Duncan Sheik – Daylight

My episodic efforts as a music critic returns. I have become somewhat obsessed with Duncan Sheik’s Daylight. If you are interested in reading my review – Daylight Sheik

Prostate cancer dilemma

First, check out these 2 links to articles about the prostate cancer surgery articles. Prostate Cancer Surgery Found to Cut Death Risk (NY Times headline) – Prostate Cancer Therapies About Equal: Having Surgery May Extend Patient’s Life (Washington Post headline). So what did the articles really say? I printed out the articles last night and digested them. While I need to consider the data a while longer, I will try to summarize my reading.

• • This is a Scandanavian study. Thus, we cannot learn if their are any racial differences. This is important because prostate cancer is a bigger problem for African-Americans than Caucasions.
  • Most patients entered this study with symptoms – only about 5% came from screening
  • The average age on study entry was 65. The data may not extrapolate to those patients in their 50s
  • Given those caveats, the disease – prostate cancer – benefits from radical prostatectomy. Less patients die from the disease. Less patients have metastases after a median followup of 6.2 years.
  • Despite improvements in treating the disease, the overall mortality did not differ at 6.2 years. The patients in the watchful waiting randomization more likely died of prostate cancer, but less likely died of other causes.

Quality of life overall did not differ, but separate components did differ. Surgery leads to more erectile dysfunction and urinary incontinence. Watchful waiting leads to more urinary obstruction.

• This study gives me more data to present to patients. I could use those data to support either side. I suspect urologists (who are surgeons) will focus on the disease benefits. I understand that position, but would argue that each patient must have his life expectancy estimated, and his preferences for side effects elicited. The decision for or against surgery is still not a slam dunk.

Another important study is still underway.

Some answers should emerge from a study, now under way, sponsored by the Department of Veterans Affairs, the National Cancer Institute, and the Agency of Health Research and Quality. It includes 731 men, mostly veterans, with localized prostate cancer, usually found by a P.S.A. test. Half were randomly assigned to have a their prostates removed and the rest to watchful waiting. The study is to continue until 2008 unless a clear survival advantage emerges for either the surgery or watchful waiting.

So far, five years into the study, no such advantage has appeared, said Dr. Timothy J. Wilt of the Minneapolis V.A. Medical Center.

“I would like to conclude that while the Swedish study is a very important piece of information, when put into context, the preferred treatment for prostate cancer still is not known,” Dr. Wilt said.

The two articles and a well written article appear in today’s New England Journal of Medicine.

Important and underappreciated

The Invisible Women – describes the plight of home health aides.

This is important work. Home health care is much cheaper and, for patients, generally preferable to lengthy hospital stays or other forms of institutionalization. And as the baby boomers continue to age, home care will become more and more common — not just in New York, but across the nation.

So now would be a good time to stop the utter exploitation of these workers, who are among the most poorly paid and poorly treated that you can find. There are more than 20,000 home health aides in New York City. Most are paid a pathetic $6 or $7 an hour. Some are paid less. Nearly all of the workers are women, and most of them receive no health care, no sick pay, and get no vacations.

Primary care troubles

As I have stated many times, insurers and society treats primary care physicians poorly. Many in this country want to blame our competitive insurance industry and lack of a single payor. This article throws cold water on that theory – One in five GPs ‘plans to quit’ – oops this is British article!

Thousands of GPs are planning to quit their jobs over the next five years, two government studies reveal.

A report for the Scottish Executive suggests that one in five doctors will leave general practice by 2007.

A second study for the Department of Health in England suggests that an even higher proportion of doctors south of the border are considering quitting.

The findings indicate that 7,000 doctors will leave general practice over the next five years and raise serious doubts over government plans to tackle the shortage of GPs across the UK.

The vaunted NHS (national health service) abuses GPs!!

The Scottish report, compiled by the National Association of Primary Care Research and Development Centre at Manchester University, found overwork and stress are the main reasons why GPs want to leave.

…

The main things influencing their dissatisfaction were paperwork, administration, demand from patients and organisational change.”

So the primary care crisis appears an international phenomenon. Patients want a relationship with a single generalist. Physicians enjoy that relationship. But those physicians have become devalued and suffer work abuse (in my opinion).

A colleague recently made me aware of a well written, thorough article in the August 21, 2002 JAMA. The following link gets you the abstract – and you can read the article if you have a subscription – A Primary Care Home for Americans: Putting the House in Order

The clearest symptom that these combined factors are creating stresses in primary care practice is the frequent complaint about lack of adequate time during office visits. As noted earlier, growing numbers of US primary care physicians believe that they cannot spend sufficient time with patients. Physicians in other nations voice similar complaints. Paradoxically, there is no evidence that the actual length of office visits in the United States is getting shorter. Between 1989 and 1998, the mean length of a primary care office visit in the United States increased from 16.3 to 18.3 minutes. What explains this paradox of longer average visit times and physician complaints of less adequate time? One explanation is the increasing distractions that cut into meaningful patient care time. The average family physician or internist in the United States wastes 40 to 50 minutes each day on managed care administrative hassles. However, the clinical demands on primary care physicians during the typical office visit are also increasing. In the face of heightened expectations for comprehensiveness, accessibility, coordination, continuity, and accountability in primary care practice, a decade’s addition of 2 minutes to the average visit time is experienced as losing rather than gaining ground.

I highly recommend the entire article. My frustration comes from understanding the problem, but not being able to visualize a proper solution. It actually is about money, because money buys time.

In obesity, we are not alone

Obesity will ‘become the norm’. Obesity may become as big a crisis in GB as in the US.

Three-quarters of the UK population could be overweight within the next 10-15 years, top experts have warned.

They say obesity will overtake smoking as Britain’s top preventable killer.

And they have accused the government of being too scared of the food and transport industries to tackle the problem properly.

I guess the blame culture lives across the pond. We should blame industries because people eat too much and exercise too little. Poppycock!

Restrictions will not work. We need to provide options. We need more fast food with low calories and reasonable portions. Subway does great business, and the do have reasonable food on the menu.

We need to make exercise easier and more desirable. Use positive reinforcements and change behaviors. But please do not blame and regulate.