to be having trouble speaking clearly (he did say that he didn't want to leave school because they were going to be building K'nex bridges. This was another warning sign for me - my son being distraught at the idea of leaving school). He was also disoriented and unsteady on his feet.

Once we were home, I consulted with Mr. Internet and came to the conclusion that I had to call the doctor. She got us to come in right away, and, after examining him, asked that we go immediately to the children's hospital. She offered to call an ambulance because she didn't want my son to be unmonitored during a potentially long drive (there is a transit strike in Ottawa right now and it has caused traffic to be very backed up during rush hour). Within a few minutes, four paramedics arrived.

We were bundled into the ambulance and taken to hospital. Poor S. had to keep getting his blood pressure taken and answer the same questions over and over again. The paramedics were really wonderful and I could tell that they were as relieved as I was when he went from not knowing what month it was to listing the items on his Christmas list (there are forty-five of them, including a flat screen TV and a Blackberry).

One of the paramedics told me that it is often this way with concussions that they can get better in the first couple of hours or much worse. We were all very relieved to see such a dramatic improvement.

He was so dramatically improved, in fact that when arrived at the children's hospital, we were no longer on the fast-track for treatment. By the time we saw a doctor (a resident, actually) hours later, my son was talking, cracking jokes and the headache and nausea had disappeared.

Diagnosis: mild to moderate concussion. Elapsed time between head bonk and being back at home: eight hours.

By the next day, S. had completely recovered and was giddy with the joy at the prospect of a day in his pajamas.

I on the other hand, am still exhausted. A concussion can really take a lot out of a mother.

Conservatives Need to Be Part of Health care Reform

Stuart Butler, Vice President of Domestic Policy at the conservative Heritage Foundation has an op-ed in Thursday’s Washington Times, “Four Steps Can Heal Health Care.”He makes some very valuable points and proposes four steps toward reforming the health care system most people—liberals and conservatives—could agree on:Making sure every working family has access to an affordable private health

CBO Issues (Positive) Report on the Option of Including Disease Management in Health Care Reform (and the Medical Home too - though not so positive)

If you’re interested in having the good, the bad, the ugly, the skinny, the inside track, the talking points, just the facts and or the lowdown when it comes to all things Federal policy health care, you may want to ‘bookmark’ or ‘favorite’ or download two just-released reports on the topic from the non-partisan Congressional Budget Office (CBO). They are briefly summarized in the CBO Director's Blog. Simplisitically stated, it's up to CBO to give evolving legislation a green light. If there is no green light, that often times means no go. This is a gateway through which all health care reform must pass.

These reports are must reading for staff, lawmakers, policy makers, regulators, academics, employers, reformers, insurers, patient advocates, consultants and bloggers. The Disease Management Care Blog, however, recommends that you resist clicking that print icon: these puppies are hundreds of pages long and that shared printer will be tied up for a long long time. Rather, don your glasses, take an NSAID, get a caffeinated beverage and go full screen…. but think about waiting until Monday and after you’ve read what the DMCB has to say.

The first is ‘Key Issues in Analyzing Major Health Insurance Proposals.' Describing its 196 pages as an exhaustive review would be an understatement, but the good news is that it’s all there: policy options for reducing the number of uninsured, altering insurance benefit design, changing the regulation of insurance, manipulating the pricing of health care services, expanding health information technology, influencing patient choices and understanding the impact on the national economy. Egads, says the DMCB, this is more like an encyclopedia, best meant for looking up your favorite topic.

And the DMCB’s favorite topic, ‘disease management' (DM), is in there. The Key Issues report recognizes that a prior CBO review and a more recent RAND review of the evidence of cost savings from DM programs was ‘inconclusive.’ It states that reasons include a) the possibility that the fees are too high, b) private plans are not in the business of sharing their results in the public domain, c) there is an economic downside/dilution of having everyone – including persons who may not benefit – participate in DM, d) it’s difficult to intervene early enough and f) conducting clinical trials in this area is very complicated. On the other hand, the report admits that just about every commercial insurer already has DM in one form or another. As a result, it predicts the U.S. impact of any future requirement ‘mandating’ DM in the commercial/private sector is likely to be blunted.

VERY interestingly, however, the CBO report goes on to indicate that ‘certain types of private-sector programs…would have a greater potential to limit federal spending,’ especially if ‘targeted…. toward the …enrollees most likely to benefit from them or most likely to generate savings….’ and if the DM programs have ‘a strong financial stake in the outcome.’ To the DMCB, this appears to suggest that the CBO is supportive of including DM as an ingredient in the reform of government-sponsored health insurance under certain circumstances: a) for some, not all chronic conditions, b) aimed at high risk enrollees and c) with DM organization risk sharing. Wow. Double wow, especially since the DMAA issued a statement applauding CBO's recognition of DM's 'potential to reduce costs.'

The medical home is also examined in Key Issues and doesn’t appear to fare as well. The report recognizes that better access to primary care and greater coordination of health care services ‘could’ translate into savings but ‘the impact of medical homes on health care spending remains unclear’ because health care utilization could paradoxically increase. Interestingly, it points out the potential for savings would be greatest if “the coordinating physician had a financial incentive to limit the use of specialty care.’ The DMCB interprets that to mean gatekeeping, which is precisely the term used in the CBO report. Ugh. It doesn’t think this is what the primary care physician advocates of the Patient Centered Medical Home (PCMH) had in mind.

Head on over to this second report on ‘Budget Options’ and you’ll find a treasure trove of 115 one to two page long summary statements that examine each and every one of the many reforms (except, curiously, disease management) currently under consideration. Option 39 deals with the Medical Home and it echoes the posture in the Key Issues discussion above: ‘CBO cannot estimate whether the net result… would be to increase or decrease spending for the Medicare program.’ The DMCB paid special attention to this write up because a paper it recently wrote for Health Affairs was referenced: CBO used it to correctly point out that many of the reports of the Medical Home’s success are not necessarily generalizable to the Medicare FFS population.

Is the notoriously dour CBO being cautiously optimistic about the potential role of disease management? The DMCB thinks the answer may be yes, but its job is to be an optimist. What do readers think?

“Irrational Exuberance” and Health Care Reform—Slow Down!!!

I think Pete Stark has it right. In a story in The Hill, Stark calls for waiting until later in 2009 or 2010 to move on a big health care reform proposal. The House Ways and Means Health Subcommittee Chair also points out that there are a number of "deferred maintenance" issues that will need to be dealt with sooner—SCHIP renewal, the upcoming Medicare physician fee cuts, and the pending health

e-Doubts on Health Information Technology Part 2: Other e-Doubters Weigh In

What’s going on? Since the e-Doubt post, the Disease Management Care Blog is becoming aware of the beginning of a bloggy backlash against electronic health and medical health records. It doesn’t usually write about other blogs (preferring instead to read them) but it appears there’s a critical mass of skepticism in two of the more highly regarded independent health policy blogs.

In this erudite December 17 post in the Health Care Blog, Rick Peters likens healthcare information technology (IT) and its EHR mainframe mentality to the inept U.S. auto industry, only worse. There is one difference though: at least Detroit didn’t try to set up ‘standards’ that unfairly perpetuate their bloated business models. He offers up some extremely sensible, lean and targeted funding suggestions that go far beyond the generalities of the DMCB’s Dec 16 post. He proposes that the Obama Team resist the siren call of EHR zealots and create specific targeted challenge awards that promote scalable, ‘cloud-based’ web-based, secure and open source IT systems that separately accomplish a) insurance claims processing, b) eligibility and claims remittances, c) ePrescribing and order entry, d) laboratory and test reporting and e) decision support. The winners will be rewarded by having all insurers including CMS be mandated to use them. The DMCB says bravo.

In retrospect, the DMCB should have suspected something was up when even blogmaster and e-sage Matthew Holt in this post in the same Health Care Blog noted the electronic health record is ‘not the be all and end all.’ The DMCB likes his concept of limited, mutually supportive and swappable specific ‘applications’ that are designed to either record, personalize, analyze, provide decision support or enable transactions. The DMCB says he who is without the sin of second thoughts should throw the first stone.

And even the taciturn and laconic Maggie Mahr of the HealthBeatBlog wonders if it’s time to call a halt to the e-irrational e-exuberance. Quoting au correspondent several scarred veterans of the healthcare IT contretemps, she discovers real physicians, i.e., the ones that actually take care of patients, don’t necessarily like having EHRs. What’s more, there are a host of other problems including the lack of a business case for interoperability, logarithmic degrees of complexity and toxic levels of radiovendoractivity.

And it may not be just the blogs. According to the December 12 Health Care Renewal post, eternal e-skeptic Scot Silverstein (one of the experts quoted by Maggie Mahr above) points out that the Joint Commission doesn’t buy into the assertion that health information technology is synonymous with safety. In fact, it can be synonymous with mislabeled bar codes, confusing screen displays, poor adaptation to work flows and dysfunctional impacts from loss of professional autonomy. It recommends that safety programs for the EHR be established and has a series of specific suggestions ultimately designed to keep patients from being added to the 98,000 getting killed every year.

The DMCB supposes there may be merit (maybe not) to the overall notion of stimulus spending and, given the percent GDP footprint of healthcare, funneling some serious coin toward health care IT reform would be a heckuva jobs program. Given the insights of Rick Peters, Matthew Holt, Scot Silverstein and the Joint Commission above, perhaps it’s time to ask President Elect Obama and Secretary Nominee Daschle to pause and think again. Can they can really be so confident that $50 billion is a wise investment?

"Expanding Coverage Without Increasing Health Care Spending: Dartmouth Institute White Paper Recommends Course for the Obama Administration"

Once again the Dartmouth Institute for Health Policy and Clinical Practice has provided a valuable contribution to our health care reform discussion with their new paper, "Improving Quality and Curbing Health Care Spending: Opportunities for the Congress and the Obama Administration."In my mind the authors made two critical points:We can insure everyone without dramatically increasing national

Who's The Guy Sitting Next to You? The Obama Health Care Reform Parties and Unexpected Guests

The incoming Obama administration is getting a quick start toward health care reform.By the end of the year, they anticipate having thousands of health care discussions in homes, businesses, coffee shops, and the like.About everyone, including the Obama health care team, believe Hillary Clinton's 1993 top-down health care reform process was a big mistake. The new folks don’t intend to make that

e-Doubts from the Disease Management Care Blog about Health Information Technology: Caution Mr. Obama

The Disease Management Care Blog couldn't help but notice David Kibbe and Brian Klepper’s ‘open letter’ to President-Elect Obama on the topic of health IT spending. It was awfully hard to avoid after being posted simultaneously on multiple blogs including e-CareManagement, the Health Care Blog, and Health Commentary, along with subsequent mirror postings on numerous other sites.

In it, Drs. Kibbe and Kepper recognize that the Disease Management Care Blog was prescient back in 2006 and that not much has changed since then. Electronic health records (EHRs) remain expensive, not cost-saving, unwieldy, clinically unproven and not yet universally interoperable. Given the EHR’s lingering limitations, Kibbe and Kepper correctly conclude that no amount of newly printed dead presidents will overcome physicians’ widespread reluctance in letting the IT Blob and its > 100,000-person army of vendors, consultants, vice presidents, CIOs and specialists distract the docs from a) patient care and b) making a living.

Kibbe and Kepper’s considered recommendation is to step back and make far more modest investments in e-prescribing (all that’s needed is internet access), e-referrals (to promote better information exchange between primary care and specialist providers) and patient e-communications (e-mail and other forms of online information sharing between doctor and patient) along with increasing broadband connectivity.

While the DMCB agrees these areas hold a lot of potential and are a good place to start, there is no shortage of e-evidence that e-suggests we have a long way to e-go before even these e-reforms should be implemented on a large e-scale. How can the DMCB say this? Because once again it had little trouble finding a host of reports indicating that even these modest reforms are not yet ready for prime time.

e-prescribing isn’t necessarily time saving, can be unwieldy, like many other aspects of health IT can create new problems and may be used to appropriately - or inappropriately - steer physician behavior.

e-referrals should work fine in health insurance settings in which patients are assigned and have a primary care physician. What about the millions of Medicare beneficiaries who switch primary care physicians from year to year or don’t rely on PCPs at all? How about commercial PPO beneficiaries who chose that kind of insurance plan precisely because they want unfettered access to specialists? What about that inconvenient fact that in many areas of the country there aren’t enough PCPs to see patients, let alone log onto some IT e-solution and coordinate referrals?

e-communication is not a panacea either. Physician buy-in is tenuous at best because of the fear of being overwhelmed by e-mails, not to mention the possibility of a drop in income. Patients have concerns about privacy and responsiveness. What’s more, the impact on overall health care utilization and costs may not be very substantial. Last but not least, the socioeconomic digital divide may exacerbate health care disparities.

The DMCB recommends that our new President exercise a higher order of caution here. Options include letting the market work its magic at finding faster, cheaper and safer solutions. If health IT is the solution many think it is, it should have little trouble independently demonstrating value to physicians and patients alike. Alternatively, large scale pilot programs in these topic areas could be performed to better determine what is generalizable to multiple health care settings, especially smaller physician-owned practices. Alternatively, a targeted X prize could be initiated.

Last – and most importantly – e-prescribing, e-referrals and e-communication must be viewed through the prism of other health care reforms, including accountability at the primary care level for the health of populations, best-in-breed disease management programs, consumerism and physician reimbursement reform. In other words, once we work out the kinks in the e-solutions being promoted by Kibbe and Kepper, we need to recognize them for what they are: necessary but not sufficient. What President-Elect Obama's team will really need to work on is how to make them fit with all the other reforms that are necessary.

The DMAA Issues a Statement on Principles for Health Care Reform: A Summary and the Implications for Disease Management

Well, it’s official. The DMAA has followed the American Medical Association, Commonwealth Fund Commission, the American Heart Association, America’s Health Insurance Plans, AFSCME, The Association of American Medical Colleges, the American Hospital Association, the American College of Physicians, and AARP in having something to say about health care reform.

Keep in mind that the DMAA represents a host of health insurers, employers, advocacy groups, health care provider organizations, research groups, pharmaceutical companies and - oh yes - for profit disease management organizations. As a result, DMAA has access to some considerable mojo in the topic of population health, particularly in the area of chronic illness, prevention and disease management. They're very much worth listening to.

By the way, think the term "population health" is some sort of jargony pseudo-scientific marketing notion cooked up by a bunch of for-profit vendors intent on sucking the life-essence out of a struggling health care system? Think again. The Disease Management Blog thanks the colleagues in the public health arena for coming up with a perfectly valid and correct definition: it saved the DMCB the effort.

But getting back to the issue at hand. According to the Statement:

“DMAA believes the goal of health care reform should be to improve the quality and efficiency of care for all consumers.” (The DMCB finds use of the term 'efficiency' curious but very appropriate. It addresses not only the notorious lack of coordination in an ala carte fee-for-service system, but speaks to the Number 1 driver of costs, the frenzied use of technology irregardless of it's incremental value).

DMAA then follows up with some bullet points (DMCB commentary in italics. It's allowed to do that because..... well, afterall, this is its blog):

Seek to improve the health of the entire population (in fact, that point is in the latest DMAA Outcomes Guidelines Report: outcomes evaluations should not be confined to only those were called by the remotely positioned nurse-coaches):

Increase access to affordable health care coverage options (compared to many other health care interventions, disease management is a bargain);

Center on the needs of consumers (patient centered care anyone? The DMCB believes a substantial proportion of enrollees like having their own nurse regularly giving them a call);

Improve consumer health knowledge and confidence (self care is truly the secret sauce in chronic illness, prevention and wellness);

Encourage engagement and accountability of patients, their families and caregivers (patient centered care part 2, anyone? The DMCB believes a substantial proportion of spouses, parents and children like having their spouse, child or parent being being regularly called by their own nurse);

Reward value and quality across all payers and providers (while there is the Holy Grail of reducing claims expense in excess of the cost of the program, sooner or later we're all just going to have to accept that sometimes when it comes to quality, you get what you pay for);

Promote integrated, coordinated care (with non-physicians - versus the physician hero doing the countless mundane tasks of chronic illness care in the course of a 12 minute 32 second one-on-one office encounter. The DMCB asks why can't some of the teaming be 'virtual?');

Increase the availability of primary and preventive care (and one approach is for disease management programs to PAY physicians for primary and preventive care services. Some disease management programs are doing just that);

Promote transparency of price and quality (what a marvelous idea. The DMCB suggests the DMAA members lead this transparency parade by being the first in the health care industry to post all their otherwise opaque fees and risk arrangements on-line).

Support providers who implement health information technology to improve safety and coordination (the DMCB would like to point out that disease management organizations have already made considerable health information technology resources available for providers);

Implement a national health data repository (and open-source it? That may be radical, but there is merit to harnessing the wisdom of crowds to independently mine data bases for new insights. Why can't the disease management organizations pool all their diabetes data?);

Include rigorous evaluation of clinical and administrative interventions, with feedback loops to continuously improve health care delivery (the DMCB believes this is so critical that it should not only be first in this list, but that organizations in the business of population health should tithe in support of studying their programs' outcomes); and

Support the continued use of tax benefits to expand insurance coverage (insurance coverage is necessary but not sufficient for access to health care).

Like the last post about the IOM Report, the DMCB likes what it's reading. Hopefully the Feds will listen.

A Crisis-Driven Reorganization of Health and Human Services?

Remember when, in response to a large crisis, the Federal government reorganized over 20 separate agencies into a new Department called ‘Homeland Security?’ How about the recent meltdown-driven foray of the U.S. government into banking and insurance? Now that there is growing consensus that there is a healthcare crisis, think the Department of Health and Human Services (HHS) will go unchanged? How can Congress resist?

And here's its cover for it to do something. The Institute of Medicine has released a report to Congress at the request of the House Committee on Oversight and Government Reform. Recall that HHS is a cabinet level Department that includes not only Medicare and Medicaid, but the National Institutes of Health, the Food and Drug Administration, the Centers for Disease Control, the Indian Health Service, the Agency for Healthcare Research and Quality (AHRQ) and a host of others. It occupies about a quarter of the entire Federal budget. Think the one-time $700 billion bailout is a lot of money? That’s HHS’ yearly budget. Given the coming Administration’s appetite for ‘change’ and the leading role of HHS in leading that change, the IOM report could catalyze crisis-style reorganization the Department.

You can access a ‘brief’ of the IOM report here. That’s free. For a full report, you’ll need to go here. That's not free, but the DMCB suspects members of Congress won’t need to pay for it.

Here’s a quick summary of the brief for you.

HHS needs to define a modern ‘vision, mission and goals’ to help persons inside and outside of the Department to understand its work. The IOM recommends the number of individual department heads within HHS be reduced and that the remainder be ‘re-aligned’ to fulfill the new mission and goals. In addition, the office of the Surgeon General needs to be revitalized and AHRQ needs more dependable budgeting. When there is overlap with outside Federal agencies (an example being food safety), it should be brought entirely within HHS. HHS also needs to begin studying and reporting on the comparative effectiveness of medical interventions and procedures. It should also invest in its own workforce recruitment and professional development. Congress should increase HHS’ accountability by getting regular reports but allow greater flexibility to fulfill a ‘new compact.’

The Disease Management Care Blog likes what it’s reading. If that sprawling bureaucracy known as HHS can be even slightly more efficient, mission driven, attentive to outcomes and modeled after entities in the private sector, patients and their providers might be better off for it. Of course, the devil is in the details of the enabling legislation. Let’s hope that Congress follows through on the IOM Report.

this explains so much

Ewoks.

Lucy.

Watch out little Ewok! It looks like you're going to become a snack!

The Best Way to Spend the Coming Federal Health IT Money: An Open Letter to the Obama Health Team

An Open Letter to the Obama Health TeamBy David C. Kibbe & Brian KlepperIt seems likely that the Obama administration and Congress will spend a significant amount on health IT by attaching it as a first-order priority to the fiscal stimulus package. We take the President-elect at his word when he recently said:“...we must also ensure that our hospitals are connected to each other through the

every time

When I turn the corner after chemo, I always want to do EVERYTHING.

Read a book.

Walk my dogs.

Write.

Organize my house.

Cook something.

Go shopping.

Knit (or finish languishing projects).

Get caught up on my email.

You'd think I would have been doing some of those things when I was recovering and I did, but it's just not the same when you feel like crap.

I had my first cup(s) of coffee this morning since chemo. And it wasn't even my usual half-caf.

I want to do EVERYTHING NOW. And I don't know where to start.

So maybe I'll just sit on my couch for a while and listen to my kids squabble over pizza.

boy we were young

In our early thirties but still so young, in hindsight.

There are two kids now.

The babe in this picture is just a head shorter than I am.

I have not seen T. without a beard since shortly after this was taken.

We have lots more gray hair between us.

We still have that red couch.

So much has happened since this picture was taken.

There's not much I would change.

Except for the cancer.

But not much else.

Talk About Value - A Webinar on Comparative Effectiveness and It's Free

The Disease Management Care Blog modestly announces it will be a speaker at an upcoming webinar December 18 at 2 PM EST. The discussion will focus on the hot topic of 'comparative effectiveness,' which underlies many of the principles being espoused by the Population Health Impact Institute. While that is good news indeed, the better news is that you'll get to hear even savvier experts, including:

Joel V. Brill, MD, Chief Medical Officer, Predictive Health
Vicki Darlington, Wellness Director, Entergy Corporation
Richard Hodach, MD, PhD, Population Health Consultant
Thomas Wilson, PhD, Epidemiologist, Trajectory Healthcare

The DMCB thinks that when you are done listening to this, you will have the qualifications necessary to serve on the former Senator Daschle's Health Fed Board. Why not? Better you than someone from the Commonwealth Fund.

By the way, it's free. Register here. Your CFO will thank you for knowing value when you see it.

Long Acting Beta Agonist Inhalers 'CAUSE' Asthma? The DMCB Explains and Reviews the Implications for Disease Management

A Food and Drug Administration (FDA) expert panel has recommended that the ‘long acting beta agonist inhalers Foradil and Serevent no longer be approved for treatment of asthma. Apparently they can cause asthma. Drugs that treat asthma can cause asthma? How can this be true? And what are the implications for disease management?

The Disease Management Care Blog at your service!

First of all, “beta agonists” are a type of drug that works by activating “beta receptors.” Receptors are a type of protein that sits on the external surfaces of cells. There are many different types of receptors that stick out from the surfaces of individual cells in the human body, each of which has a different function and each of which lead to a cascade of chemical signals on the inside of the cell. This in turn leads to changes in cell function. The DMCB thinks these receptors were named “beta” because they were the second type of receptor that scientists discovered after they found the ‘alpha receptors.’

Think of this as a lock (the receptor) and a key (the agonist*). The human body uses these receptor-‘locks’ to orchestrate responses to changes in the external environment. For example, epinephrine is one of many agonist-‘keys’ that are transported via the bloodstream throughout the body. A boost in epinephrine levels causes stimulation of beta receptors in the body, which prompts cells to act. In the case of the muscle cells that line the airways of the lung, the cells relax, which causes the airways to dilate. That makes sense, because if you are in a situation that is physically stressful, you want your lungs to be wide open.

The problem? Scientists have known for decades that when beta receptors are stimulated repeatedly and excessively, human cells ‘uncouple’ them from the cells’ internal machinery and remove them from the surface of the cell. There are beta receptors in the heart, for example, and repeated doses of epinephrine-like drugs over days of treatment become less effective. Among persons with asthma, the impact of epinephrine inhalers can also decrease. In other words, beta agonist drugs work great at first, but with time, they can become less and less effective. This loss of effectiveness is far more likely to occur if large and repeated doses are used over many days.

Asthma is a condition in which inflammation of the air passages causes the muscles that surrounds those air passages to go into spasm. Inhaled beta agonist drug mists cause those muscles to relax. The good news is that small, judicious doses of beta agonists do not cause loss of effectiveness. The bad news is that asthma is a variable disease and beta agonists may not be enough for a bad attack. There is a temptation among doctors and patients to increase doses of the beta agonist drug when symptoms are getting worse, which leads to poor receptors which can lead to a paradoxical loss of effectiveness.

Check out this report from the New England Journal of Medicine from as far back as 1992 that showed that beta agonists were associated with increased asthma death rates. In this instance, there were over 12,000 asthma patients and 129 died from an asthma related death. The odds were very small, but death seemed to be associated with the ‘regular’ use of the beta agonist. Think of it this way: beta agonist treatment leads to improvement in most persons with asthma, but a small fraction of persons will be exposed to excessive doses, leading to loss of disease control and death.

What about ‘long acting’ beta agonists? These drugs were just recently invented and are chemically formulated to resist metabolism, which means they stick around longer. That means patients don't need to use them as often, which is good. Recall that repeated stimulation of beta receptors can cause dwindling of effectiveness, so long acting beta agonists could theoretically be worse than their shorter acting and older cousins. Research scientists were looking for that side effect in this study and found that there was a small increase in deaths. There were about 10 excess deaths among more than 26,000 patients.

The FDA says that there are clinical trials that show that if you are going to use a long acting beta agonist inhaler, it should be paired with a drug that reduces inflammation. By reducing the inflammation, the airways are more likely to respond to the agonist which reduces the chance of repeated dosing and the paradoxical loss of effectiveness. The opposite may be true also: use of the long acting beta agonist drug may permit the use a lower dose of the anti-inflammatory drug. These are steroids, which may have their own problems including osteoporosis and eye problems such as cataracts and glaucoma.

What does the DMCB think about all this?

1. The mechanism behind the paradoxical loss of effectiveness from over-stimulation of beta receptors have been known about for a long time. Smaller judicious doses are safe.

2. While the excess death rate from long acting beta agonists is small, it’s real and it’s been known about for a long time. Adding an anti-inflammatory medicine makes sense. Using both medications makes the risk of each lower.

3. The DMCB suspects asthma disease management organizations were already managing this risk during the course of their coaching and patient education. That was true in the DMCB’s former life when it was helping to run a disease management organization. Too bad there don’t appear to be any publications about it (do any readers know otherwise?)

4. If you are working for a disease management organization while you are reading this the day after the FDA announcement, ask yourself if your company is currently telephoning all the persons on just a long acting beta agonist inhaler to help them switch one that also contains an anti-inflammatory component. If not, maybe you should be.

5. If you are working in a medical home and have an electronic medical record that lists everyone’s diagnosis and medications, ask yourself if your clinic is currently telephoning all the persons on just a long acting beta agonist inhaler to help them switch to one that contains an anti-inflammatory component. If not, maybe you should be.

* as an aside, there are drugs that can block receptors, causing them to be inactivated. These dummy keys are called 'antagonists.' Now you know how beta blockers got their name.

against "the tyranny of positive thinking"*

"It is...widely believed that, once you have a cancer a positive attitude and a good mental state positively will affect the outcome of the disease..."

"Blaming the patient helps those who do not have the disease feel safe, and perhaps superior. If we can identify something the patient has done, or chooses to do, then maybe, the reasoning goes, then we will not get that cancer if we are careful. Hence our desire to find things in patients' lives that set them apart from healthy people.

...It may make us feel better at the expense of the patient but it simply isn't a reflection of the the truth."

Excerpts from "Cancer Is A Word, Not A Sentence" by Dr. Robert Buckman.

I listened to the tail end of a talk by Dr. Buckman on the CBC the other evening. It was called "Humour As A Coping Strategy or Laughter, The Second Best Medicine." His point was that, while humour absolutely does help us cope, it doesn't cure is or as he said, "Medicine is the best medicine."

I wish I had a transcript (updated to add that the podcast will be available on December 29th. Really worth checking out. I really enjoyed the part I heard and, ironically, found it to be very positive).

Laughter, love, friendship and a positive attitude can definitely help us cope with having cancer. Medicine, however, remains "the best medicine."

*This post is for my friend S., who coined that brilliant phrase.

Cross-posted to Mothers With Cancer.