Saturday, December 31, 2005

America's "Bottom 10"?

There's an interesting challenge that has been issued by Alexandra at All Things Beautiful -- it seems that British historians have put together a list of the ten worst Britons in the last 1000 years, one for each Century, for the BBC History Magazine. Since one good list deserves another, Alexandra decided to issue A Challenge To The Blogosphere: 'The Ten Worst Americans' List:

It is very interesting how a few names are emerging as a constant. On everyone's lips and the number one favorite is Benedict Arnold, very closely followed by Jimmy Carter, Joseph McCarthy, Richard Nixon, George Soros, Aaron Burr, Julius and Ethel Rosenberg (no particular order). Jane Fonda has appeared on quite a few lists, and so has George Bush, J. E. Hoover, John Kerry, Lyndon Johnson and Alger Hiss.
Given my lack of proper attention to anything meaningful in my decadent youth, I defer the nomination of historical figures to, well, those bloggers who read something other than science fiction in high school (I'm trying to catch up; at least I read Atlas Shrugged when I was 15!.). It's kind of fun to peruse the thoughts of bloggers coming up with names -- sometimes of folks I would not have necessarily thought of as among the "worst." The lovely Atlas, for example, listed Robert E Lee ("His military genius actually prolonged the agony of the Civil War") and John Sherman ("author of the >Sherman Anti-Trust Act, 15 U.S.C. Crucial turning point in the descent of the American economy was the passing of anti-trust laws").

From a purely contemporary standpoint, I nominate Arthur O. Sulzberger, Jr., publisher and chairman of the New York Times. Since the time I was old enough to read the paper, the "Gray Lady" has steadily been given over to the mad rantings of the far left in this country. A sane man would have long ago sent MoDo and Krugman packing, to follow Howell Raines into obscurity. By extension, I would have to state that the majority of these folks should be nominated to round out my "bottom 10," especially Gail Collins, the editorial page editor. The shrill, anti-American, anti-anything-positive-about-Bush/GOP, heavily Democratic Party-biased nature of the editorials have led many to follow the advice of a friend of mine: "I read the NY Times editorial page just to find out how far left the Democratic party will lean this week."

On the other hand, I'd like to name Will Shortz, the crossword puzzle editor at the NY Times, as a personal fave --- I can't get through the week without a challenging Sunday Times crossword.

UPDATE: Perhaps even the NY Times' public editor might agree with me (just a little bit). Hugh Hewitt may as well:
Perhaps by January 2, 2007 the New York Times will have gotten around to admitting that its reputation as a reliable reporter of facts was lost long before Jason Blair and has never been recovered, that Maureen Dowd and Paul Krugman are jokes among most center-right Americans and a good portion of the left as well, that Valerie Plame has always been a non-story, that leaking of top secret surveillance programs of al Qaeda conducting surveillance on it sagents in America etc etc etc was the problem, not the rise of a new information network.

Friday, December 30, 2005

'Coaching' in labor makes little difference, UT Southwestern researchers say

Does this mean that expectant dads should go back to smoking cigars in the waiting room?

Tuesday, December 27, 2005

80 hour week Redux

This month's American Journal of Surgery contains an interesting article from the Dept. of Surgery at Baylor in Houston entitled Impact of the 80-hour work week on resident emergency operative experience. As I have written previously, I am not convinced the 80 hour work restrictions will deal an even hand to surgeons in training, or their future patients.

The current study is a retrospective comparison of the emergent operative experiences of PGY-4 and PGY-5 residents before (group 1) and after (group 2) imposition of work hour restrictions. Similar to a previous study published in JACS (reviewed extensively by Dr. Bard Parker), overall operative numbers were essentially unchanged between the two groups. However, the residents' "numbers" were preserved by increasing performance of less complex, less emergent procedures that were previously performed by more junior residents:

The mean total of procedures per resident as primary surgeon was similar between the groups. However, a qualitative analysis of the level of technical complexity of laparotomies showed an obvious shift from advanced to basic procedures: a resident in group 2 (after work hour restrictions) performed, on average, 40% fewer advanced laparotomies compared with those in group 1. In addition, there was a concomitant 44% increase in the mean number of basic laparotomies done by residents in group 2.

(in the comments section) In other words, senior residents are now preserving their "numbers" by encroaching on the operative experience of their juniors. The long-term consequences of this phenomenon are obvious and must be addressed.
Additionally, there was a dramatic drop in the residents' experience acting as first assistant or as teaching assistant in major emergent operative procedures:
An 82% reduction in the opportunity to participate as a learning first assistant in a major abdominal trauma procedure means that a senior resident will often be called upon to do a major trauma case without ever having had the opportunity to see one. Similarly, fewer cases done as teaching assistant translate into less opportunity to develop operative independence and technical self-confidence. Surgical training is thus evolving into a "read one, do one" situation.
While some may not feel that decreased operative experience is necessarily a bad thing (I don't share that view), what was more striking was the change in continuity of care.
The total number of cases that required a return to the operating room for another procedure during the same hospital stay remained the same throughout the study period. However, in group 1, 60% of reoperations were performed by the same resident who did the original procedure. This percentage dropped to 26% in group 2.
I have always felt that continuity of care is one of the most important hallmarks of general surgery; basically, the surgeon shoulders the responsibility to see his or her patient through the perioperative period, and be the one responsible for returning the patient to the OR in the case of an adverse event if at all possible. In fact, the surgeon's ability to deal with postoperative complications is perhaps his/her most important asset. If residents are only taking their own patients back to the OR a quarter of the time, they are missing out on what I would consider a critical part of their education. From the article's abstract:
Conclusions: The ACGME regulatory environment is adversely affecting the emergency operative experience of surgical residents. Our findings underscore the need to develop alternative methods to augment the residents' operative experience.
For another perspective, Dr. Parker has had other interesting posts about this subject -- here, here, and here.
Experience is the worst teacher; it gives the test before presenting the lesson.
Experience teaches only the teachable.
—Vernon Law

Grand Rounds -- The Last of '05

Matthew Holt is hosting the last Grand Rounds session of 2005 at The Health Care Blog; it's a good roundup of this year's medical blogging.

This is a special edition as it’s the last of 2005 and so I’ve asked my fellow bloggers for their best posts of 2005. For some of them, like any great soccer player whose best goal is their last, their best post is their most recent. But for many we’ve gone back into the archives. There’s some great stuff, and some great series of posts too. So let me act like the consultant I am and put it into sections, and act like the blogger that I also am, and give you some not so unbiased commentary. Oh, and it’s pretty long with some nearly 60 posts mentioned. But you weren’t doing anything else this week, were you? So settle in and enjoy.
It's worth the time to read, as there are a lot of great posts to be seen!

Saturday, December 24, 2005

Glass Half Full

Some time ago, I wrote a post about the Porkbusters effort that has been supported by a number of folks across the blogosphere. I feel it is high time that our congressional representatives take a stance against the astounding degree of wasteful "pork" spending that gets tacked on to otherwise needed legislation. The best analogy I can come up with is this:

Imagine you are a new father, with bills to pay, a baby to feed, and diapers to buy. Your wife sends you out to the grocery store to pick up those few items that you [a] need and [b] can afford. If you act like a US Senator, you promptly call 99 of your drunk frat brothers to join you, who then load the grocery cart with every last item that they desire....because they are not paying for it. Beer, chips, soda, guacamole dip, a big screen TV, etc., all of the great things you could have if you had an unlimited budget; and all on your tab, sometimes without the money left over to buy the things you truly needed.
Now, imagine the hell you'd catch when you got home with an empty wallet and with your buddies taking home the goodies to their houses! I can tell you SWIMBO would be so mad it would be hot tongue and cold shoulder for dinner that night, and every night for a good year. It is amazing to me that the US taxpayers don't respond in the same manner, and that we accept the idea that "pork" in legislation is simply a fact of life. It. Does. Not. Have. To. Be!

I wrote my two Senators, asking them to support the Fiscal Watch Team Offset Package --- which basically says that we need to cut out the extras in order to pay for true national needs, such as Katrina relief. One has finally responded, and although he did not specifically endorse the Porkbusters effort, he did state (emphasis mine):
"In short, I will be open to any and all proposals that will effect greater discipline. If we must change Senate rules, current law, or even amend the Constitution to instill fiscal discipline in this process so be it."
Ok. The glass is half full. Perhaps we may be able to get Congress to change its rules so that last minute spending does not get tacked on to, for example, a highway bill. Perhaps pigs will fly too, but one can hope. In this era of easy communication with your congressional representatives (believe me, you and your internet savvy friends can send a lot of emails), it's time to put the pressure on those folks, and keep them out of your grocery basket.

Tuesday, December 20, 2005

The Death Star of American Medicine

I wish I had written this (JCAHO Unplugged; registration required), because it gives voice to the feelings that I (and probably 99% of the physicians in this country) have about the Death Star of American medicine -- JCAHO. A few excerpts (emphasis is mine):

That is why it really upsets me to watch the JCAHO people walk through my hospital like they were navigating a toxic waste dump. What upsets me even more is the utter paralysis of normal activity that occurs months before their visit and the huge sums of money spent on mock drills and consultants to prepare for the JCAHO invasion. JCAHO (the Joint Commission on Accreditation of Healthcare Organization) arouses more fear in hospitals than MRSA gone wild, and their "visit" has a greater institutional paralytic effect than circulating a neuromuscular depolarizing agent through the ventilation system.

A few unsigned verbal orders, or an anesthesiologist carrying a syringe of Anectine in his or her scrubs, or not locking up I.V. bottles of normal saline will result in conditional or provisional approval, and failure to take remedial action within 30 days may result in the death penalty, which for the hospital means bad PR, and more significantly, loss of all federal money. That's right, you can get the chair for parking tickets in the JCAHO world.

It doesn't matter that the hospital admits 50,000 patients a year, saves countless lives and performs daily miracles. Write q.i.d. twice and you can get your liver transplant someplace else.
A response by Russell Massaro, MD, FACP, Executive Vice President Accreditation and Certification Operations, JCAHO, follows Dr. Cossman's screed. The only thing I can say about it is that he makes clear that unannounced surveys will be forthcoming in 2006. Oh, joy!

A lot of the press in the past few days has been discussing issues such as oversight, accountability, and clearly expressed legal authority. JCAHO operates without any real semblence of these niceties, and does so with all the subtlety of a bureaucracy run by Darth Vader. Watching hospital administrators lose bowel and bladder control the minute a JCAHO inspection is brought up has always reminded me of Vader's underlings wilting in his presence --- and for good reason. Without the JCAHO seal of approval, they cannot operate an otherwise well-run, caring facility. The organization, as it was originally intended, was designed to ensure a basic level of safety for all hospitals. It has now become yet another "certifying" agency which must come up with new "critical" problems to fix in order to ensure its ongoing existence (those of you who have gone through the most recent mental masturbatory experience of banning QD and QID in orders know what I mean). What is most galling to me, however, is that hospitals must fork over a hefty sum for these frequent torture sessions, and the inspections are done not by practicing physicians or nurses, but by folks who long ago gave up the difficulties of actually caring for patients for the safety of a clipboard to hide behind.

Maybe I have my metaphors mixed up --- JCAHO comes in like the Death Star, but leaves no room for different institutions to solve problems in their own way. The JCAHO mantra can really be translated as "Resistance is futile. You will be assimilated!" As a result, I suppose JCAHO is really The Borg.

Grand Rounds

Medpundit is hosting Grand Rounds this week --- take a stroll over to her place and check out this week's best medical blogging!

Thursday, December 15, 2005

Purple Celebration


This photo is a cause for celebration, in Iraq, in the US, and anywhere people love freedom. (Tip of the hat to Lifelike Pundits)

Another Criminal Charge for a Colorado Health Care Provider

As noted in a previous post, manslaughter charges have been brought against a Colorado physician who removed a tracheostomy tube in a patient who subsequently suffered respiratory arrest and anoxic brain injury. While unusual, this incident was soon followed by another manslaughter charge -- this one against a nurse in Colorado:

A former nurse at the Denver veterans hospital is accused of killing an elderly World War II vet in 2003 when she disabled a machine monitoring the oxygen level in his blood. Carol Elkins was treating William Thomas Leslie when she disconnected a pulse oximeter, which resulted in his death, according to a federal indictment unsealed Tuesday.

Federal involuntary manslaughter charges were brought because this incident occurred at a VA facility, where federal authorities have jurisdiction. According to the article, federal authorities will be notifying state regulatory authorities.

Why does removal of this monitoring device matter, and what does it involve? Basically, a pulse oximeter measures how well a patient is receiving oxygen, and how well he is delivering that oxygen to his tissues. In the event of respiratory compromise or cardiovascular failure, the pulse oximeter will alarm to allow potential intervention. If the unit is disconnected, the patient may become hypoxic without anyone knowing. Pulse oximeters are used throughout the hospital in a variety of situations, and the newspaper reports don't specify why this patient needed one. As for its removal, the indictment does not state why the nurse would have disabled the unit; a "mercy killing" is not suspected.
The government contends that Elkins was bothered by noise from the monitor.
Interestingly, this incident was apparently not reported to the state health department, which is required by law. It was also not an issue with this nurse obtaining another job two years ago; a routine pre-employment check turned up nothing of substance:
Elkins was suspended Tuesday from her job in an adult medical unit at the Medical Center of Aurora, where she had worked for about two years, according to spokeswoman Beverly Husted-Petry.....She said there was no report of any alleged incident at the veterans' hospital.
Despite the lack of a report to the state health department, the family was able to press for, and receive, a civil settlement from the Dept. of Veterans Affairs. To make their case, prosecutors will need to have plenty of witnesses who will be able to back up their charge of "wanton and reckless disregard for human life;" or, as in the case of Dr. Hogle in my previous post, this may be a case of an error in judgement that led to a very bad outcome. Or, given the financial settlement from the VA, this could also have resulted from a "system issue," rather than the erroneous, or criminally negligent, actions of a single nurse. And if I was an ICU nurse caring for critically sick patients, I'd worry about the potential for criminal charges in the event of an unexpected death.

Tuesday, December 13, 2005

Grand Rounds

Grand Rounds are being held this week by Derek Lowe at In the Pipeline. Take a gander at the best of the medical blogs this week!

Not all slippery slopes in Colorado are at the ski resorts

Something interesting occurred in Denver, Colorado the other day -- a physician was arrested and charged with manslaughter. This is not a typical case of jealousy, financial problems, an auto accident, etc. He was arrested for something he did in the care of a patient. Obviously, all of the facts of the case are not well known, but there has been some new information come to light since the original charges were filed and noted in the news.

The physician, Dr. Greg Hogle, is a 56-year-old Denver ENT specialist. He was referred a patient with a tracheostomy tube in place, and saw her on April 8, 2005.

(another physician) referred the case to Hogle after concluding the patient likely needed surgery to repair blockage, court records show. She sent images of the blockage with the medical records. But Hogle told investigators that the patient was accompanied by a woman who had trouble translating from Russian to English. The doctor decided based on his examination to remove the tracheostomy tube, records show.
The patient, Khusni Yusupova, age 46, developed swelling at the tracheostomy site and therefore difficulty breathing after she left Dr. Hogle's office. She was taken to the hospital, but suffered significant anoxic brain injury before a new tracheostomy tube could be placed. She was taken off life support and died two days later.

So, what happened? Without the records, it's difficult to speculate; it does seem, however, that this patient had upper airway obstruction and was not able to breathe without a tracheostomy.
According to the Denver Medical Examiner report, the only way she could have breathed at the time of her death is through her neck.
It also appears that the treating physician did not adequately review the patient's history and records; the history was likely difficult to obtain due to translation issues.
Denver Police say Dr. Hogle admitted he removed the tube without reviewing Yusupova's medical records, which she had brought to the appointment.
So, based upon his examination, Dr. Hogle decided that it was safe to remove the tube -- this presumably involved an examination of the upper airway with a determination that it was patent enough to allow breathing through the mouth and nose, with no obstruction to air flow. He was wrong, and admits he made an error in judgement:
Hogle admitted to police, "I made a serious mistake." He went on to tell police, "she did need the tube for her airway...because she had an obstructed airway, it means she did need the tube and I made a mistake."
Criminal charges might seem to be unthinkable in delivery of medical care, but actually occur -- including relatively recently in Colorado.
In a highly publicized case, a Denver anesthesiologist was charged with manslaughter after prosecutors alleged he fell asleep during a routine surgery in 1993 at St. Joseph Hospital. The patient, an 8-year-old boy, died during the operation. After two manslaughter trials, the doctor, Joseph Verbrugge, was ultimately convicted of a misdemeanor, but that conviction was later thrown out on appeal. He was stripped of his medical license.
But there are other wrinkles to this case. To muddy the waters further, the coroner ruled the death a suicide. Why? Be cause this relatively young lady had a tracheostomy and an obstructed upper airway as a result of an attempt to take her own life.
The report doesn't dispute that Dr. Hogle's decision played a role in the death. However,the report reveals that the reason Yusupova had the tracheostomy tube in the first place was because she had " ... Ingest(ed) ... A caustic liquid (concentrated acetic acid) in a suicide attempt months earlier." Therefore, the coroner ruled "the manner of death is suicide."
What is interesting to me is the apparent lack of involvement by the Board of Medical Examiners, with criminal charges being filed before the BME has made even preliminary recommendations public. Under most circumstances, cases that appear to be egregious failures of judgement and care are rapidly dealt with by the Board. That process allows a complete review of the medical issues and facts, so that an appropriate action can be taken (see the case above where despite the anesthesiologist not being convicted, he was stripped of his license).

While I do not have at my disposal all of the case data, the fact that criminal charges have been filed, for an error in judgement in the delivery of medical care, is worrisome to me. All physicians make errors, just like the remainder of humanity. What about this case rises to the level of criminality? And as we stand atop that slippery slope, that is the crux of the issue. When I or one of my colleagues makes an error in judgement that results in death, will we too be criminally charged?

UPDATE: Colorado Medical Society President Dr. Rick May issued this statement about the charges against Dr. Hogle:
"In medical practice, bad things can happen to good people, and good doctors can and do make mistakes. These are not purposeful assaults. They are errors, however rare, that we all work very diligently to prevent. Medical mistakes are not criminal, clear and simple, and should never be dumped in the criminal justice system. Colorado's civil justice system allows our patients broad rights to seek redress through the courts, and the State Medical Board has full legal authority to discipline an errant physician, including license revocation."

Sunday, December 11, 2005

Reheating the Leftovers

I always appreciate nicely designed, well-executed studies that address a common problem in a sensible manner. Such is the case with a report in this month's Journal of the American College of Surgeons (subscription required, but abstract available). It comes from Turkey (hardly a major contributor to American surgical literature), and is the lead article this month --- "Use of Resterilized Polypropylene Mesh in Inguinal Hernia Repair: A Prospective, Randomized Study," by Asim Cingi, M.D., et al.

The article addresses the resterilization of polypropylene mesh, such as when only a portion of a larger sheet of mesh needs to be used for a given operation. The authors initially evaluated mesh that was manually manipulated, divided into smaller pieces, and resterilized. Sort of like reheating leftovers.Subsequent cultures proved to be negative, and tensile strength was only minimally altered. They then embarked on a double-blinded, randomized study, placing either "virgin" or divided and resterilized polypropylene mesh in patients undergoing first-time inguinal hernia repair. No differences were noted in either group (total 184 patients) with a median follow-up of two years.

OK, so what's the big deal? Actually, we're talking about a significant amount of cash, particularly in poor countries. Inguinal hernias are extremely common, and it has been very well-established that the recurrence rate for non-mesh repairs is unacceptably high (in adults), leading to lost work and productivity.....an even bigger problem in poor countries. If larger sheets of mesh can be "tailored" to be used in several operations, the costs to the health system in developing countries will be significantly lower. This might allow increased mesh use in those regions, lowering recurrence rates to about 2%. As my daughter would say, "cool beans."

What about here in the good old USA? Actually, this was done routinely back in the dark ages (when I was but a wee intern), but was subsequently abandoned, primarily over theoretical concerns with HIV infection. I would love to see a much larger similar study done here, with standardization of how the mesh is handled and sterilized, potentially to include resterilization of large sheets that are cut to size on the "back table." The specter of prion disease is also one that would have to be dealt with. I suspect the results would be similar; I also suspect that study will never be done here, due to potential liability issues (can you imagine the consent form that your local IRB would come up with?).

Disclaimer : I'm not just the president of The Mesh Club For Men; I'm also a client! I got my mesh in 2004!

Sunday Ear Candy

It's been a long weekend, and it ain't over yet! Oh, well, at least I got to sleep last night; tonight may very well be a different story. After two emergency laparotomies today, rounds, and spending time in medical records so the hospital will hopefully let me continue to practice here, the past hour has been spent on....paperwork! I am having fun, however, as I have a new 'puter, with great speakers, and I have loaded more than a few CDs onto iTunes. so, the drudgery of paperwork has been eased by the company of Yes, Van Morrison, The Kinks, Jeff Beck, John Wesley Harding, Elvis Costello, and the lovely lady Diana:



























At least I have a little ear candy to get me through the day. Even as someone who cannot carry a tune with a forklift, I have always loved music; fortunately, the surglings have inherited SWIMBO's talents, and can all play (quite well, if I may brag). I, on the other hand, can play the stereo with grace and accomplishment!

Thursday, December 08, 2005

CPOE Difficulties

Dr. Andy reviews a very interesting study about computer physician order entry, which has been found to be a bit troubling at one pediatric hospital. A cautionary tale, to be sure, but worth being aware of.

Wednesday, December 07, 2005

Tuesday, December 06, 2005

Catching up with Grand Rounds and the Medical Weblog Awards

I've been remiss lately in pointing anyone interested towards Grand Rounds. This week's edition has been put together by the always entertaining Dr. Charles --- well worth the time to read!

Additionally, Medgadget is taking stock of the medical blogosphere in a different way, asking for nominations for the 2005 Medical Weblog Awards. A very nice person was kind enough to nominate me --- why, given my recent lack of posting, I have no idea --- which is quite flattering!

Monday, December 05, 2005

Pandora and the NHS

I haven't much felt like blogging lately -- I blame it on a combination of excess turkey intake, too much work, and good old fashioned procrastination. While there are certainly a few posts percolating around the few remaining sulci in my frontal lobes, nothing has sprung forth in a frenzy of keystrokes (yet).

I did find something interesting recently while perusing the news, however. It is the kind of governmental decision that generates all sorts of interesting dilemmas, all under the guise of saving money and "doing what's right for patients." It will also generate rather intense debate, I suspect. Fortunately for those of us on the western side of the great Atlantic pond, this debate will be taking place in Great Britain. It seems that the National Health Service has issued a "guidance" to physicians permitting them to refuse to treat a patient if they judge that an illness is self-inflicted. It also appears that this directive has already been an undeclared policy for some NHS physicians:

The guidelines will be introduced as a poll shows that one in five doctors admits that he or she has already denied patients treatment because they drink heavily, smoke or are obese.
Wow. It seems that Pandora's box has been nicely untied and opened, not by the lovely Pandora herself, but by bureaucratic fiat!
Just as Pandora loosed a torrent of ills for humanity upon opening that crate, the potential ramifications of this decision may be quite far-reaching (and beyond the expectations of those who crafted it). To be sure, the obvious self-inflicted diseases can be, and frequently are, listed by any second grader:
  1. Smoking, with the potential sequelae of lung, oropharyngeal, and bladder cancer; COPD/emphysema; coronary artery disease; peripheral artery disease....
  2. Alcohol abuse, which may result in cirrhosis and liver failure; pancreatitis (acute or chronic....and eventual diabetes); alcohol-related accidents and injuries; withdrawal; depression.....
  3. Drug abuse, a culprit in hepatitis and liver failure; endocarditis; renal failure; severe dental problems (seen particularly in meth abusers)....
  4. Obesity, which can lead to diabetes; sleep apnea; heart disease; degenerative joint disease; depression; steatohepatitis;....
That's a laundry list of potential medical problems that some physicians may not feel bound to treat unless the patient chooses a different lifestyle. No one can argue that it is imperative for patients with these issues to take charge of their own health, quit smoking, stop drinking, lose weight, etc. It appears, however, that the real reason behind this decision is a bit less idealistic, and a bit more pecuniary in nature:
This weekend Sir Michael Rawlins, chairman of the National Institute for Health and Clinical Excellence (Nice) said the guidelines would ensure that the limited National Health Service budget was well spent.... He singled out alcoholics by saying the institute├é’s new social value judgments will make it clear that if patients continue to drink they will not be given a liver transplant....The Nice guidelines state that care cannot be denied simply on the grounds that a condition is self-inflicted. However, according to a draft of the code to be debated next week, the treatment can be withheld if the patient├é’s lifestyle affects the success or cost effectiveness of the operation.

I know that Sir Michael Rawlins must be in a difficult position, trying to help a nationalized health system be both a deliverer of good medical care and be fiscally responsible. Make no mistake, however --- this is health care rationing (which has always gone on in the British system), but it is doing so while singling out certain types of behavior which clearly cost the system a lot of cash.

One could easily argue that we in the US do this all the time --- the morbidly obese patient may be told to lose weight before having a total knee replacement, the smoker may be told to quit before the distal bypass can be done --- but it is hardly an official policy of our "system" as a whole. There is certainly no unanimity among American physicians about which patients should and should not receive certain types of therapies. Nor, I suspect, will there ever be.

Perhaps before the British (or we) embark on such a policy, it might be a good idea to expand the above laundry list, and look at a wider array of diseases that have a hefty self-inflicted component:

  1. Sexually transmitted disease from promiscuity -- including HIV, with all of its financial ramifications; HPV infection resulting in cervical cancer; STD induced infertility...
  2. Sporting activities --- leading to orthopedic injuries, head injuries, and later development of arthritic conditions requiring expensive joint replacement surgeries
  3. Tattoos and piercings --- associated with a higher risk of hepatitis
  4. Sun-worshippers and tanning salon users --- obviously risk development of skin cancers
  5. Loud music --- those who like to listen to "head banger heaven" on MTV are at a huge risk for hearing deficits in the future
  6. Political junkies --- risk mental illness and ulcer disease when their party leaders make boneheaded statements, and may get lund disease while inhaling the orations of political windbags

Yes, the last one was (a bit of) a joke. In the long run, it will be difficult to make such blanket decisions that affect only one type of self-inflicted disease. Those of you who are familiar with the legend of Pandora (ok, ok, I had to look it up!) will remember that she opened the box a second time, and released Hope. I would hope for a more market-based approach --- if patients are a bit more responsible for the financial costs of their health care, they may be more incentivized to change their behavior.

A few British reactions can be read at The Scotsman and at this pro-smokers' rights site.