Vol. 81 January 1, 2013 Happiness is Not a Warm Gun*

December 31, 2012

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JUST LIKE SEAT BELTS AND BIKE HELMETS, GUNS ARE A CHILD-SAFETY ISSUE.
-Eileen Costello, MD, pediatrician Boston Globe 6/13/12

The discussion about gun control is not a rational one. “How does one argue with someone convinced that the routine massacre of our children is the price we must pay for our freedom to have guns, or rather to have guns that make us feel free? You can only shake your head and maybe cry a little.” Adam Gopnik July 7, 2012

As both sides relentlessly quote statistics, some good old satire and ridicule is needed to help us cut through all that smoke. Like something Stephen Colbert would do.
That’s it!
We need Stephen Colbert caressing his warm gun on TV while spouting NRA truisms to show us how ridiculous we are as a nation in controlling everything BUT guns.

“The United States is responsible for over 80% of all the gun deaths in the 23 richest countries combined. Considering that the people of those countries, as human beings, are no better or worse than any of us, well, then, why us?” (Michael Moore)

In the U.S. there are 98 guns per 100 people. In the U.K. there are 6 guns per 100. “If America’s real concern, as expressed by its Second Amendment, is that the British are coming, I think they got that one covered.” (Tabatha Southey, Vancouver B.C. Globe and Mail, 12/29/2012)

3000 people died in the September 11th attack. In response we started two long wars and built a vast Homeland Security Apparatus that cost us trillions of dollars. Since that time 275,000 Americans were killed by gunfire at home and our response has been weakened gun laws. (Doonesbury, Feb 13, 2011)

Better still. Stephen Colbert’s Super PAC money, if there is any left, could be aimed at the NRA.There is no BIG gun control lobby. Just several well-meaning small ones.Without a well-financed lobby the outlook for any gun control legislation is bleak in our current democracy.
How about a new NRA (“Now Reduce Arms”) or “NRA 2, the sequel” Super PAC for Colbert Nation?
Stephen could pull it off.

A few “fun facts” to throw out to your social network (includes old-fashioned cocktail parties):

The number of children and teenagers killed by guns in Massachusetts was double that killed in motor vehicle accidents during 2003 -2007 (CDC)

Many guns used in school shootings come from the shooters’ homes. (CDC)

The firearm suicide rates among children aged 5-14 was 8 times higher in the U.S. than in comparable high-income countries.

Children in the United States are 11 times more likely to be killed accidentally with a gun than children in other developed countries. On average, 38 children and teens are shot and 8 of them are killed every day in the United States from gun violence.

Guns in a home increase the risk of suicide. NO data supports successful defensive use of guns against homicide. “It appears that gun ownership is associated with a net increase in the risk of death for a typical household.”

Why not tax guns?
“Cigarettes should be $25 a pack to pay for the damage they cost”.  The CDC has estimated that the cost of smoking (estimated cost of smoking-related medical expenses and loss of productivity) exceeds $167 billion annually. The smoker paid approximately $5 a pack up front, but the additional cost of medical expenses and lost productivity is born by all of us taxpayers and anyone who buys health insurance. Raising the taxes on a pack of cigarettes so that they would cost $25 a pack could cover that.
Could they do those calculations for the medical costs, lost productivity, AND  costs of criminal prosecution/civil litigation for gun-related deaths?

“Things NOT to do”:
Put armed guards in schools – “3 COPS SHOT IN POLICE STATION BY ARRESTEE” –  a New Jersey headline December 29, 2012
Increase mental health screening – “The government has no business knowing that you have a dozen AR-158s” says the NRA in defense of the right to privacy. “Why then would the NRA suggest that the government needs to know if your Aunt Jean is arachnophobic?”, says Tabath Southey, Vancouver Globe

In half of my lifetime our culture has moved from arguing that sometimes it was “better to not wear a seat belt in case there was a car fire” to having my grandchildren remind me that I shouldn’t start the car until MY seat belt is buckled.

No ONE law accomplished that, and it happened despite critics and opposition from big time lobbyists. Why can’t we do the same for gun control?

Other sources:
Violence Policy Center, CDC,  and Law Center to Prevent Gun Violence
http://www.nij.gov/nij/topics/crime/gun-violence/prevention/welcome.htm
*Apologies to The Beatles, The White Album


Vol. 80 December 15, 2012 Pet Health Insurance

December 15, 2012

hubThis subject springs to my mind this month
because my friend got a free kitten for Christmas last year.
Her daughter had rescued him from a dumpster.
His name is Charlie.
More on Charlie later.

According to industry statistics $13 Billion (yes, that is a “B”) was spent in 2010 on veterinarian care for pets in 73 million households; a 40% increase over 2006. In 2006 there were about 86 million cats in the U.S. If they could vote, and did so as a bloc, they would bury the 78 million dogs. With the number of pets and costs rising like that, I wondered what the pet health insurance market was like. Does the pet health insurance marketplace have lessons, or even “best practices”, for us in our struggle with health insurance costs and coverage for humans? Is it time for an Affordable Care Act for pets? I decided to take a look.

As I surfed through pet health insurance plans I was struck by the similarities to our (human) health insurance plans of the 70’s and 80’s. The subscriber pays the vet and gets reimbursed 90% of “usual and customary” fees. The companies promise “quick-turn around” of claims, of course. The vet has no forms to fill out or sign. The subscriber does it all. These familiar phrases sound like “the good old days” to physicians who now have two or more full-time office people filling out all sorts of insurance billing forms and/or an IT consultant to do it electronically.

You can go to any licensed vet. There is no concern about “eligible providers” or being “out of network”, but policies do differ from state to state. Reimbursement is not dependent on diagnosis (no need for bulky code books or sophisticated computer programs). None of the policies cover pre-existing conditions or preventative care services (routine visits to the vet). Those are optional coverages available for additional premium.

It all sounds pretty simple and straight forward until you start reading more closely. An asterisk here and a double asterisk there sends you to fine-print footnotes defining “eligibility criteria”, “waiting periods”, “continuing care”, “pre-existing conditions”, and “congenital conditions”. That’s not only identical to our “good old days”, but it also holds true today.

A neighbor just spent $400 on the annual visit and necessary vaccines for his three Labradors. When I asked him if he had health insurance for them, he replied, “No way was I going to spend all that time figuring out what they covered, and when, and for how much. It was too complicated. I struggle enough trying to understand the policies I buy for my employees.”

Pet health insurance was started in Sweden in 1924  and was adopted  in the U.K. around 1947. The first pet insurance policy in the U.S. was written in 1982 for the protection of our TV hero Lassie.  (Do Socialist countries always lead the way in developing health insurance plans?)  NAPHIA, North American Pet Health Insurance Association, was founded in 2007. In Canada there are 10 cat health insurance plans while in the U.S. you have the choice of 36 plans for cats. (Capitalism is so-o-o predictable sometimes)

Back to Charlie….Remember Charlie?….This is a blog about Charlie.
He is an extremely cute, solid black kitten that made my friend’s last year’s Christmas stocking begin to wiggle. When his head popped out with those big, wide open green eyes, the mystery of the stocking was over, and the love affair began. Health insurance for him was available after a mandatory 30-day waiting period (the insurance company wanted to be sure he survived that long I guess).  The waiting period for coverage of “congenital conditions” is 180 days, presumably for the same reason. It would cost from $4.08 per month to $67.14 per month depending on coverage options, BUT excluded preventative care and routine visits to the vet.  After reading Consumer Reports my friend decided not to buy any.

The first visit to the vet cost $103.75. That included $26.00 for a FVRCP shot against Feline Viral Rhinotracheitis, aka “a bad cold”, and $21.75 for a fecal specimen exam. The second visit a month later was $161, and the third month it was $277. That one was higher because of the anesthesia charge for the neutering ($36.00) and a Catalyst Chem 10 test ($62.00). The lab business for pet tests seems as lucrative as for our tests. The neutering operation itself seemed like a bargain at $50.50.  It was only slightly higher than the placement of the ID microchip under his skin. (ER docs and police eat your hearts out!  The technology is here.)

Rather than continue to bore you with the details, suffice it to say, my friend’s “free” kitten cost over $500 for vet visits in the first year alone. I am not even going to try to total up all the other costs because someone else already has.  According to a 2010-2011  survey the average annual maintenance cost of a cat in the U.S. is $1217.

Maybe a “free kitten” should have been included in my list of Christmas presents to give your enemies rather than your friends.  But as the commercial says:

” Vet visits -$500…
Food for a year – $400…
Toys -$21…
Having Charlie’s warm meows greet you when you return home or when you awake in the morning – Priceless!”


Vol. 79 December 1, 2012 Ten Medical Christmas Gifts for Your Enemies

December 1, 2012


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“I once bought my kids a set of batteries for Christmas with a note on it saying, toys not included.” ~Bernard Manning

1. A Gift Certificate for a CT Scan
This is what inspired my slightly twisted view of Christmas giving. Several Christmas’s ago a new private, for-profit imaging center in our town advertised gift certificates for a CT scan to “give to a friend or loved one”. This marketing ploy implied that it was the kind of gift that showed that “you really cared”. Many local physicians considered it as a good gift, not for your friend, but for your enemy.

Besides the considerable exposure to radiation, at least 30% of CT scans performed have an unexpected “finding”; a shadow or bright spot where none is supposed to exist, an organ or other structure that is bigger or smaller than expected, etc. If the radiologist reading the CT scan is particularly compulsive, aggressive, or extraordinarily risk-averse, that “finding” may be called an “abnormality”. Abnormalities need further work-up that usually involves more radiation, use of intravenous and/or oral contrast medium, more aggressive procedures like inserting scopes into various body orifices, and even needle or open biopsy of one of your favorite organs.

Physicians often call these findings, “ditzels“.  Since about one out of three people getting a CT scan will have one or two ditzels that prompt a new cascade of diagnostic testing, this is a perfect gift for an enemy. CT scans are a superb diagnostic tool for people who are sick, but they are so sensitive that they are not so great as a screening tool. If you should ever be told that you have a “finding” on your CT scan, just ask the doctor if it is really significant or is just a “ditzel.”

2. A screening mammogram
 The current controversy surrounding the mammogram as a screening test for breast cancer makes this a perfect gift for that passive-aggressive Ex whose impenetrable ambivalence was so vexing. Data about the number of “false positive” or equivocal results in mammograms that generate lots of repeat imaging, more expensive imaging technology, consultation referrals, biopsies, and even “unnecessary” surgery and chemotherapy has reordered the risk/benefit ratio of screening mammograms. Different scientific groups have different guidelines for when (women can be too young or too old) and how often (annual, every three years, once?) women should get one. Several studies indicate that mammogram screening has not improved the survival rate of women with breast cancer at all. A side effect of the drive for early diagnosis is that “if you look really hard , you find forms that are ultimately never going to bother the patient” (1)

3. A Prostate Specific Antigen (PSA) blood test
This is a very suitable response from the woman who gets a mammogram gift from her despised Ex. This very popular test has lost its initial considerably positive blush as more and more data appeared that the PSA has had no real impact on reducing the death rate from prostate cancer (spoiler alert: deaths from prostate cancer itself are so few that most studies try to focus on “quality of life” measures.). The PSA’s simple number can prompt a lot of unnecessary specialist consultations, biopsies, and even aggressive surgery.

Besides raising your Ex’s anxiety while awaiting the results, an “abnormally high result” suggests the presence of cancer. This usually causes your Ex to enjoy a series of awkward digital (by finger, that is) rectal exams and even multiple long needle biopsies. The biopsy needles are inserted just below his scrotum as he lies flat on his back with his feet up in stirrups (“sweet justice” you might say if you have happened to bear any of his children.)

Of interest to you as his Ex, an abnormally high PSA may also be caused by an ejaculation within the previous two weeks. About 7% of men who do get biopsied (an office procedure) have to be hospitalized within 30 days for post-biopsy complications.  “The overall balance of benefits and harms results in moderate certainty that PSA-based screening…has no net benefit“.

4. A motorcycle for the one you really hate.
About 4,500 people died in motorcycle crashes last year. That is 1 in 7 of people killed on the nation’s roads annually. This is double the death rate in 1997 while car fatalities decreased by 5% last year.  If you are in a motorcycle crash you are 30 times more likely to die than people in car crashes. Of course, if you gift him a helmet he could drop his chances of death by a third. In case he or she doesn’t get the point, include a certificate granting him or her amnesty for NOT wearing a helmet in the 19 states that require it by law.  (2)

5. A year’s supply of vitamins and other supplements
This is the perfect gift for that annoying vegetarian marathoner friend who won’t stop badgering you to eat healthier and get more exercise. The initial response of gratitude at your surprising thoughtfulness and respect for his life style may fade as he reads the fine print or comes across select issues of Consumers Report. Multiple studies in peer-reviewed medical journals have found no decrease in cardiovascular disease, cancer incidence, or death for any reason among multivitamin users. In a study of over 35,000 men the incidence of prostate cancer was  elevated by 17% in those who took Vitamin E supplements. Supplemental calcium (a 1 gram pill per day) with or without any supplemental vitamin D increased the risk of both heart attack and stroke.

Stocking stuffers for those who don’t want to make a big committment, and two holiday tips:
1. gift certificate for 6 sessions in a tanning booth. (for every 4 visits the risk of skin cancer increased by 15%) (Cancer Research Oct. 2011)
2. gift certificate for an MRI for back pain. (2/3 of asymptomatic people showed “serious disk problems” on their MRI) (NEJM 1994)
3. a bumper sticker that says, “Give your kid a motorcycle for his LAST birthday”.
4. a supply of statins (anticholesterol medication) to anyone over 70 yo. (a high cholesterol may decrease heart attacks in the elderly)
5. a chest x-ray to screen for lung cancer (no benefit) (JAMA Oct.26,2011)
6.. forget the cell phone – it won’t cause brain cancer.
7. But remember, if you leave milk and cookies out for Santa Claus make sure they are lactose-free and gluten-free…and FORGET about peanuts. You don’t want a swollen, wheezing Santa Claus with diarrhea stuck in your chimney Christmas morning.

References:
1. Ann Int Med April 3, 2012 , “Overdiagnosis of Breast Cancer” (Bos Globe,G.Welch, MD A11)
2. Cape Cod Times, Nov. 30, 2012, reporting on a recent GAO Report stating that the 2010  societal costs of motorcycles crashes was $16 billion.
3. Choosing Wisely: Tests to Avoid – http://choosingwisely.org/?page_id=13
4. “Surprising Dangers of Vitamins and Supplements”, Consumer Reports Sept.2012


Vol. 78 November 15, 2012 The TWO Oldest Professions

November 16, 2012

A recent visit to Greek/Roman ruins ringing the Eastern Mediterranean Sea reminded me again about how much has changed, and how nothing has changed.

Every guide in Pompei takes their group to see the brothel. On its walls are the best preserved and most colorfully restored frescoes in this Roman town buried under 30 feet of Mt. Vesuvius’s volcano ash in 79 AD. Since most Pompei residents, and certainly the visiting sailors and merchants, could not read nor write, the services offered were depicted by pictures. The picture of each sexual position was marked with its relative price; one, two, or three hash marks. The route to the brothel in this city of crisscrossing streets was clearly marked by a street stone carved with  a graphic phallus and scrotum and a left-pointing arrow showing the way.

At Ephesus, a Roman city in Turkey that rivaled the size of Rome in 100 AD, there are no restored brothel walls. Its most striking restoration is the facade of the Celsus Library, one of the largest if not the largest library of its era. Every guide there gleefully points out the secret tunnel that led from the library to the brothel.  A stone block carved with a single serpent entwined around a winged staff, the sign of a physician(1), rests on the approach to the Celsus Library facade. (That’s a traveling bag from the Duffy Health Center for the Homeless perched on top of the stone.)

In both Pompei and Ephesus one of the temples was used as the gathering place for ill people to be ministered to by special priests. The “admitting process” to these “hospitals” started with an examination of the patient to determine how near death he or she might be. The priests were quite protective of their hospital’s reputation and did not want it to be known as “the place to go to die.” If a patient was considered near death or even with a questionable chance for cure, the patient was instructed to go back home, pray to the Gods for relief, and return in a few days.

This triage process is strikingly similar to the one described to us by the guide at the temple of Amenhotep, Egypt, which we visited on a previous trip. Hippocrates (the “father of medicine”) and later Galen studied at the temple of Amenhotep, and acknowledged the contribution of ancient Egyptian medicine to Greek medicine. The earliest known surgery was performed in Egypt around 2750 BC. The wall hieroglyphics there documented all kinds of easily recognized forceps, cutting tools, clamps, and other surgical instruments.The floor carvings and pictographs in this temple were less formal, but still understandable, and are thought to be the work of “patients” waiting in the gallery to be admitted or to be sent home after “triage” by their priests.

So, generals still fall because of beautiful women, hospitals still worry about their mortality rates, and “how best to die” is still a public issue for discussion, BUT now-a-days the hieroglyphics are electronic (2).

References:
1. The caduceus with TWO serpents entwined around a winged staff, now considered the physicians’ sign,  was actually the sign for merchants, commerce, and the god Mercury.
2. The Telegraph (UK) reported that the FBI had 20,000 – 30,000 pages of communication, mostly emails, between General Allen and Ms. Kelly.


Vol. 77 November 1, 2012 Obamacare and Romneycare: Are They Different? Do You Care?

November 1, 2012

The New England Journal of Medicine invited President Obama and Governor Romney to submit statements of their health care platforms for publication. They were published in the October 11 issue. Below I have extracted only the concrete action elements in each statement. I have omitted tedious repetition “of the problems we face” since we are all familiar with those. I have made no attempt to discern or define any “code words”.  Both statements do not include all of their plan’s elements since these statements are specifically directed at physicians. I hope to have highlighted only what each candidate will try to do when they are President“ in their own words”.

President Obama
“Securing the Future of
American 
Health Care”
Governor Romney
“Replacing Obamacare with
Real 
Health Care Reform”
-restore health care as a basic pillar of middle-class security -Repeal Obamacare
-maintain employment-based health insurance -keep employer-sponsored coverage
-small business able to pool together for leverage on private insurance rates -facilitate purchasing pools and open up an interstate market
-tax credits to small business to provide worker coverage -empower people to buy their own insurance plans
-tax credits for middle class families who don’t get coverage at work -insurers will compete for the business of these price-sensitive, quality conscious consumers
-establish strong consumer protections as they purchase insurance
-revise Medicare flaws that threaten physician reimbursement -genuine entitlement reform but no change to Medicare for those who are now over 55 yo
-form Accountable Care Organizations and initiate bundled payments to providers -develop a set of Medicare insurance plans to choose from with premiums set by competitive bidding. Will always include a fee-for-service plan.
-reduce health-care associated infections and preventable admissions -FDA committed to a practical and predictable approval process
- have 30 million currently uninsured begin to purchase affordable coverage in 2014 -government will provide premium support for poor and sick
-medical malpractice reform but no arbitrary caps on awards -medical malpractice reform (with federal caps for awards)
-interoperability of information technology
-convert Medicaid to a block grant program to allow flexibility for the states
-children up to 26 yo covered under parent’s plan (2010) -already accepted by insurance companies due to market forces
-no exclusion for pre-existing conditions in children -prevent insurers from excluding people with pre-existing conditions who maintain continuous coverage
-already accepted by insurance companies due to market forces
-”BOTTOM LINE” in President Obama’s words:
-everybody should have the basic security of health care
-we will work together to implement and improve this plan
-we will be better off 5, 10, and 20 years from now if we do this
-”BOTTOM LINE” in Governor Romney’s words:
-markets over regulation
-doctors and patients over bureaucrats
-tailored state programs over a Washington solution
-reformed insurance markets with fair competition
-real entitlement reform

What each says about the other’s plan

President Obama says that Romney  will Governor Romney says that Obama will
-cause excessive copays of preventive care -cause $1 trillion in increased taxes
-eliminate 1600 NIH grants -not reduce Medicare costs by $470 billion
-convert Medicare to a voucher program and cut funding by 1/3 - expand coverage by using the broken Medicaid system for 1/3 of the newly covered
-make millions for insurance companies and hurt seniors and the disabled with a voucher program -provide no long-term solution to entitlement crisis
- undo progress made toward a more coordinated delivery system -create an unelected board of 15 bureaucrats to cut costs without congressional approval

What others say:

On Romney – “When Mitt Romney campaigned in 2002 to become governor of Massachusetts, he offered no hint that he would lead the enactment of the most consequential state health care reform law in U.S. history…His [current] Medicare and Medicaid proposals would irrevocably transform these programs. His budget and tax proposals would threaten the country’s basic health infrastructure as few in living memory have done. One can only hope that if elected President, Romney would surprise the United States as he did Massachusetts.”   NEJM 367 Oct. 18.2012, Eli Adashi, MD et al.

On Obama – Not heavy enough on penalties for non-compliance with the individual mandate, not far enough on the reorganization and reimbursement of care, not far enough on reforming of physician reimbursement “which is the most dysfunctional part of Medicare”, “too modest  bonuses” for improving quality, not far enough on alternative physician reimbursement to encourage multi-specialty group practices, BUT too far on ACO’s which should be just a pilot program since their outcomes are not proven. It is not “market-friendly”. “If market-friendly Medicare reform is your aim, a good place to look is the plan proposed by vice-president candidate Paul Ryan.”  NEJM 367 Oct.18.2012, Gail Wilensky, Ph.D.

My 2 cents worth: President Obama says “this election offers a fundamental choice between two very different visions for the future of the country.” In terms of health care reform, I am not too sure of that. I remember the expanded coverage and cost “containment” (better called “cost shifting” in both plans) elements in the Romneycare of Massachusetts. At this point the election looks like a toss-up. Clearly it is difficult to understand Obama’s complicated plan and all its unintended consequences and real costs, but it is impossible to even guess about Romney’s unrevealed ones.

We shall begin to see after January when the Supreme Court Chief Justice says  “Will the real President of the United States please stand up.”


Vol. 76 October 15, 2012 The High Life and A Good Death

October 15, 2012

“Hey, D-u-u-de!”
-The Big Lebowski, 1998
.

“She had a good death.”
-traditional Irish Catholic saying

On Nov. 6 Massachusetts will vote on two medically related referendum questions: Medical Marijuana and Physician-Assisted Suicide.  In the spirit of transparency and to offer a break from mind-numbing candidate debates, I offer this short commentary on the two…and a proposal to combine them.

Ballot Question 3: “Do you approve of  a law that would eliminate state and criminal and civil penalties related to the medical use of marijuana allowing certain patients to obtain by a physician’s prescription marijuana  produced and distributed by new state-regulated centers,or, in specific hardship cases, to grow marijuana for their own use?”

Short name: Medical Use of Marijuana
A better name: “Marijuana by request of certain consenting adults”
Street spin: Very positive

Who’s against it:  AMA and Mass Medical Society – Concerns: “The slippery slope” What’s next? Legalization of marijuana?
Local police very concerned about increased cost of investigating and enforcing multiple backyard plots.
Anti-Smoking organizations.
When Congress passed the Marijuana Tax Act in 1937 making it illegal for anyone, including doctors, “to move cannabis without proper documentation”, the AMA opposed the bill!  (1)

Who’s for it: Lester Grinspoon, MD (2), most people under 50, and anybody who answers to the name, “Dude.”

What does the data show: Illegal marijuana is currently a bigger cash crop in Kentucky than tobacco. There are more medical marijuana shops in Denver than Starbucks. It IS (is NOT) a “gateway” drug…take your pick of positions…data supports both. 17 states have legalized medical marijuana.

Worst case scenario: Prescriptions for marijuana surpass number of prescriptions for SSRIs, Ritalin, and Oxycodone… or maybe that would be an improvement?

Economic implications: Could be a significant economic stimulus… in Kentucky, at least. The price of medical marijuana in California and Colorado is half the price that illegal marijuana was.

Possible future headline: “Legal Marijuana Aids Economic Recovery, Second Only to Casino Development.”

Ballot Question 2: “Do you approve of a law that would allow a physician licensed in Massachusetts to prescribe medication, at the request of a terminally ill patient meeting certain conditions, to end that person’s life?”

Short name: Physician Assisted Suicide
A better name: “Death with Dignity by request of certain consenting adults.”
Street spin: How can anything be positive about the term “suicide”? “Physician-assisted dying” is closer to the reality.

Who’s against it: AMA and Mass Medical Society; incompatible with the “curative and healer” roles of physicians – Concerns: “The slippery slope” What’s next? Lethal injections for psoriasis?
We can’t always be certain of which months are “the last 6 of my life”, but about 83% of hospice patients were right in one study.
Who’s for it: Many members of Ethics Committees in acute care hospitals who have helped patients and families endure prolonged, high-tech deaths.

What does the data show: Since its passage in 1997 less than 100 Oregon patients per year have requested end-of-life medications. In 2011 only about one-half of the people getting such prescriptions in Oregon actually took the pills. (Maybe it IS a question of patients’ desire for lost autonomy and control) In Oregon 90% of requesting patients were enrolled in a hospice program and nearly 90% had cancer.

Worst case scenario: Patients may desire more power over their medical life as well as their medical death.

Economic implications: May have positive impact on medical care costs if people choose not to go into hospitals and be admitted to ICUs in the last 6 months of their life.

Possible future headline: “AMA Admits Physicians Can’t Cure Everyone, Calls For More Dignity In Dying”

Proposed Ballot Question 4: “Do you approve of a law that would allow physicians to prescribe marijuana to end the life of a terminally ill patient?”

Short name: “Physician Assisted Dying by Marijuana”.
Street spin: It will never happen. Marijuana is the ONE drug that can NOT cause a lethal overdose (unlike alcohol, aspirin, and the others). Dr. Grinspoon described it as “remarkably non-toxic”. He initiated his intensive research into the effects of marijuana when he observed its benefits in his son undergoing chemotherapy. (His wife got the marijuana for Danny in the parking lot of a local high school because Dr. Grinspoon was initially so skeptical of its effects).(1)

References:
1. “Where’s the Pipe?”, Casey Lyons, Boston Magazine, October 2012
2. Marijuana Reconsidered, Lester Grinspoon,MD; 1971 and Marijuana:The Forbidden Medicine; 1997


Vol. 75 October 1, 2012 Is Great Grandma a Danger on the Road?

October 1, 2012

Drivers ages 80 and older have the 2nd highest fatal accident rate of any age group,
BUT the accident rate among drivers over 75  is half the accident rate for drivers who are between the ages of 35 and 44  and one fifth of the accident rate of drivers who are under the age of 19.
In the next 20 years, the number of elderly drivers in the United States will triple.
Should every state require doctors to report their concerns about the ability of older drivers to safely be on the road?
33 states do so now.

My two aunts, Aunt Nin and Aunt Do, were both looking forward to their day in court.

Actually, it was “Granmamere’s” day in court. She was 88 years old and had been involved in a car accident. No one had been injured, but she was cited by the police for some driving infraction or another. The twin aunts were looking forward to having the court take her license away, since they had been unsuccessful over many months to get here to give up driving.

“Granmamere” lived alone in an apartment complex in Newburgh, N.Y. Today we would call it “assisted living”, but that marketing term wasn’t yet created in the 60’s. She was hale and hearty and loved to drive, but her reflexes were getting slower. She had the means to hire a driver, and the aunts were increasingly concerned about her safety, and the safety of others, with her on the road.

She had to appear before the judge in Dobbs Ferry, a town just south of Newburgh and her old hometown.  She and her twins sat patiently in the hot, stuffy courtroom waiting for the court to plow through all the other cases. As the cases droned on and on that summer day even the judge’s majestically leonine head undeniably began to bob and nod above his stolid, black-robed pillar of authority as he, too, fought against the post-lunch doldrums.

Finally, “Granmamere’s” case came up.

“The State of New York vs. Pauline Ramsdell Odell”, intoned the bailiff.

The judge’s head immediately bolted upright and directed his now clear, piercing gaze directly at the defense  table, “Is that you Pauline?”

“Why yes.” was her quick reply.

“We will have a 15 minute recess, and the plaintiff is invited back into my chambers for a private conference”, announced the judge.

Having to remain in the courtroom my aunts could only guess what the judge and “Granmamere” were talking about.

“Case dismissed”, proclaimed the judge when court resumed.

“Oh shit”, thought Nin and Do.

“He was one of my high school flames”, chirped “Granmamere.”

“Granmamere” drove for another year without incident before giving up her license voluntarily.

She died peacefully in her sleep several years later.

A study from Ontario Canada in last week’s New England Journal (1) reported that a physician warning a patient over 18 yo. that they were at risk for a motor vehicle accident decreased the subsequent visits of “warned patients” to the ER for car accident trauma by 27%  for all ages. Only one-third of the patients in the study were over 75 y.o., BUT the decrease in event rate per 1000 patients after the physician’s warning was the greatest in this age group.

Of interest is that Ontario Province designated “warnings to unfit drivers” as an “affirmative duty” ( a requirement) of physicians in 1968. Compliance was very low until 2006 when they started paying physicians $36.25 to provide such warnings. Unintended side-effects of the warning may have been increased ER visits for depression and decreased return visits to the same physician.

References:
1. New Engl J Med 36;13 September 27, 2012, p.1228


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