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Lifestyle and habits

When Posting Baby Photos Became Illegal

Though no identifiers such as names or contact information are included, it is illegal for doctors and midwives to post photos of the babies of their patients on their office wall, though this has been a common practice since not long after the advent of photography.

Under HIPAA (the Health Insurance Portability and Accountability Act), baby photos are a type of protected health information, no less than a medical chart, birth date or Social Security number, according to the Department of Health and Human Services. Even if a parent sends in the photo, it is considered private unless the parent also sends written authorization for its posting, which almost no one does. A thoughtful piece in The New York Times mulls over this and is worth the read for those involved with protecting health information. The comments are thought-provoking as well, such as this one:

“Yes, the HIPAA privacy rules do forbid public displays of baby pictures. That’s perhaps too bad, but it’s not life threatening.

“The real problem with the HIPAA privacy regulations is that while they do address a real issue – the use and often abuse of private medical information for non-medical purposes (for example marketing), the rules have brought about a much more serious problem: the frequent inavailability to legitimate health care providers of important medical information regarding patients, information these doctors (and other providers) need to make urgent, life saving, medical decisions.

“The HIPAA rules and data security requirements are well intentioned, but complex and difficult to implement, and the penalties for non-compliance severe. In the real world it’s hard for the custodians of medical data (such as hospitals) to prohibit unauthorized access, while at the same time permitting it for care providers with a real need to know. And sometimes medical care suffers as a result. The security requirements can be particularly troublesome, as it’s hard with present technology to implement data security that is both secure and functional.

“HIPAA regulations will probably some day find the right balance. But we’re not there yet. And medical care is sometimes shortchanged as a result.”

Certainly the IME and peer review industry has been impacted in recent years, as has the larger world of health care and insurance, with ongoing focus and concerns on maintaining data security, to where it is a cornerstone of providing quality services to claimants. As this reader notes, it is important to remember what the purpose of these industries is—providing for the health of the patient—and to ensure our procedures all work to this end.

The Happiness Calculation for Smokers

How do you quantify happiness levels? The question has relates to a longstanding requirement — first codified under the Clinton administration — that every set of federal regulations with more than a $100 million effect on the economy needs an analysis to prevent the adoption of regulations with high costs and low benefits.

Now it is being applied to the government’s new tobacco regulations proposed this past April, specifically to a cost-benefit calculation which assumes that the benefits from reducing smoking — fewer early deaths and diseases of the lungs and heart — have to be discounted by 70 percent to offset the loss in pleasure that smokers suffer when they give up their habit.

Is this a problem? Well, yes, according to many, as the proposed regulations could water down the agency’s ability to regulate tobacco products. If the formula for assessing costs and benefits remains unchanged in the final version of the regulations, it could set a dangerous precedent that would constrain public-policy making for years to come.

“This is the single biggest obstacle facing the F.D.A. in executing the job Congress gave it,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, an advocacy group. “There’s no way the F.D.A. can do its job if this is applied.”

An F.D.A. spokeswoman, Jennifer Haliski, said that there was “still a great deal of uncertainty” surrounding the calculation, and that the agency was helping fund research to explore the issue. So far the Food and Drug Administration has received at least 69,000 public comments on the new regulations, some quite high profile. Earlier this month a group of economists, including one Nobel Prize winner, weighed in, asking that the calculation be changed before the ruling takes effect. Read more…

Trying to Bring Down Oz

Concerned with the public health impact of Dr. Mehmet Oz’s health advice, in 2013 University of Rochester medical student Benjamin Mazur asked state and national medical associations to take action. However, though for over a hundred years the federal government has passed legislation and created agencies to prevent consumers from being deceived or harmed by “bad medicine,” the situation is a complicated one. For instance, though the Federal Trade Commission has the legal authority to prosecute people who mislead and injure consumers, they can’t do anything about Oz since he’s not actually selling the products he talks about.

With regard to his concerns, Mazur noted: “I’m definitely not the only one.”  Sen. Claire McCaskill, for instance, told Dr. Oz during a Capital Hill hearing: “The scientific community is almost monolithic against you in terms of the efficacy of…three products that you called miracles.”

Mazur explains his concerns:

This issue was brought up by a number of physicians I worked with during my family medicine clerkship. We had all of this first-hand experience with patients who really liked his show and trusted him quite a bit. [Dr. Oz] would give advice that was really not great or it had no medical basis. It might sound harmless when you talk about things like herbal pills or supplements. But when the physicians’ advice conflicted with Oz, the patients would believe Oz.

Mazur is not entirely anti-Oz, of course; as he explains, “I would probably say that he does have the health interest of his viewers in mind. But in the long term, undermining good science and the relationship patients have with their current physicians is probably doing much more harm than good. If they’re not going to listen to advice from physicians—who are providing good, evidence-based advice—if they’re going to listen to other doctors on the show, it’s going to do more harm than good.” Read more…

The Growing Risk of Measles

MCNTalk has written about the question of foregoing childhood immunizations multiple times over the past few years. As these two articles (Measles Cases in U.S. Reach a 20-Year High and Putting Us All at Risk for Measles) notes, consequences of individual choices are serious ones, not just for those involved in the decision to not vaccinate, but for society at large. As editorialist Pauline W. Chen, MD succinctly explains: In any given population, there would always be individuals who would not develop immunity to measles, even after receiving the vaccine, or who could not receive the vaccine because they were too young (less than a year old) or had immune systems already weakened from diseases like cancer or AIDS.

But health care experts discovered that if at least 95 percent of a community were immunized against measles, all the members of that group would be safe. Even if someone with the disease entered the community, the immunized majority would serve as a “buffer zone” preventing further spread to unimmunized individuals.

The initial study indicating a possible connection between vaccinations and autism has been thoroughly debunked, and its author debarred from the practice of medicine for ethical lapses, but the number of measles cases in the US and worldwide continues to increase. In fact, measles remains the greatest vaccine-preventable cause of death among children worldwide. At what point do individual rights outweigh the public good? Read more…

Opioid Deaths Drop in Florida as the State Cracks Down

Prior postings have decried deaths and abuse in prescribing of opiates. Florida was the poster child of abuse, with strip mall featuring “pain clinics” where patients from other states would fly into to receive bogus prescriptions.

The sheer number of prescriptions nationwide has helped drive abuse in the United States. In 2012, more than 259 million prescriptions for pain pills were dispensed, federal researchers said, enough for every American adult to get a bottle of them. For the past decade, more than 20,000 Americans have died each year from prescription pain pill overdose.

As this article and associated editorial demonstrate, change is possible. Florida and other states have made a good start in curbing abuse. Lives have been saved in the process. There is more to be done in curbing the misuse of opiates for chronic pain. Opioid painkillers are dangerously overprescribed, but Florida has shown how states can confront this problem.

Politicians’ Prescriptions for Marijuana Defy Doctors and Data

Brian L. Grant MD

This is a fascinating article on a number of levels. The comments by readers as well as the article are illuminating. I come to it as a person who came of age in the 70s, trained in psychiatry and reside in Washington State. I also have an interest in medical anthropology which among other issues looks at cross-cultural health care systems and beliefs. Finally, I have a strong interest in medical politics and economics which are major drivers of policy and practice in US Healthcare.

Washington State is one where medical marijuana (cannabis) is legal and recreational marijuana will be legal in July with a rigorous permitting and taxation system. In observing the medical marijuana “industry” and practice in Washington, what has been clear is that it is a parallel system whereby anyone can obtain a prescription for medical marijuana and that a tiny minority have the sorts of diagnoses such as glaucoma, terminal pain, cancer, and the like that were invoked to justify medical marijuana in the first place. Furthermore, given the wide array of symptoms that may be “helped” by medical marijuana, most of which are subjective, such as pain and anxiety – there is not a person reading this post who could not receive authorization if they so choose. The dispensaries that provide pot use nice euphemisms such as “medicine” to describe cannabis, and “donations” as what one pays to receive their medicine. Whether one can obtain marijuana while declining a donation is not clear.

So in my view, medical marijuana at least in principle, if not in practice, is by and large a sham. It makes liars out of decent people who want to get high, have a good time, harm nobody in most cases, and perhaps relieve some real symptoms. Similarly, it promotes disingenuous behavior on the part of practitioners who prescribe it, some of whom are true believers, but all of whom are paid good money to write a script often based upon one visit with someone they will never see again.

Therefore, with reasonable reservations and concerns, one should be pleased to see marijuana become legal for recreational use. Like alcohol, which was touted during prohibition as having medicinal value as a way to access whiskey and other drinks  and more, read here and here), marijuana as a medical substance has by and large been a back door to access by those who want to smoke it for its mood altering attributes.

There are many similarities between alcohol and marijuana. Both are substances that can alter one’s thinking and are psychoactive. Both can be sources of enjoyment and conviviality and both can and do cause harm. One is by and large legal and the other not and therein lies the problem. If we as a society wish to ban all substances and behaviors with potential for harm, the list would be long, not end with alcohol, and would certainly start with tobacco and include excessive caloric consumption and other quite legal and common substances. Unlike alcohol, or increasingly prescribed opiates, marijuana has little propensity for physical addiction and tolerance.

Relatively speaking, the end organ damage and aggressive behaviors that excess or chronic use of alcohol induce significantly outweigh the degree of harm seen in typical marijuana users. The numbers of those who use alcohol abusively with resulting damage to themselves or others is significant. Since marijuana use is generally defined as abuse per se, studies looking at actual damage from the use of marijuana need to focus on objective rather than regulatory criteria. Is marijuana harmless? Of course not. Dosages are imprecise as one smokes something with inconsistent intake and varying amounts of active THC. “Edibles” can be misused or accidentally fall into the hands of children. One can simply lack balance and overuse marijuana in lieu of more productive and useful activities, just as could happen with alcohol consumption. And the impact of smoking marijuana is of unknown concern as at least one study suggests that lung damage from typical use is not an issue.

Neither cannabis nor alcohol belong in the hands or mouths of children and make no mistake – increased access to either creates some collateral damage that non-use would avoid, just like opiates or the 70 MPH speed limit on the highways.

Interesting systemic questions include: What is the role of the health care system in deciding that it owns a portion of the human experience, or that something is a medical issue rather than a component of general life? What are the economics of the system and the impact of a substance like marijuana that can be easily grown and distributed outside of the pharmaceutical industry with no inherent barriers to entry other than access to sun or artificial light, soil, fertilizer, water and seed stock? Could there be an element of those in power wanting to maintain control of an income stream, resulting in criminalization, and restrictive regulations along with false or distorted claims of harm to control distribution and access?

Finally, what damage has flowed from criminality of cannabis? How many have died as a result of criminal and gang drug traffic? How many harmless individuals have been prosecuted and jailed for use or distribution of marijuana? How many of the judges, prosecutors, and jurors sitting in judgment on these defendants can with a straight face deny their own use of cannabis in their own lives at some point? What can we learn from countries like Holland where cannabis has long been legal?

We are about to embark on an experiment in Washington state, already started in Colorado, with legal recreational marijuana. The ultimate results remain to be seen. Whatever one’s personal views on legalization of cannabis, facts and data should inform both personal and government decisions on the policies and use of cannabis and other products. Unfortunately the subject is often polarized by advocates and opponents.

Judge Upholds Policy Barring Unimmunized Students from School during Outbreaks

Brian L. Grant MD

MCNTalk has been following the vaccination refusal controversy for some time. As noted in this recent Times article, a NY court has affirmed the right to deny access to schools by unvaccinated children when another student is ill with a vaccine-preventable disease.

These particular cases are interesting because they illustrate a clash in values between sincerely held beliefs, religious or otherwise, and the public good. It leaves unanswered or at least unresolved the question of whether beliefs may trump good science. Also un-addressed is the practice in place whereby one can invoke religion where convenient, though scriptures are silent on vaccines and many other practices that individuals may choose to invoke religion to justify or excuse behaviors and choices.

Vaccines are a medical miracle that have virtually eliminated smallpox, diphtheria, measles, pertussis, and polio, maladies that have killed and maimed untold millions in the world and which can easily re-emerge when there is a sufficient number of unvaccinated to allow for transmission from person to person, versus current herd immunity that keeps the diseases in check.

Beyond the bad science claiming dangers of vaccinations are the polarizing effect of well-meaning parents and others who have come to believe these claims, clashing with other parents and authorities who do not want to support policies that in turn support the unvaccinated exposing their children and others to preventable risk.

The comments by readers, available along with the article, contain many compelling arguments worth considering on the topic.

Are Doctor Ratings Misleading?

Have you ever read their on-line ratings before you’ve gone to see a new physician? It seems like a logical thing to do — after all, you’re trusting a stranger to make decisions about your health that are quiet likely to be life-affecting. That is, after all, why you are going to see them in the first place.

Yet just how useful or accurate are on-line ratings? This Atlantic Monthly article explores the question, pointing out some obvious dilemmas: reviewers are often influenced by secondary considerations such as easy access to parking or their waiting room experience, and there’s no guarantee that the reviewer was even seen by the physician being reviewed.

To top it all off, there is evidence that satisfied patients are not the best cared for or healthiest. A March 2012 study in the Archives of Internal Medicine showed that patients with the highest satisfaction scores were more likely to be taking prescription medications, visit doctors’ offices, and enter the hospital. They were also likelier to be in poor health and die in the ensuing years. Read more…

30% of the world’s population is overweight

Almost a third of the world population is now overweight or obese – about 2 billion people worldwide. No country has been able to curb obesity rates in the last three decades, according to a new global analysis released in May, led by Christopher Murray of the Institute for Health Metrics and Evaluation at the University of Washington. He and colleagues reviewed more than 1,700 studies covering 188 countries from 1980 to 2013.

“Our children are getting fatter,” Dr. Margaret Chan, the World Health Organization’s director-general, said bluntly during a speech at the agency’s annual meeting in Geneva. “Parts of the world are quite literally eating themselves to death.”

Read more…

Gender Differences in Behavioral Skills

by Laura McFarland, MCN Communications Director

A gender difference in behavioral skills, seen as early as kindergarten, is hurting boys’ academic prospects and their earning potential:

In an economy that rewards knowledge, the academic struggles of boys turn into economic struggles. Men’s wages are stagnating. Men are much more likely to be idle — neither working, looking for work nor caring for family — than they once were and much more likely to be idle than women.

My son is six, and though he reads at a middle school level and figured out on his own that if the square root of sixteen is four, the square root of four must be two, it would probably take him two hours to put on his pajamas or brush his teeth if left unattended. Why? Because of the pirates he needs to battle, or the book he can’t put down, or the Legos that come across his line of vision. We talk about how one of my jobs as mommy is to help him learn how to focus on the task at hand.

Frequently I think it must be hard to be a six-year-old boy and constantly be told not to touch something, put that down, leave it alone. He is, after all, amazing. I wouldn’t want him to be anyone other than who he is, and I am just beginning to see how lucky I am to know him. Is what we are teaching him enough? Is he too young for us to worry about his economic future? Articles like this one, “A Link Between Fidgety Boys and a Sputtering Economy” give me pause, to say the least.  

I also have a four-year-old daughter, so part of me is celebrating what I’m reading – wasn’t this the goal, to reach a point where the school system did not reward one group of people based on the behaviors they were allowed solely because of their membership in a group, one which no one else could join? Isn’t it wonderful, the opportunities in store for her?

But clearly we have not reached our goals if people are not learning the skills to be able to support themselves and feed their families. This is true whether we’re talking about education or peace in the Middle East. As author David Leonhardt is wise to note, every group faces their own challenges. And the points he makes are well worth addressing regardless of which group of people he means:  

The problem doesn’t simply involve men trying to overcome the demise of a local factory or teenage boys getting into trouble. It involves children so young that most haven’t even learned the word “gender.” Yet their gender is already starting to cast a long shadow over their lives.