I enjoy collecting pertinent quotes. This quote appeared in the latest issue of JAMA. I love it! It has made the db Quotes of Fame list in the right column.

An education isn’t how much you have committed to memory, or even how much you know. It’s being able to differentiate between what you do know and what you don’t.
- Anatole France

Prostate Cancer Indolent in Early Stage, More Aggressive Later

Early-stage prostate cancer has an indolent course but becomes more aggressive after about 15 years, according to the results of a long-term cohort study published in the June 9 issue of JAMA. The investigators recommend earlier radical treatment, whereas the editorialists are more conservative and recommend waiting for results of ongoing long-term intervention trials.

“Without understanding the natural history of prostate cancer diagnosed at an early, localized stage, patient counseling and clinical management are difficult. The challenge is to maximize the possibilities for survival without extensive overtreatment,” write Jan-Erik Johansson, MD, PhD, from Orebro University Hospital in Sweden, and colleagues. “Even without initial treatment, only a small proportion of all patients with cancer diagnosed at an early clinical stage die from prostate cancer within 10 to 15 years following diagnosis…. However, little is known about disease progression and risk of death beyond 10 to 15 years of watchful waiting.”

Of 223 consecutive patients from central Sweden with early-stage, initially untreated prostate cancer who were observed for a mean period of 21 years, 49 patients were still alive at 15 years, and 39 patients (17%) had generalized disease during complete follow-up. At enrollment, classification was T0-T2 NX M0. Symptomatic patients with tumor progression underwent orchiectomy or estrogen treatment.

Although most cancers had an indolent course during the first 10 to 15 years, the course became more aggressive from 15 to 20 years. During that time, there was a substantial decrease in cumulative progression-free survival (from 45.0% to 36.0%), survival without metastases (from 76.9% to 51.2%), prostate cancer–specific survival (from 78.7% to 54.4%), and prostate cancer mortality rate (from 15 per 1,000 person-years during the first 15 years to 44 per 1,000 person-years beyond 15 years of follow-up (P = .01).

This study adds to our understanding of the natural history of prostate cancer. It does not answer the question that continues to plague physicians and patients - how should we best manage early prostate cancer.

We have ongoing studies which are comparing aggressive management and watchful waiting. This article does not (in my opinion) invalidate the goals of that study.

Certainly, as patients get older (with lower life expectancy), the urgency of aggressively treating early prostate cancer decreases. Hopefully, we will gain more information that will allow us to best understand when to convert from watchful waiting to aggressive therapy for younger patients.

Validated Model Predicts Mortality in Patients With Acute Coronary Syndrome

An international research team has developed a prediction model that appears useful in assessing the 6-month risk of death after hospitalization for acute coronary syndrome (ACS).

Using data from the Global Registry of Acute Coronary Events (GRACE), Dr. Kim A. Eagle, from the University of Michigan in Ann Arbor, and colleagues created a risk-prediction model for death within 6 months of hospital discharge. The model was developed using a cohort of 15,007 patients and then was validated in a group of 7638 patients.

The researchers’ findings are published in the June 9th issue of the Journal of the American Medical Association.

The 6-month mortality rates in both cohorts were nearly the same-about 4.7%, the authors point out.

In creating the model, the authors identified nine variables that were predictive of mortality: older age, prior myocardial infarction, heart failure history, increased heart rate at admission, low systolic blood pressure at presentation, increased initial creatinine level, increased cardiac biomarker levels, ST-segment depression on initial ECG, and not undergoing angioplasty/stenting while hospitalized.

Since I care for inpatient VA patients, this article is very important. Three factors strike me as extremely important - heart failure history, increased initial creatinine level and lack of PCI during hospitalization. I plan to use this article regularly.

Resistance Training Curbs Diabetic Peripheral Neuropathy

In the study, 11 elderly type 2 diabetics with clinical evidence of peripheral neuropathy engaged in roughly 30 minutes of supervised resistance training of the lower extremities three times per week for 12 weeks. “This was a pilot study to see if this was doable and to see if we could get some good data –and we did,” Dr. Kurian said.

Resistance training was associated with improved muscle strength in the calf (p < 0.05) and hamstring (p < 0.005) and a reduction in waist circumference (p < 0.01), systolic (p < 0.05) and diastolic BP (p < 0.01), and an increase in HDL cholesterol (p < 0.01).

Resistance training also led to improvements in scores on the Michigan Neuropathy Screening Instrument and the Neuropathy Disability Score (p < 0.05 for both). "Vibration sense in the foot measured by the on/off method" was also improved in both feet (p < 0.05), Dr. Kurian and colleagues note in a meeting abstract.

Based on these results, the investigators suggest considering resistance training in the management of type 2 diabetics with peripheral neuropathy.

Sure, this is a small study, and we must await confirmation of the results. Nonetheless, I favor resistance training for all adults. Few of us have jobs which help us maintain muscle mass. Resistance training works to slow muscle mass loss, increase metabolism, and decrease injuries. It might help in other ways - like this article suggests.

Dr. Jeffrey Friedman disagrees with prevailing opinion. This article explains his view: The Fat Epidemic: He Says It’s an Illusion

But Dr. Jeffrey Friedman, an obesity researcher at Rockefeller University, argues that contrary to popular opinion, national data do not show Americans growing uniformly fatter.

Instead, he says, the statistics demonstrate clearly that while the very fat are getting fatter, thinner people have remained pretty much the same.

Let it be said that Dr. Friedman, a Howard Hughes Medical Institute investigator and the discoverer of the gene for leptin, a hormone released by fat cells, is not fat. He is tall and gangly, with the rumpled look of an academic scientist.

As an obesity researcher, he might be expected to endorse the prevailing view that obesity in this country is out of control. But Dr. Friedman said he was outraged by the acceptance of what he sees as a hurtful myth, one that encourages people to believe that if you are fat, it is your fault.

The obesity arena “is so political, so rife with misinformation and disinformation,” he said.

Dr. Friedman points to careful statistical analyses of the changes in Americans’ body weights from 1991 to today by Dr. Katherine Flegal of the National Center for Health Statistics. At the lower end of the weight distribution, nothing has changed, not even by a few pounds. As you move up the scale, a few additional pounds start to show up, but even at midrange, people today are just 6 or 7 pounds heavier than they were in 1991. Only with the massively obese, the very top of the distribution, is there a substantial increase in weight, about 25 to 30 pounds, Dr. Flegal reported.

As a result, the curve of body weight has been pulled slightly to the right, with more people shifting up a few pounds to cross the line that experts use to divide normal from obese. In 1991, 23 percent of Americans fell into the obese category; now 31 percent do, a more than 30 percent increase. But the average weight of the population has increased by just 7 to 10 pounds since 1991.

Dr. Friedman gave an analogy: “Imagine the average I.Q. was 100 and that 5 percent of the population had an I.Q. of 140 or greater and were considered to be geniuses. Now let’s say that education improves and the average I.Q. increases to 107 and 10 percent of the population has an I.Q. of above 140.

“You could present the data in two ways,” he said. “You could say that the average I.Q. is up seven points or you could say that because of improved education the number of geniuses has doubled.”

He added, “The whole obesity debate is equivalent to drawing conclusions about national education programs by saying that the number of geniuses has doubled.”

He has studied the data, and I have not. Nonetheless, obesity remains a major health risk (which he does not deny). Whether we have an epidemic or just a continuation of the status quo is (in my opinion) moot. I care for one patient at a time, and that patient will do better as they approximate ideal body weight.

The Democrats will not allow tort reform and the national level. Fortunately, many states understand the issues more clearly. 3 states pass tort reform; others still waiting

State lawmakers in most cases aren’t agreeing to the doctor-sought $250,000 noneconomic damages cap in medical malpractice lawsuits. But as numerous state legislatures wrapped up sessions in recent weeks, several made other strides toward reforming the tort system physicians say is driving up insurance costs.

New Jersey, Ohio and Oklahoma passed bills. Tightening expert witness requirements and creating funds to help offset rising medical liability insurance premiums are among the adopted reforms. Oklahoma doctors came up the biggest winners with a $300,000 noneconomic damages cap that applies per case.
In New Jersey, doctors say the changes will help. But, they add, the new laws are just a first step in the fight to stop physicians from retiring early, giving up high-risk procedures and moving to states with affordable insurance premiums.

This issue remains the most important issue in health care! Without a better way to handle malpractice we will eventually have decreased access to care. Physicians cannot practice when overhead exceeds reimbursement.

Reagan’s Next Victory

The outpouring of respect and affection for Ronald Reagan — the principled president and principal Alzheimer’s victim — may help resolve the impasse blocking greater federal support of the use of embryonic stem cells in biomedical research.

Today’s stem-cell debate is more far-reaching than Iraq, tax policy or Medicare. How do we follow the promise of genetic cures for terrible diseases without falling into the abyss of unrestricted human cloning?

President Bush wrestled with this two years ago. He came up with a compromise that permitted federally financed research on the few cell lines existing then, but not on new lines until we thought this issue through.

Embryonic stem cells may bring new life to dying organs, including the brain. They are taken from blastocysts, the union of sperm and egg that — less than two weeks old — can fit on a pinhead. Opponents say the harvesting of these cells destroys potential human life; proponents say these are left over from in vitro banks and already destined for destruction, donated by people to whom “pro life” also means saving the lives of suffering patients.

I ranted on this issue recently - On stem cell research

My thoughts have not changed, and I doubt that the opinions of the opponents will change either.

ADA Guidelines Recommend Statins for Most Diabetics

Dr. Clark said the ADA decided to add statins to the guidelines after seeing the results of a British study, published earlier this year in The Lancet, which showed that statin use can lower stroke risk by one third. Their study included adults over the age of 40 whose total cholesterol levels were as low as 135.

Dr. Clark said diabetics are a special case. “It is now a consensus that having diabetes is the equivalent in terms of cardiovascular risk of already having had a heart attack,” Dr. Clark said.

Alabama is number 1 in the nation - for prevalence of type II diabetes mellitus. One must become skilled at helping patients manage diabetes mellitus. This NY Times article does a nice job summarizing the problem - Type 2: From Mother to Daughter, Shared Genes and a Burden

Type 2 diabetes is more strongly inherited than Type 1, which occurs when immune cells destroy the insulin-producing cells of the pancreas. As recently as 15 years ago, most children and teenagers who developed diabetes had Type 1. Today, with obesity common among the young, clinics report that a third to a half of the new cases of childhood diabetes are Type 2, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

The family tie is an indication that Type 2 diabetes has genetic foundations, as is the fact that the disease is prevalent in certain ethnic groups: Hispanics, African-Americans, American Indians, Alaska Natives, Asian-Americans and Pacific Islanders.

But genes cannot account for the soaring rates of diabetes in the United States. What’s changed are the eating and exercise habits of Americans. About two-thirds of American adults are overweight or obese, as are about 15 percent of children from ages 6 to 19. And overweight people tend to be sedentary.

“As someone once said, genetics loads the gun, and the environment pulls the trigger,” said Dr. Judith E. Fradkin, of the National Institute of Diabetes and Digestive and Kidney Diseases. “In Type 2 diabetes, it’s clearly a combination of the two.”

I have previously blogged my mneumonic for diabetes management, but since that was a while back, here goes again:

• Feet care
• Lipid management
• Eye exams
• Control
• Kidney, screen for early kidney disease and treat hypertension
• Shots - i.e., keep immunizations up to date

As physicians we must help our type II diabetic patients receive optimum care. Patients should treat this disease with great respect, and understand that their actions have a major impact on their results.

50 year old man with known cirrhosis is admitted to our service with a mild exacerbation of his ascites. His hemoglobin has dropped 2 gms, so we scheduled him for an endoscopy.

On admission he appears volume contracted. We give him IV fluids over night, then obtain this electrolyte panel:

This week’s question:

1. Explain the bicarbonate level of 18. What further testing do you need?

Case #1

A 45 year old man (known HIV) is admitted with headache, fever and nausea. An LP reveals the diagnosis of cryptococcal meningitis and therapy with Amphotericin-B and 5-FC is initiated. One week into therapy the patient has become more “confused”. Lab data at this time reveal:

and

Your questions to consider:

• Why is the patient hypernatremic and what test would you order?
• What is the acid-base disorder and what further testing do you need?

1. Why is the patient hypernatremic?

We considered central diabetes insipidus and nephrogenic diabetes insipidus. We felt that central was more likely (secondary to the meningitis). Secondary causes of nephrogenic diabetes insipidus include lithium, severe hypokalemia and hypercalcemia.

We obtained a serum osm = 315 and a urine osm = 150. The patient responded to DDAVP with resolution of the dilute urine and normalization of the serum sodium, confirming a central diabetes insipidus.

2. What is the acid-base disorder and what further testing do you need?

The patient has a normal gap acidosis. We first performed a urine anion gap to distinguish between renal acidoses and bicarbonate loss (usually diarrhea).

Urine Na 25 Urine K 45 Urine Cl 38 Urine AG +32
Urine pH 6.0.

Positive urine anion gap confirms a renal cause. The elevated urine pH in the setting of acidosis makes Type II or distal RTA the diagnosis. As several commentors noted, amphotericin B is known to cause a distal RTA. The patient’s acidosis corrected with supplemental bicitra.

Kudos to Instapundit for alerting me to this article - The Barriers Don’t Exist

When I was originally asked to write the designated dissent piece for TIME’s special issue on obesity, I went back and forth with a fact-checker over my assertion that state and federal governments prevented health insurers from tying health insurance premiums to risk – the same way car and life insurers do. Charging everyone within a group plan the same amount for health insurance removes an important financial incentive to stay healthy, and forces fit people to subsidize health care for the not-so-fit. Allowing folks who keep the weight off and the blood pressure and cholesterol down to pay less for health insurance (and allowing health insurers to provide it to them) would also strike a needed blow for personal responsibility in the obesity debate.

The problem is that though several health care policy experts told me they were certain health insurers were barred from such “medical underwriting,” no one could say exactly why. In fact, I talked to several health insurance companies themselves, and none could point to any specific law, regulation, or case law laying out the prohibition. I even called tort king John Banzhaf, who – believe it or not – is actually on record supporting lower premiums for fit health care consumes, though only as it applies to obesity and blood pressure.

Banzhaf told me the bar stems from a mid-1980s ruling by the Department of Health and Human Services at the request of health insurance commissioners. The commissioners had asked HHS to allow higher premiums for smokers, overweight and obese people, and those who don’t take basic steps to reduce high blood pressure. HHS, Banzhaf said, okayed the smoking provisions, but balked on obesity and blood pressure.

The problem is that I couldn’t find any independent confirmation of Banzhaf’s explanation.

I addressed this issue, albeit theoretically and without complete research, in a rant earlier this year - Obesity costs us money

At that time I said:

That we must as a society address obesity is not a new thought. Placing this battle into an economic perspective makes sense. I still believe that the obese should have to pay higher insurance premiums. You should be rewarded for a healthy lifestyle. A move to HSAs would place the burden of obesity on the obese. Maybe that would change behaviors.

Read the entire article linked above. The author has done a very nice job of researching the problem of underwriting health insurance. This is, in my opinion, an idea whose time has come. Remember this would reward healthy behaviors, and how could that be bad?

In a red-hot job market, some residents are taking time off

As I said last year, the law of supply and demand must work!

In today’s job market for internists, residents are in the driver’s seat when it comes to finding work after training. Some recruiters even say that the red-hot market is encouraging some young internists to not push themselves in their second or even third years of residency to land their first job.

“Some residents are waiting until their training is complete to look for jobs,” said Mark Smith, executive vice president of Merritt, Hawkins & Associates, a Texas health care staffing firm. “Some are even taking a year off.”

Because of the demand for internists, recruiters say that residents who put off the job hunt are unlikely to be out of work for long. And they point out that young physicians—just like their older colleagues—are taking advantage of abundant locum tenens possibilities.

Internists remain an important cog in the health care wheel. We provide the vast majority of hospitalists. Most subspecialists want a good general internist as their personal physician. Many subspecialists want a good general internist to assume overall care of their patients - allowing them to focus solely on their subspecialty.

I believe most patients understand these issues. Now we just have to educate the insurers. But are they educable?

Statin Use May Improve ACS Outcome

Investigators used the Global Registry of Acute Coronary Events (GRACE) project – a large multinational, observational study of patients with ACS – to look at previous and early in-hospital statin use and outcome in 19,537 patients admitted to 94 hospitals in 14 countries for an ACS.

Compared with patients who never took statins, those taking statins on admission were less likely to have ST-segment elevation or MI with odds ratios of 0.79 and 0.78, respectively. Patients who were taking statins at presentation and continued taking them during their hospital stay were less likely to experience complications or die than patients who never took statins, with an odds ratio of 0.66.

Initiating statin therapy in the hospital was also associated with a decreased risk of in-hospital mortality (OR, 0.38 ). However, this association was significantly attenuated in adjusted analyses (OR, 0.84).

“This study,” Dr. Spencer said, “adds to the ample data already out there from randomized controlled trials as well as observational studies that statins are a good thing for people with coronary disease and that if you have the opportunity you should get your patient with ACS on a statin and keep them on it.”

The data supporting early statin therapy in ACS keeps mounting. I know of no contraindication to statins in these patients. Therefore, I am now teaching that a statin should be part of the initial therapy.

This study does not answer the questions:

• Which statins?
• What dose?
• How soon after admission?

Nonetheless, I will make an educated guess and start a routine statin on the day of admission. Unless I see data on dosing, I will use a routine dose.

New York State Official Sues Drug Maker Over Test Data

Understanding the problem -

Richard Merrill, a University of Virginia law professor and a former general counsel at the F.D.A, compared Mr. Spitzer’s suit to product-liability lawsuits by individuals. He said the suit was the first by a public official against the drug industry.

Pharmaceutical companies sponsor most clinical trials of drugs and, in many cases, they jealously guard the data that results. If a test suggests that a drug is effective in treating a certain condition, the company will push to get its results published in a prestigious journal. If the results reflect poorly on the drug, they often never appear in public.

Experts have long criticized the tendency in the industry to publish only positive clinical trials, arguing that this distorts medical practice and undermines the scientific process. Some have suggested that the results of all clinical trials should be published in a federal registry.

But some say that doctors are unlikely to consult such a registry and will continue to be influenced by trial results published in leading journals.

Mr. Spitzer’s suit is the first to suggest a way of resolving such matters. If a company’s marketing message is at odds with the results of its own, suppressed clinical trial, he argues, the company is liable for damages under consumer fraud laws.

In the case of Paxil, GlaxoSmithKline sponsored five trials of the drug in adolescents suffering from major depression. The company undertook the trials to qualify for a six-month extension of Paxil’s patent granted under a federal law that encourages the testing of drugs in children. But it published only one of the trials, which showed mixed effect. The unpublished trials failed to show any benefit for the drug and suggested that it might increase the risk of suicide.

An internal memo cited in the suit said the company should have “effectively managed the dissemination of these data in order to minimize any potential negative commercial impact.”

I greatly dislike using the courts to solve commonsense problems. However, commonsense does not work here. We either need new explicit laws governing pharmaceutical research, or the success of this (or similar) lawsuits.

We cannot practice evidence based medicine unless we have access to all the evidence. Withholding such data is disingenuous at least, and more likely dangerous to patient care. This suit deserves scrutiny and attention.

They work again - just click on the links to the right.

Thanks for the heads up!!!

I am having difficulties with the RSS feed. In the meantime use:

Medrants RSS feed

I hope to have the links fixed soon.

db

Antidepressant Seen as Effective in Treatment of Adolescents

This articles describe a government agency (NIMH) funded study.

The government study, called the Treatment for Adolescents with Depression Study, involved 439 youths ages 12 to 17 who were suffering from moderate to severe depression.

The adolescents were randomly assigned to be treated for a period of 36 weeks with either Prozac, the antidepressant drug made by Eli Lilly & Company; a form of talk therapy known as cognitive behavioral therapy; placebo pills; or a combination of Prozac and talk therapy.

The researchers collected data on the subjects for a year, but have only analyzed information from the first 12 weeks so far. Of the youths recruited for the study, 378 completed the first 12 weeks of treatment. Their mean age was 15. Depression levels were measured using several common psychological scales.

Using one measurement scale, the researchers found that after 12 weeks, 71 percent of the subjects who received Prozac and talk therapy responded well to treatment, compared with 61 percent of those who received Prozac alone, 43 percent of who received talk therapy alone and 35 percent of those who received a placebo treatment. By another measure, talk therapy alone fared no better than treatment with placebos.

The researchers also found that patients became significantly less suicidal, no matter which treatment they were given. No patient committed suicide during the trial. But the risk of a suicide attempt among the patients given Prozac was twice that of those who did not, the study found. There were five suicide attempts among those given Prozac and just one among other participants.

Dr. John March, a professor of psychiatry at Duke University and the study’s lead investigator, said that the findings showed Prozac’s benefits for depressed teenagers and children far outweighed its risks. “The take-home message is that these adverse events are extremely rare,'’ he said.

I find depression a complex and fascinating problem. Major depression results in profound changes. Having never suffered depression, I know that I cannot really understand. This disease has the wrong name. We all get depressed when things go wrong in our life. However, these blue moods are not the same as the disease.

I have incredible respect for this disease. It destroys lives. We must aggressively address these patients.

This study confirms my anecdotal experience. Many patients do respond dramatically to antidepressants. However, treatment must include more than providing a prescription.

This problem vexes most primary care providers. First, they have minimal training in psychotherapy. Second, talking to depressed patients can make one depressed. We naturally try to avoid that discomfort. Finally, talking to depressed patients takes time - time with no apparent compensation.

We need a better national approach to true major depression. Those how suffer (and I choose that word carefully) deserve our best efforts.

Trent over at Proximal Tubule has ranted today on drug prohibition. He did not realize that I had blogged on this issue last year. Here is his take - Paternalism In Medicine - Part III: The War On Drugs and one of my many posts - Canada providing safe sites of IV drug users

First a quote from Trent’s opus

From here Miron jumps into his normative analysis of the drug war and he examines the collateral costs and benefits of drug prohibition. First he differentiates between rational and irrational drug use. Rational use is defined as that which is responsibly done and which brings pleasure to the user, much like millions do with regard to alcohol. He states that while the reduction in use described above would be considered by many to be a benefit of prohibition, the elimination of rational use, regardless of how big one thinks that amount is, would actually have to be regarded honestly as a cost. Indeed if something brings pleasure to an individual at no cost to society, its disappearance is most certainly a negative thing. On the other hand, irrational use is what we imagine when we talk about drug use. Miron describes the irrationality of drug use consisting of two variables: the addictiveness of drugs and the amount of harm to the users health. I’ll get into this later, but Miron and others have provided data that indicate drug warriors, with the help of physicians and public health experts, have overstated these effects.

Second, Miron discusses the externalities of drug use that many often bring up in debate. These include: those injured in driving and work-related accidents committed by those under the influence and unborn babies harmed by abusing mothers. Some of these effects are not as large, according to data that he presents, as some have led us to believe. But more importantly, these externalities can occur from legal substances also, and their presence per se does not constitute a valid argument for prohibition. Indeed, many of these can be handled via legal avenues that traditionally punish or compensate for unjust harm to innocents.

Last, the War on Drugs has led to some extremely negative collateral damage. It has negative health effects, namely the undertreatment of pain and contributing to the spread of HIV in IV drug users. It has negative economic effects because it costs $33 billion per year. It has negative diplomatic effects by causing the US to interfere in the domestic policies of other nations. It has contributed to the racial divide here in the United States. It has led to vast amounts of corruption in government and law enforcement agencies. It has supported terrorism by driving drug prices up and giving an economic boon to terrorist organizations. It has led to the erosion of civil liberties by lending incentive for unconstitutional searches and seizures. And it has eroded liberty in general, by solidifying the erroneous idea that the government can tell us what we can and can not put into our own bodies.

From all this, Miron comes to the overwhelming conclusion that the War on Drugs is awful policy, and I have to say I agree. In fact, it continues to baffle me how so few people can come to the same conclusion. I applaud Miron on his intelligent efforts in this cause.

And a quote from my post last year

We need this logical approach. The political hysteria over drug abuse in this country has too many adverse consequences. While these are unintended consequences, they are consequences nonetheless. We need politicians and leaders with the courage to look at drug abuse as a societal problem which needs societal answers. We should neither demonize the abusers nor the drugs. We should put the pushers out of business the old fashioned way, using capitalism. We should provide legal safe drugs - even those which we know will harm the users. As we sell the drugs, we can then invest money (the money which we are saving on law enforcement and HIV care) on user education and drug treatment programs.

We already sell drugs that we know harm people - cigarettes and alcohol. While I lecture every patient why they should stop smoking, I would not try to make cigarettes illegal. Most people who drink have no problems - and the data even suggest that moderate drinking is good for one’s health! I suspect that we would find the same with many illegal drugs (especially marijuana).

Before you quickly label me a kook on this subject, please carefully consider the costs of our current war on drugs. How many lives are ruined or killed from the gun battles over drug distribution? How many young adults have serious legal problems because of recreational marijuana use? How many AIDs victims come from no access to safe needles?

Drug abuse, whether cocaine, heroin or alcohol, can lead to serious health problems. Just as we do our best to prevent alcohol abuse, so should we address the illegal drugs. But we should recognize drug abuse as a medical condition, not a legal problem. I believe that legalization would solve many more problems than it would cause. But then, this libertarian view is unlikely to develop widespread support. We have focused too long on drug abuse and not on the unintended consequences of our drug laws.

One of today’s commenters write:

However, it seems like the odds are stacked against listening - not with time and compensation pressures in the real, managed care, world. What are some tips you can recommend to balance staying “on-time” (and inevitably interrupting) with letting the patients tell their story?

Please reread the article and focus on this quote:

Even among doctors who do recognize that they ought to invest more in forming good relationships with their patients, resistance is common, usually because the doctors are concerned about adding to their already considerable time constraints.

Dr. Levinson’s research, however, indicates that allowing patients the time to talk can lead to shorter appointments. When patient complaints are ignored, or their expression is interrupted, there is an increased likelihood that they will re-emerge, “just when the visit’s ending,” she said.

Anecdotally, I have found that sitting and listening does actually shorten visit time. Most patients tell their story in around 1 minute. We clearly have a minute. Letting the patient present their agenda should speed the visit. Please try it a few times. Make yourself listen.