As with other well-intentioned laws, this one over-reaches by attempting to prescribe what I am still convinced should be a private contract.

However, once medicine became a force of social reform, requiring government payment and control, it was inevitable that laws like EMTALA would become a necessity. The payor had to assure that all subjects would be treated equally. To put it more starkly, the master has the right and responsibility to see after all his slaves.

For decades, in order to draw in reluctant physicians, reimbursement under government programs was lucrative. Then it became necessary to tighten those payments. In order to maintain the control, the payor then forbade balance billing. EMTALA was just one more step to assure control of the system.

The question remains, what is the next step of control now that EMTALA is backfiring? The original plan by Cabot called for physicians to be salaried employees. This has to a large extent been accomplished. It only remains to capture the rest. As I observed in Eastern Europe, when I made my decision to enter med school, doctors were vilified, then enslaved to the state. The people deserve no less.

Flexner said in his report, "the physician's role is fast becoming social and preventative, rather than individual and curative." Flexner is, of course, the fellow who wrote the report recommending that medical schools across the US be forced to follow the Hopkins/MGH model of education, standardizing education, making the physician an academic doctor (requiring a bachelor, usually BS, prior to matriculation and imbuing the principles of "scientific medicine." This was a conscious shift in emphasis. It has been accepted without question that this was a good and necessary shift. It has not been without its negative consequences though, as is true for many social changes that appear to be well-motivated.

It has been my contention through many of the posts here that the scientific emphasis in medicine has failed us. The wrong questions are asked and this leads to the false impression of success. This is as true of CABG and stents as of industrial medicine or STD's.

Another significant negative consequence to this shift is the dissatisfaction of doctors. Most doctors have some altruistic motivation. But the conflict between being social reformer and caring for individuals frustrates even the most compassionate. Add to that frustration the government control that is the inevitable end of such a social reform model. ("End" in two senses: Such a social reform model must have a controlling power and the institution that sucks all power to itself when there is no restraint is the modern State. Also, though, this will be the end of medicine as we know it, as the State has repeatedly through history proven itself incapable of practicing medicine.)

I should note that I thought that I recalled Starr referencing Taylor in his acclaimed study The Social Transformation of American Medicine. Maybe I just thought that he should have done so. His thesis builds on Taylor's pretty closely.

What Mark Graber points out in this Journal Club format is that not only is the mortality not affected by these drugs alone or in combination, but the benefits touted for the drug are not very meaningful. The NNT (Number Needed to Treat) to prevent an exacerbation of COPD is 4, which is good. But the NNT for one year to prevent a hospitalization is 33. That means that 33 patients have to be treated with this medicine to even keep one out of the hospital. That is of arguable meaningfulness.

Where the study is deceptive is in downplaying the increase in cases of pneumonia. The NNH (number need to harm) for one year for pneumonia is 41. If 41 people are treated for one year, there will be one additional case of pneumonia in the combination treatment group. These did not translate to deaths, apparently. But certainly the benefit is offset by the harm.

The Journal Club also points out that there were a lot of dropouts from the study, and all the drugs were made by the drug company sponsoring the study, with no comparison with other helpful treatments in COPD.

It is refreshing to see an increase in such analyses.

What is most interesting to me about this analysis is that Dr. Hellman identifies two factors that might explain the differences between the studies. Both are patient characteristics: the ability to detect one's own low blood sugar, and the decreased mental acuity or cognitive function of advanced diabetics.

This is a novelty: a recognition that real patients with real and multiple problems don't fit our neat study categories. Sure, maybe it is true that intensive therapy for diabetics save lives, if the study is done under controlled other-worldly conditions. But in real patients with difficult lives, intensive therapy kills.

Dr. Hellman calls for individualizing therapy. This is certainly important. Knowing the patient, loving the patient and caring for the patient are essential. And then, the A1c isn't so important.

Only 6% responded "mostly individuals." The rest responded that some combination of employers, government, and/or individuals should share costs.

This undoubtedly is how people feel about that most precious and essential to life commodity, food. It seems just as reasonable to demand that others pay for my food, while allowing me my choice in culinary delights. If my tastes happen to be more expensive than the average, so be it. And of course, only those foods deemed healthy by the experts will be paid for. The reality that these experts can't agree on what is healthy food should not deter us. Whoever is in power has the divine right and responsibility to make those choices.

So in the upcoming election, maybe you should be asking what Hillary, Obama and McCain like to eat.

An article in Family Practice News summarizes data from the KP Vaccine Study Center's Dr. Klein, whose analysis of the Vaccine Safety Datalink data for that week in February showed an increase in post vaccination seizures for MMRV (the combination of MMR with Varicella -chickenpox). There were 5 additional seizures for every 10,000 children who received the MMRV instead of the separate vaccines.

So how many seizures were there after the separate vaccines? Well, depends on how many days post vaccination and which vaccines you are asking about. The biggest cluster is at 7 -10 days post vaccination, with 9.6 for MMRV, 4.9 for MMR plus a separate V, 3.5 for MMR alone, and 1.5 for varicella alone. But the "expected number of seizures total after MMRV is 14.7/10,000 or 1/680. The increase that caught their attention was to 1/440 or 22.7/10,000.

The discussion is on whether administering these vaccines together is worth this possible extra risk.

But based on my previous discussions of vaccine efficacy, my question is whether they are worth it at all. Remember that these diseases are very rarely fatal. The vaccines are sold on the promise of peace of mind. But if one in 500 will have a seizure, up to 42 days after administration, how peaceful will the parents' minds be?

I am not sure of the pain scale used, or how accurate it is. But this seems to be a clear case of data overload. Besides the confusion of using the term "anesthesia" for this response to sugar, there is the issue of whether water is an adequate placebo. What baby wouldn't cry if given water instead of sugar?

But knowing this much information about the (presumed) pain response of infants after immunizations (and they received DTaP, IPV, Hep B and Hib over the several minutes) assumes that the vaccines are worth it, an assumption that has been significantly challenged, both on these pages and elsewhere. But even assuming they are worth it, does it really help us to have this much information about the relatively minor pain of what the advocates consider to be worth any risk or cost? Couldn't any grandmother have told us that an infant is happier with a sugar tit? Is this not yet another attempt to shepherd the wind?

The question still remains: is an absolute risk reduction of 1% (which I would challenge) worth the risk of the medicines?

But the bigger question is not even asked: Is an attempt to reduce this one risk by this 1%, in light of the thousands of other risks we daily face, tantamount to idolatry?

"Contrary to the public's common belief, all drugs are dangerous. Just because a drug is approved by the US Food and Drug Administration (FDA) does not mean that it won't cause problems; all usually do, from minor side effects to permanent disability, to life threats, and even death.[1-3] The FDA approves drugs on the basis of benefits outweighing the risks, not because there is a complete lack of danger."

Good overview of the ways that patients, pharmacists and physicians generally view adverse drug reactions.

This will bear watching.

I do not doubt that many people feel better after taking shark cartilage or C/G for their joint pain. The original Mass VA study using ground up chicken cartilage had some 20 of 21 end-stage knees or hips walking out of the hospital without surgery. But if the scientific method means anything, it is capable of proving that certain interventions are not accomplishing what they claim.

Science cannot determine truth, which is a person, Jesus Christ, in whom all things cohere. But it can demonstrate the uselessness of many of our interventions.

What should be done to the purveyors of the millions of these procedures and pills?

But most interesting is the response of the drug companies. They emphasized the safety of these drugs when used as directed. They failed to mention the lack of efficacy when used as directed. Which may be why parents don't use them as directed.

But it should give those pause who advocate CT for cancer and CAD screening.

There are several articles he relies on (footnotes) that I would love to chase down if I can find the time and access. And I am in sympathy with his basic argument. I frequently wonder what I am missing, and whether the habits of thinking (including history taking, examination and diagnosis) I have developed over the decades are misleading me.

One very important caveat in all this (which should be a separate post) is that no matter what errors medicine commits or corrects, it all pales in significance to the number of abortions which it continues to commit each year. By any measure of efficacy, medicine will long remain in the negative. Roe v Wade lessened the legal guilt but not the moral, and it allowed increased numbers of men and women to have their children slaughtered. The recent decrease announced probably only reflects the decrease in conceptions last year, not a repentance.