Wednesday, September 30, 2009
Super Glue Eyelid
This little girl accidentally got Super Glue onto her eyelid. She came to the doctor without pain and she was able to move the eyeball under the lid but could not open it.Her doctor in Decatur, Ala gently irrigated the eye area with normal saline and applied antibiotic ointment and a gauze patch over the eye area but the lid remained stuck together. The next day he was able to gently pull the
The Psoas Muscles and Abdominal Exercises For Back Pain
Common opinion notwithstanding, the proper purpose of abdominal exercises is to awaken control of the abdominal muscles so they coordinate better with the other muscles of the trunk and legs (which include the psoas muscles). It is that better coordination that improves alignment, and not merely higher tone or strength. When the psoas muscles achieve their proper length, tone (tonus) and responsiveness, they stabilize the lumbar spine in movement as well as when standing, giving the feeling of better support and "strength". Mutual coordination of the psoas and other muscles causes/allows the spine and abdomen to fall back, giving the appearance of "strong" abdominal muscles -- but it is not the strength of abdominal muscles, alone, but the coordination of all the involved muscles that gives that appearance.
To improve psoas functioning, a different approach to abdominal exercises than the one commonly practiced is necessary. Instead of "strengthening," the emphasis must be on awareness, control, balancing and coordination of the involved muscles - the purview of somatic education. I will say more...
.. but first: A discussion of the methods and techniques of somatic education is beyond the scope of this paper, which confines itself to a discussion of the relation of the psoas muscles, abdominal exercises, and back pain. For that, see the links at the bottom of this article.
The Relationship of Psoas, Abdominal Muscles and Back Pain
The psoas muscles and the abdominal muscles function as agonist and antagonist (opponents) as well as synergists (mutual helpers); a free interplay between the two is appropriate. The psoas muscles lie behind the abdominal contents, running from the lumbar spine to the inner thighs near the hip joints (lesser trochanters); the abdominal muscles lie in front of the abdominal contents, running from the lower borders of the ribs (with the rectus muscles as high as the nipples) to the frontal lines of the pelvis.
Take a moment to contemplate each of these relationships until you can feel or visualize them
In the standing position, contracted psoas muscles (which ride over the pubic crests) move the pubis backward; the abdominal muscles move the pubis forward. (antagonists)
In walking, the ilio-psoas muscles of one side initiate movement of that leg forward, while the abdominals bring the same-side hip and pubis forward. (synergists)
The psoas major muscles pull the lumbar spine forward; the abdominal muscles push the lumbar spine back (via pressure on abdominal contents and change of pelvic position). (antagonists)
The psoas minor muscles pull the fronts of attached vertebrae (at the level of the diaphragm), down and back; the abdominals push the same area back. (synergists)
Unilateral contraction of the psoas muscles causes rotation of the torso away from the side of contraction and sidebending toward the side of contraction (as if leaning to one side and looking over ones raised shoulder); abdominals assist that movement.
Now, if this all sounds complicated, it is -- to the mind. But if you have good use and coordination of those muscles, it's simple -- you move well.
Words on Abdominal Exercises
Exercises that attempt to flatten the belly (e.g., crunches) generally produce a set pattern in which the abdominal muscles merely overpower psoas and spinal extensor muscles that are already set at too high a level of tension.
High abdominal muscle tone from abdominal crunches interferes with the ability to stand fully erect, as the contracted abdominal muscles drag the front of the ribs down. Numerous consequences follow:
(1) breathing is impaired,
(2) compression of abdominal contents results, impeding circulation,
(3) deprived of the pumping effect of motion on fluid circulation, the lumbar plexus, which is embedded in the psoas, becomes less functional (slowed circulation slows tissue nutrition and removal of metabolic waste; nerve plexus metabolism slows; chronic constipation often results),
(4) displacement of the centers of gravity of the body's segments from a vertical arrangement (standing or sitting) deprives them of support; gravity then drags them down and further in the direction of displacement; muscular involvement (at the back of the body) then becomes necessary to counteract what is, in effect, a movement toward collapse. This muscular effort
(a) taxes the body's vital resources,
(b) introduces strain in the involved musculature (e.g., the extensors of the back), and
(c) sets the stage for back pain and back injury.
The psoas has often been portrayed as the villain in back pain, and exercise is often intended to overpower the psoas muscles by pushing the spine and abdomen back. However, it is obvious from the foregoing that "inconvenient" consequences result from that strategy. A more fitting approach is to balance the interaction of the psoas and abdominal muscles.
When the psoas and the abdominal muscles counterbalance each other, the psoas muscles contract and relax, shorten and lengthen appropriately in movement. The lumbar curve, rather than increasing, decreases; the back flattens and the abdominal contents move back into the abdominal cavity, where they are supported instead of hanging forward.
It should be noted that the pelvic orientation, and thus the spinal curves, is also largely determined by the musculature and connective tissue of the legs, which connect the legs with the pelvis and torso. If the legs are not directly beneath the pelvis, but are somewhat behind (or more rarely, ahead of the pelvis), stresses are introduced through muscles and connective tissue that displace the pelvis. Rotation of the pelvis, hip height asymmetry, and/or excessive lordosis (or, more rarely, kyphosis) follow, all of which affect the psoas/abdominal interplay.
Where movement, visceral (organ) function, and freedom from back pain are concerned, proper support from the legs is as important as the free, reciprocal interplay of the psoas and abdominal muscles.
More on the Psoas and Walking
Dr. Ida P. Rolf described the psoas as the initiator of walking:
Let us be clear about this: the legs do not originate movement in the walk of a balanced body; the legs support and follow. Movement is initiated in the trunk and transmitted to the legs through the medium of the psoas.
(Rolf, 1977: Rolfing, the Integration of Human Structures, pg. 118).
A casual interpretation of this description might be that the psoas initiates hip flexion by bringing the thigh forward. It's not quite as simple as that.
By its location, the psoas is also a rotator of the thigh. It passes down and forward from the lumbar spine, over the pubic crest, before its tendon passes back to its insertion at the lesser trochanter of the thigh. Shortening of the psoas pulls upon that tendon, which pulls the medial aspect of the thigh forward, inducing rotation, knee outward.
In healthy functioning, two actions regulate that tendency to knee-outward turning: (1) the same side of the pelvis rotates forward by action involving the iliacus muscle, the internal oblique (which is functionally continuous with the iliacus by its common insertion at the iliac crest) and the external oblique of the other side and (2) the gluteus minimus, which passes backward from below the iliac crest to the greater trochanter, assists the psoas in bringing the thigh forward, while counter-balancing its tendency to rotate the thigh outward. The glutei minimi are internal rotators, as well as flexors, of the thigh at the hip joint. They function synergistically with the psoas.
This synergy causes forward movement of the thigh, aided by the forward movement of the same side of the pelvis. The movement functionally originates from the somatic center, through which the psoas passes on its way to the lumbar spine. Thus, Dr. Rolf's observation of the role of the psoas in initiating walking is explained.
Interestingly, the abdominals aid walking by assisting the pelvic rotational movement described, by means of their attachments along the anterior border of the pelvis. Thus, the interplay of psoas and abdominals is explained.
When the psoas fails to lengthen properly, the same side of the pelvis is restricted in its ability to move backward (and to permit its other side to move forward). Co-contracted glutei minimi frequently accompany the contracted psoas of the same side, as does chronic constipation (for reasons described earlier). The co-contraction drags the front of the pelvis down. The lumbar spine is bent forward, tending toward a forward-leaning posture, which the extensors of the lumbar spine counter to keep the person upright; as the spinal extensors contract, they suffer muscle fatigue and soreness. Thus, the correlation of tight psoas and back pain is explained.
As explained before, to tighten the abdominal muscles as a solution for this stressful situation is a misguided effort. What is needed is to improve the responsiveness of the psoas and glutei minimi, which includes their ability to relax.
A final interesting note brings the center (psoas) into relation with the periphery (feet). In healthy, well-integrated walking, the feet assist the psoas and glutei minimi in bringing the thigh forward. The phenomenon is known as "spring in the step."
Here's the description: When the thigh is farthest back, in walking, the ankle is most dorsi-flexed. That means that the calf muscles and hip flexors are at their fullest stretch and primed for the stretch (myotatic) reflex. This is what happens in well-integrated walking: assisted by the stretch reflex, the plantar flexors of the feet put spring in the step, which assists the flexors of the hip joints in bringing the thigh forward.
Here's what makes it particularly interesting: when the plantar flexors fail to respond in a lively fashion, the burden of bringing the thigh forward falls heavily upon the psoas and other hip joint flexors, which become conditioned to maintain a heightened state of tension, and there we are: tight psoas and back pain. (Note that ineffective dorsi-flexors of the feet prevent adequate foot clearance of the ground, when walking; the hip flexors must compensate by lifting the knee higher, leading to a similar problem.)
Thus, it appears that the responsibility for problems with the psoas falls (in part, if not largely) upon the feet. No resolution of psoas problems can be expected without proper functioning of the lower legs and feet.
SUMMARY
The psoas, iliacus, abdominals, spinal extensors, hip joint flexors and extensors, and flexors of the ankles/feet are all inter-related in walking movements. Interference with their interplay (generally through over-contraction or non-responsiveness of one or more of these "players") leads to dysfunction and to back pain. The strategy of strengthening the abdominal muscles has been shown to be a misguided effort to correct problems that usually lie elsewhere - which explains why, even though abdominal strengthening exercises are so popular, back pain is still so common. Sensory-motor training (somatic education) provides a more pertinent and effective approach to the problem of back pain than abdominal strengthening exercises.
by: Lawrence Gold
To improve psoas functioning, a different approach to abdominal exercises than the one commonly practiced is necessary. Instead of "strengthening," the emphasis must be on awareness, control, balancing and coordination of the involved muscles - the purview of somatic education. I will say more...
.. but first: A discussion of the methods and techniques of somatic education is beyond the scope of this paper, which confines itself to a discussion of the relation of the psoas muscles, abdominal exercises, and back pain. For that, see the links at the bottom of this article.
The Relationship of Psoas, Abdominal Muscles and Back Pain
The psoas muscles and the abdominal muscles function as agonist and antagonist (opponents) as well as synergists (mutual helpers); a free interplay between the two is appropriate. The psoas muscles lie behind the abdominal contents, running from the lumbar spine to the inner thighs near the hip joints (lesser trochanters); the abdominal muscles lie in front of the abdominal contents, running from the lower borders of the ribs (with the rectus muscles as high as the nipples) to the frontal lines of the pelvis.
Take a moment to contemplate each of these relationships until you can feel or visualize them
In the standing position, contracted psoas muscles (which ride over the pubic crests) move the pubis backward; the abdominal muscles move the pubis forward. (antagonists)
In walking, the ilio-psoas muscles of one side initiate movement of that leg forward, while the abdominals bring the same-side hip and pubis forward. (synergists)
The psoas major muscles pull the lumbar spine forward; the abdominal muscles push the lumbar spine back (via pressure on abdominal contents and change of pelvic position). (antagonists)
The psoas minor muscles pull the fronts of attached vertebrae (at the level of the diaphragm), down and back; the abdominals push the same area back. (synergists)
Unilateral contraction of the psoas muscles causes rotation of the torso away from the side of contraction and sidebending toward the side of contraction (as if leaning to one side and looking over ones raised shoulder); abdominals assist that movement.
Now, if this all sounds complicated, it is -- to the mind. But if you have good use and coordination of those muscles, it's simple -- you move well.
Words on Abdominal Exercises
Exercises that attempt to flatten the belly (e.g., crunches) generally produce a set pattern in which the abdominal muscles merely overpower psoas and spinal extensor muscles that are already set at too high a level of tension.
High abdominal muscle tone from abdominal crunches interferes with the ability to stand fully erect, as the contracted abdominal muscles drag the front of the ribs down. Numerous consequences follow:
(1) breathing is impaired,
(2) compression of abdominal contents results, impeding circulation,
(3) deprived of the pumping effect of motion on fluid circulation, the lumbar plexus, which is embedded in the psoas, becomes less functional (slowed circulation slows tissue nutrition and removal of metabolic waste; nerve plexus metabolism slows; chronic constipation often results),
(4) displacement of the centers of gravity of the body's segments from a vertical arrangement (standing or sitting) deprives them of support; gravity then drags them down and further in the direction of displacement; muscular involvement (at the back of the body) then becomes necessary to counteract what is, in effect, a movement toward collapse. This muscular effort
(a) taxes the body's vital resources,
(b) introduces strain in the involved musculature (e.g., the extensors of the back), and
(c) sets the stage for back pain and back injury.
The psoas has often been portrayed as the villain in back pain, and exercise is often intended to overpower the psoas muscles by pushing the spine and abdomen back. However, it is obvious from the foregoing that "inconvenient" consequences result from that strategy. A more fitting approach is to balance the interaction of the psoas and abdominal muscles.
When the psoas and the abdominal muscles counterbalance each other, the psoas muscles contract and relax, shorten and lengthen appropriately in movement. The lumbar curve, rather than increasing, decreases; the back flattens and the abdominal contents move back into the abdominal cavity, where they are supported instead of hanging forward.
It should be noted that the pelvic orientation, and thus the spinal curves, is also largely determined by the musculature and connective tissue of the legs, which connect the legs with the pelvis and torso. If the legs are not directly beneath the pelvis, but are somewhat behind (or more rarely, ahead of the pelvis), stresses are introduced through muscles and connective tissue that displace the pelvis. Rotation of the pelvis, hip height asymmetry, and/or excessive lordosis (or, more rarely, kyphosis) follow, all of which affect the psoas/abdominal interplay.
Where movement, visceral (organ) function, and freedom from back pain are concerned, proper support from the legs is as important as the free, reciprocal interplay of the psoas and abdominal muscles.
More on the Psoas and Walking
Dr. Ida P. Rolf described the psoas as the initiator of walking:
Let us be clear about this: the legs do not originate movement in the walk of a balanced body; the legs support and follow. Movement is initiated in the trunk and transmitted to the legs through the medium of the psoas.
(Rolf, 1977: Rolfing, the Integration of Human Structures, pg. 118).
A casual interpretation of this description might be that the psoas initiates hip flexion by bringing the thigh forward. It's not quite as simple as that.
By its location, the psoas is also a rotator of the thigh. It passes down and forward from the lumbar spine, over the pubic crest, before its tendon passes back to its insertion at the lesser trochanter of the thigh. Shortening of the psoas pulls upon that tendon, which pulls the medial aspect of the thigh forward, inducing rotation, knee outward.
In healthy functioning, two actions regulate that tendency to knee-outward turning: (1) the same side of the pelvis rotates forward by action involving the iliacus muscle, the internal oblique (which is functionally continuous with the iliacus by its common insertion at the iliac crest) and the external oblique of the other side and (2) the gluteus minimus, which passes backward from below the iliac crest to the greater trochanter, assists the psoas in bringing the thigh forward, while counter-balancing its tendency to rotate the thigh outward. The glutei minimi are internal rotators, as well as flexors, of the thigh at the hip joint. They function synergistically with the psoas.
This synergy causes forward movement of the thigh, aided by the forward movement of the same side of the pelvis. The movement functionally originates from the somatic center, through which the psoas passes on its way to the lumbar spine. Thus, Dr. Rolf's observation of the role of the psoas in initiating walking is explained.
Interestingly, the abdominals aid walking by assisting the pelvic rotational movement described, by means of their attachments along the anterior border of the pelvis. Thus, the interplay of psoas and abdominals is explained.
When the psoas fails to lengthen properly, the same side of the pelvis is restricted in its ability to move backward (and to permit its other side to move forward). Co-contracted glutei minimi frequently accompany the contracted psoas of the same side, as does chronic constipation (for reasons described earlier). The co-contraction drags the front of the pelvis down. The lumbar spine is bent forward, tending toward a forward-leaning posture, which the extensors of the lumbar spine counter to keep the person upright; as the spinal extensors contract, they suffer muscle fatigue and soreness. Thus, the correlation of tight psoas and back pain is explained.
As explained before, to tighten the abdominal muscles as a solution for this stressful situation is a misguided effort. What is needed is to improve the responsiveness of the psoas and glutei minimi, which includes their ability to relax.
A final interesting note brings the center (psoas) into relation with the periphery (feet). In healthy, well-integrated walking, the feet assist the psoas and glutei minimi in bringing the thigh forward. The phenomenon is known as "spring in the step."
Here's the description: When the thigh is farthest back, in walking, the ankle is most dorsi-flexed. That means that the calf muscles and hip flexors are at their fullest stretch and primed for the stretch (myotatic) reflex. This is what happens in well-integrated walking: assisted by the stretch reflex, the plantar flexors of the feet put spring in the step, which assists the flexors of the hip joints in bringing the thigh forward.
Here's what makes it particularly interesting: when the plantar flexors fail to respond in a lively fashion, the burden of bringing the thigh forward falls heavily upon the psoas and other hip joint flexors, which become conditioned to maintain a heightened state of tension, and there we are: tight psoas and back pain. (Note that ineffective dorsi-flexors of the feet prevent adequate foot clearance of the ground, when walking; the hip flexors must compensate by lifting the knee higher, leading to a similar problem.)
Thus, it appears that the responsibility for problems with the psoas falls (in part, if not largely) upon the feet. No resolution of psoas problems can be expected without proper functioning of the lower legs and feet.
SUMMARY
The psoas, iliacus, abdominals, spinal extensors, hip joint flexors and extensors, and flexors of the ankles/feet are all inter-related in walking movements. Interference with their interplay (generally through over-contraction or non-responsiveness of one or more of these "players") leads to dysfunction and to back pain. The strategy of strengthening the abdominal muscles has been shown to be a misguided effort to correct problems that usually lie elsewhere - which explains why, even though abdominal strengthening exercises are so popular, back pain is still so common. Sensory-motor training (somatic education) provides a more pertinent and effective approach to the problem of back pain than abdominal strengthening exercises.
by: Lawrence Gold
Natural Cure for Flatulence (Wind)
Why does it always happen in a crowded elevator? That's what I'd like to know. Or even worse, you are out with a potential new boyfriend or girlfriend, and you really want to impress, when all of a sudden, WOOMPPFF! Embarrassing or what???
But don't despair! The problem is probably a simple result of eating the wrong foods or too much beer. Lets check out some darn fine ways of dealing with bad smells that don't cost much, and are totally natural.
Tip 1 - try eating 'activated charcoal'. Charcoal tablets absorb the gases that cause wind, and you can eat 'em inconspicuously several times a day if the problem is really bad.
Tip 2 - Chew food thoroughly. At www.freeremedies.com we always chew our food 100 times, whether it needs it or noMore chewing means less air when you swallow, and less air means less ammo for the old 'asscannon'.
Tip 3 - avoid know 'hell raiser' foods like cabbage, beans, sweetcorn, brussel sprouts, spinach, squid and monkfish. Although high-fibre foods are useful in your diet, they can lead to bloating, and unpleasant sound effects, especially when fermeted internally with any kind of alcohol.
Tip 4 - Fizzy drinks are a no-no. Give up the colas, 7-ups, beers, and other carbonated drinks. Champagne in moderation is actually ok, for reasons scientists don't fully understand yet.
Tip 5 - Caffeine causes colonic combustion! The caffeine in tea, coffee, pepsi etc can irritate the colon, and this obviously doesn't help.
Tip 5 - and this is the biggie, never try to 'hold it in'. Boffing is a natural function, and cracking one out is just the body's way of expelling un-needed gas. If you try to bottle it up, it will only come back later, double the strength. Don't give 'em time to brew, just sneak them out whenever you can!
by: Stu Collins
14 Effective Home Remedies for Cough
Read this article to know the best Home Remedies for Cough. First of all let me tell you what is Cough?
Coughs caused by the common cold, or flu, generally clear up after a small number of days. Cough can be a troublesome problem for the patient and the physician similar.
Cough is an important protection mechanism that plays a major role in sustaining the integrity of the airways and can be voluntary or involuntary. Cough is normally triggered by mechanical or chemical inspiration of receptors in the pharynx, larynx, trachea and bronchi. Cough receptors also survive in the nose, paranasal sinuses, external auditory ear canals, tympanic membranes, parietal pleura, esophagus, stomach, pericardium and diaphragm.
A cough is a symptom of many illnesses and conditions including: asthma, bronchitis, common cold, influenza (flu)smoking, and whooping cough. The cure of cough is useful only if directed at the cause, but patients should be offered indicative relief while awaiting the results of specific therapy.
Cough is the most ordinary respiratory symptom for which patients look for medical attention.
Here is a list of some best Home Remedies for Cough:
Home Remedies for Cough
1) Mix equal parts of ginger juice and honey and have it 2-3 times in a day which is fine for cough
2) Cinnamon is a well recognized herb which is used in cooking, and as addition to tea, apple cider and more. Make a cup of tea and put some cinnamon to it to relief the cough. This is simple and effective Home Remedy for Cough.
3) To decrease the cough, boil oregano in water, filter and drink up.
4) Gargle sage leaves and elder blossom tea with a little almond oil, oil of clove, and honey to reduce the cough and soothe the throat.
5) One good Home Remedy for Cough is the root of the turmeric plant which is helpful in a dry cough. The root should be baked and crushed. This powder should be taken in three gram dosage two times daily, in the morning and evening.
6) Another effective Home Remedy for Cough is a sauce made from raisins. This sauce is made by crushing 100 gm of raisins with water. 100 gm of sugar should be mixed with it and allow the mixture to heat. When the mixture obtains a sauce-like constancy, it should be conserved. Twenty grams should be taken at bedtime every day.
7) Aniseed is another useful remedy for a hard dry cough with complex expectoration. It shatters up the mucus. A tea made from this spice should be taken habitually for treating this state.
8) Put 2 cups of cherries in a pan and add just enough water to it. Add some lemon slices and 2 cups of honey. Boil the mixture until cherries are soft. Eradicate from heat. Take away the lemon slices and the cherry pits from the mixture. Store at a low temperature and take some tablespoons as needed for coughing.
9) A syrup of 1 teaspoon raw onion juice with 1 teaspoonful of honey kept over 3 to 4 hours serves as an excellent cough syrup. This is another superior Home Remedy for Cough.
10) Chewing betel leaf with 3-4 black Tulsi (Krishna Tulsi) leaves, a clove and a small quantity of menthol thrice a day provides relief from severe cough.
11) For dry coughs, start eating apples each day for 2-3 weeks until your cough is cured.
12) For severe cough, mix tulsi juice with garlic juice and honey. A teaspoonful of this mixture taken once in every three hours will treat excessive cough.
13) A teaspoon of honey, a pinch of turmeric powder, chewing cardamom for a while, a stick of clove, all these have proven very beneficial in treating dry cough.
14) A cup of grape juice mixed with a teaspoon of honey is recommended for cough relief.
by: Dr. John Anne
Could Your Vitamins be Killing You?
Billions are being spent annually on vitamin and mineral supplements. It can also be argued that never in history has so much money been spent on the advertising and purchasing of any merchandise, with so little knowledge of the product itself, on the part of either the seller or the buyer,
Most consumers and even salespeople know the difference between a synthetic, a crystalline, and a truly natural whole food vitamin.
I feel that the following information is essential for you to read and hope that it will provide you with enough information and clinical evidence so that you can make an educated decision on the health and well being of you and your family members.
“You can trace every ailment, every sickness and every disease to a vitamin and mineral deficiency.” Dr. Linus Pauling, renowned scientist and two time Nobel Prize Winner
Chronic conditions like cancer and heart disease take decades to develop. So do wrinkles and fuzzy brains. The core foundation of how Young you feel, how much Energy you have, how healthy you remain and are able to function all starts with proper nutrition.
Research through numerous scientific studies have conclusively shown that proper daily nutrition when coupled with daily exercise, as simple as walking, promotes the very essence of how well you feel, and as you age your body’s ability to prevent, ward off, and minimize diseases such as obesity, diabetes, heart disease, and cancer.
Lester Packer, Ph.D., a molecular and cell biologist at the University of California at Berkeley, after many years of research, worries that more than 70 percent of people will die prematurely from diseases caused by or compounded by deficiencies of antioxidants. But starting young – in your 20’s, 30’s and 40’s – can help keep your body youthful and disease-free instead of in need of repair later. Antioxidants are also called phytochemicals and/or phytonutrients and carotenoids.
NUTRITIONALLY, WHAT EXACTLY IS HAPPENING TO US?
We are the direct product of what we eat and the lifestyles we have elected to live. Granted, there are diseases that are passed along to us genetically, but even in those instances through proper nourishment and lifestyle changes, we can greatly reduce our risk of premature illness and death causing diseases.
In the 1980’s, a study was conducted in the United States by the U.S. Department of Agriculture. Using 50,000 people, it was found that not a single person was getting the recommended amounts of the 10 essential vitamins required for normal health.
For years you have been advised to look to the food pyramid, which recommends that you eat at least 3-5 servings of vegetables and 2-4 servings of fruits daily. Sadly, the vast majority of us, and you know who you are, fall woefully short of these guidelines. The problem is we can’t eat the volume of food it would require. More than 90 percent of people don’t eat the recommended daily servings of fruits and vegetables. Even if we did, food today doesn’t have the vitamins and minerals that they had 40 or 50 years ago. In those days farmers restored the soil by mulching, using natural fertilizers and rotating crops. Today, extensive use of chemical substances depletes the soil of many of the essential elements needed for adequate nutrition…giving us a supply of beautiful products that look great, but don’t have the vitamins and other important nutrients we think they should have and, not near the vitamin, mineral and other essential nutrients (phytochemicals) they had 50 years ago.
Another problem is that most vitamins and other valuable nutrients are lost in processing. Cooking and freezing dramatically reduce vitamins, nutrients and food value. Added to this problem, are the presences of flavor enhancers, artificial colors, stabilizers and chemical food preservatives. Additionally, studies show that the nutrient value of our food is continually decreasing due to more air pollutants and less oxygen.
Additionally, mainstream marketing of supplemental vitamins and minerals has successfully created the myth that vitamins and minerals may be isolated from each other, that correct amounts may be measured out, and then we can derive total benefit from taking these fractionated chemical (synthetic) creations. Nothing could be farther from the truth. Vitamins and minerals, and also enzymes, work closely together as co-factors for each other’s efficacy. If one part is missing, or in the wrong form or the wrong amount, entire chains of metabolic processes will not proceed normally. Result: a downward spiraling of health, probably imperceptible for long periods of time.
SO WHAT’S THE ANSWER?
The dilemma we are faced with is; if we cannot get all of the nutrients we need through diet alone then how do we get them? We get them by taking supplements…but the right kind of supplements.
“We now have a substantial body of data showing that if everyone took a few supplements every day, they could significantly lower their risk of a multitude of serious diseases.” David Heber, M.D., Ph.D., of the Center for Human Nutrition at UCLA
While you may think that you have filled this need, you may be getting little benefit from using the vitamin & mineral supplements available today. Studies show that 90 percent of vitamin pills pass through your body unabsorbed! This is primarily due to the fact that most all vitamin & mineral supplements contain nothing but laboratory developed synthetic ingredients. Natural ingredients are more effectively used by your body which is designed to reject synthetic and foreign substances.
Your synthetic, fractionated chemical vitamin never grew in the ground, never saw the light of day, and never was alive or part of anything alive. It’s a chemical. In your body it’s just another drug. Synthetic vitamins have toxic effects in mega-doses and actually can increase the white blood cell count. Vitamins are only necessary in minute quantities on a daily basis. Whole food vitamins, by contrast, are not toxic and trigger no immune response.
Whole food vitamins are obtained by taking a vitamin-rich plant, removing the water and the fiber in a cold vacuum process, otherwise known as freeze–drying, free of chemicals, and then packaged for stability. The entire vitamin complex in this way can be captured intact, retaining its “functional and nutritional integrity.” Upon ingestion, the body is not required to draw on its own reserves in order to complete any missing elements from the vitamin complex.
“We have yet to improve on what Mother Nature has given us to eat. Foods simply cannot be artificially duplicated in the science laboratory.” Gabriel Clousens, M.D.
Examples from clinical tests conducted in Finland and reported in the New England Journal of Medicine.
• 25 mg of Vitamin C in its natural whole-food form will cure scurvy but, 250 mg of synthetic vitamin C (ascorbic acid) will not!
• “Saltwater” can be synthesized in a laboratory, but when you put a fish in it the fish dies.
WHAT OCCURS IN THE BODY WHEN YOU INGEST SYNTHETIC VITAMINS OVER A PERIOD OF TIME?
Most people are not aware that most vitamins are processed at high temperature, contain petroleum derived chemical solvents, such as coal tar derivatives and ethyl cellulose and are coated with methylene chloride, a carcinogenic material. These sources are not living foods but dead chemicals and over a period of extended use can be potentially dangerous.
According to Dr. Zoltan P. Rona, M.D., “Although most healthy people will have no obvious side effects from ingesting small amounts of toxins found in most vitamins, the long-term consequences of continuous, daily intakes are potentially dangerous.” Dr. Rona says that reactions include fatigue, memory loss, depression, insomnia and potential liver disorders.
A recent Finnish study published in the New England Journal of Medicine states that “taking synthetic vitamins is worse than starvation! The synthetic vitamins will kill you quicker.” Admittedly, this statement is a bit aggressive, but does show the emphasis the researchers wanted to make regarding the potential health danger of using synthetic vitamins.
Living systems are very complex and specific in their need for building materials. In addition, living systems are constantly breaking down cells, organs and tissues, and rebuilding and repairing themselves. For these processes, the body must have a continual supply of specific, high-quality materials.
If you build a house with cheap, imitation construction materials, your house will quickly fall into disrepair. The same is true for the physical body. The body has a very precise design, which is so incredibly intricate and complex that even with all the scientific and medical research thus far; we have only scratched the surface of understanding it.
The following examples are a handful of hundreds that could be given to illustrate this point:
• Reported on April 14, 1994 in the New England Journal of Medicine was a study in which 29,000 male smokers were given synthetic beta-carotene and synthetic Vitamin E to evaluate the cancer-protective effect of the “vitamins”. After 10 years, the men taking the synthetic beta carotene had an 18% higher rate of lung cancer, more heart attacks, and an 8% higher overall death rate. Those taking Synthetic Vitamin E had more strokes. Food sources of these same nutrients, such as fruits, and vegetables, consistently demonstrate protection against cancer, heart attacks and stroke.
• On November 23, 1995, the following was reported in The New England Journal of Medicine. 22,748 pregnant women were given synthetic Vitamin A. After four years the study was halted because of a 240% increase in birth defects in babies of women taking 10,000 IU daily, and a 400% increase in birth defects in babies of women taking 20,000 IU a day. Women eating natural food sources of Vitamin A showed no increase in birth defects.
• Reported in Reuters Health, March 3, 2000 was a study of men who took 500 mg of synthetic Vitamin C daily. It was found that over an 18-month period, these men had a 250% increase of the intima-media lining (inner lining) of the carotid artery. This thickening is an accurate measurement for the progression of atherosclerosis. That is, synthetic Vitamin C induced atherosclerosis, even at 500 mg dose. Whole food Vitamin C protects and repairs the inner lining of blood vessels, and is preventative against atherosclerosis.
WHAT IS BEST FOR ME?
Using years of research and clinical data published by the National Cancer Institute, American Heart Association, USDA and the International Food Information Council Foundation, the American Diabetic Association and countless medical studies we need to keep our bodies free of refined and processed food, eliminate high fructose and artificial sweeteners . We need to consume a “Rainbow” of fruits and vegetables to get as much color variety in your diet as possible, so that you can maximize your intake of a broad range of nutrients. The colors of fruits and vegetables are a small clue as to what vitamins and nutrients are included. By getting a variety of different colored fruits and vegetables, you are guaranteed a diverse amount of naturally created essential vitamins and minerals. Choose grains, fruits and vegetables that are grown in deep mineral rich, alluvial soils without the use of pesticides, herbicides and fungicides…there’re grown as mother-nature intended.
The Choice is yours
110 companies sell vitamins in the United States. Less than 5 of them use whole food vitamins. The reason is simple: whole food vitamins are expensive to make. A few of the largest pharmaceutical firms in the world mass produce synthetic vitamins for the vast majority of these 110 “vitamin” companies, who then put their own label on them, and every company claims theirs is the best! Americans spend over $9 billion per year for synthetic vitamins and our health is worse now than it’s ever been…something is wrong….it’s called synthetics!
Don’t you think it’s time for a change?
by: Denise McKinley
Most consumers and even salespeople know the difference between a synthetic, a crystalline, and a truly natural whole food vitamin.
I feel that the following information is essential for you to read and hope that it will provide you with enough information and clinical evidence so that you can make an educated decision on the health and well being of you and your family members.
“You can trace every ailment, every sickness and every disease to a vitamin and mineral deficiency.” Dr. Linus Pauling, renowned scientist and two time Nobel Prize Winner
Chronic conditions like cancer and heart disease take decades to develop. So do wrinkles and fuzzy brains. The core foundation of how Young you feel, how much Energy you have, how healthy you remain and are able to function all starts with proper nutrition.
Research through numerous scientific studies have conclusively shown that proper daily nutrition when coupled with daily exercise, as simple as walking, promotes the very essence of how well you feel, and as you age your body’s ability to prevent, ward off, and minimize diseases such as obesity, diabetes, heart disease, and cancer.
Lester Packer, Ph.D., a molecular and cell biologist at the University of California at Berkeley, after many years of research, worries that more than 70 percent of people will die prematurely from diseases caused by or compounded by deficiencies of antioxidants. But starting young – in your 20’s, 30’s and 40’s – can help keep your body youthful and disease-free instead of in need of repair later. Antioxidants are also called phytochemicals and/or phytonutrients and carotenoids.
NUTRITIONALLY, WHAT EXACTLY IS HAPPENING TO US?
We are the direct product of what we eat and the lifestyles we have elected to live. Granted, there are diseases that are passed along to us genetically, but even in those instances through proper nourishment and lifestyle changes, we can greatly reduce our risk of premature illness and death causing diseases.
In the 1980’s, a study was conducted in the United States by the U.S. Department of Agriculture. Using 50,000 people, it was found that not a single person was getting the recommended amounts of the 10 essential vitamins required for normal health.
For years you have been advised to look to the food pyramid, which recommends that you eat at least 3-5 servings of vegetables and 2-4 servings of fruits daily. Sadly, the vast majority of us, and you know who you are, fall woefully short of these guidelines. The problem is we can’t eat the volume of food it would require. More than 90 percent of people don’t eat the recommended daily servings of fruits and vegetables. Even if we did, food today doesn’t have the vitamins and minerals that they had 40 or 50 years ago. In those days farmers restored the soil by mulching, using natural fertilizers and rotating crops. Today, extensive use of chemical substances depletes the soil of many of the essential elements needed for adequate nutrition…giving us a supply of beautiful products that look great, but don’t have the vitamins and other important nutrients we think they should have and, not near the vitamin, mineral and other essential nutrients (phytochemicals) they had 50 years ago.
Another problem is that most vitamins and other valuable nutrients are lost in processing. Cooking and freezing dramatically reduce vitamins, nutrients and food value. Added to this problem, are the presences of flavor enhancers, artificial colors, stabilizers and chemical food preservatives. Additionally, studies show that the nutrient value of our food is continually decreasing due to more air pollutants and less oxygen.
Additionally, mainstream marketing of supplemental vitamins and minerals has successfully created the myth that vitamins and minerals may be isolated from each other, that correct amounts may be measured out, and then we can derive total benefit from taking these fractionated chemical (synthetic) creations. Nothing could be farther from the truth. Vitamins and minerals, and also enzymes, work closely together as co-factors for each other’s efficacy. If one part is missing, or in the wrong form or the wrong amount, entire chains of metabolic processes will not proceed normally. Result: a downward spiraling of health, probably imperceptible for long periods of time.
SO WHAT’S THE ANSWER?
The dilemma we are faced with is; if we cannot get all of the nutrients we need through diet alone then how do we get them? We get them by taking supplements…but the right kind of supplements.
“We now have a substantial body of data showing that if everyone took a few supplements every day, they could significantly lower their risk of a multitude of serious diseases.” David Heber, M.D., Ph.D., of the Center for Human Nutrition at UCLA
While you may think that you have filled this need, you may be getting little benefit from using the vitamin & mineral supplements available today. Studies show that 90 percent of vitamin pills pass through your body unabsorbed! This is primarily due to the fact that most all vitamin & mineral supplements contain nothing but laboratory developed synthetic ingredients. Natural ingredients are more effectively used by your body which is designed to reject synthetic and foreign substances.
Your synthetic, fractionated chemical vitamin never grew in the ground, never saw the light of day, and never was alive or part of anything alive. It’s a chemical. In your body it’s just another drug. Synthetic vitamins have toxic effects in mega-doses and actually can increase the white blood cell count. Vitamins are only necessary in minute quantities on a daily basis. Whole food vitamins, by contrast, are not toxic and trigger no immune response.
Whole food vitamins are obtained by taking a vitamin-rich plant, removing the water and the fiber in a cold vacuum process, otherwise known as freeze–drying, free of chemicals, and then packaged for stability. The entire vitamin complex in this way can be captured intact, retaining its “functional and nutritional integrity.” Upon ingestion, the body is not required to draw on its own reserves in order to complete any missing elements from the vitamin complex.
“We have yet to improve on what Mother Nature has given us to eat. Foods simply cannot be artificially duplicated in the science laboratory.” Gabriel Clousens, M.D.
Examples from clinical tests conducted in Finland and reported in the New England Journal of Medicine.
• 25 mg of Vitamin C in its natural whole-food form will cure scurvy but, 250 mg of synthetic vitamin C (ascorbic acid) will not!
• “Saltwater” can be synthesized in a laboratory, but when you put a fish in it the fish dies.
WHAT OCCURS IN THE BODY WHEN YOU INGEST SYNTHETIC VITAMINS OVER A PERIOD OF TIME?
Most people are not aware that most vitamins are processed at high temperature, contain petroleum derived chemical solvents, such as coal tar derivatives and ethyl cellulose and are coated with methylene chloride, a carcinogenic material. These sources are not living foods but dead chemicals and over a period of extended use can be potentially dangerous.
According to Dr. Zoltan P. Rona, M.D., “Although most healthy people will have no obvious side effects from ingesting small amounts of toxins found in most vitamins, the long-term consequences of continuous, daily intakes are potentially dangerous.” Dr. Rona says that reactions include fatigue, memory loss, depression, insomnia and potential liver disorders.
A recent Finnish study published in the New England Journal of Medicine states that “taking synthetic vitamins is worse than starvation! The synthetic vitamins will kill you quicker.” Admittedly, this statement is a bit aggressive, but does show the emphasis the researchers wanted to make regarding the potential health danger of using synthetic vitamins.
Living systems are very complex and specific in their need for building materials. In addition, living systems are constantly breaking down cells, organs and tissues, and rebuilding and repairing themselves. For these processes, the body must have a continual supply of specific, high-quality materials.
If you build a house with cheap, imitation construction materials, your house will quickly fall into disrepair. The same is true for the physical body. The body has a very precise design, which is so incredibly intricate and complex that even with all the scientific and medical research thus far; we have only scratched the surface of understanding it.
The following examples are a handful of hundreds that could be given to illustrate this point:
• Reported on April 14, 1994 in the New England Journal of Medicine was a study in which 29,000 male smokers were given synthetic beta-carotene and synthetic Vitamin E to evaluate the cancer-protective effect of the “vitamins”. After 10 years, the men taking the synthetic beta carotene had an 18% higher rate of lung cancer, more heart attacks, and an 8% higher overall death rate. Those taking Synthetic Vitamin E had more strokes. Food sources of these same nutrients, such as fruits, and vegetables, consistently demonstrate protection against cancer, heart attacks and stroke.
• On November 23, 1995, the following was reported in The New England Journal of Medicine. 22,748 pregnant women were given synthetic Vitamin A. After four years the study was halted because of a 240% increase in birth defects in babies of women taking 10,000 IU daily, and a 400% increase in birth defects in babies of women taking 20,000 IU a day. Women eating natural food sources of Vitamin A showed no increase in birth defects.
• Reported in Reuters Health, March 3, 2000 was a study of men who took 500 mg of synthetic Vitamin C daily. It was found that over an 18-month period, these men had a 250% increase of the intima-media lining (inner lining) of the carotid artery. This thickening is an accurate measurement for the progression of atherosclerosis. That is, synthetic Vitamin C induced atherosclerosis, even at 500 mg dose. Whole food Vitamin C protects and repairs the inner lining of blood vessels, and is preventative against atherosclerosis.
WHAT IS BEST FOR ME?
Using years of research and clinical data published by the National Cancer Institute, American Heart Association, USDA and the International Food Information Council Foundation, the American Diabetic Association and countless medical studies we need to keep our bodies free of refined and processed food, eliminate high fructose and artificial sweeteners . We need to consume a “Rainbow” of fruits and vegetables to get as much color variety in your diet as possible, so that you can maximize your intake of a broad range of nutrients. The colors of fruits and vegetables are a small clue as to what vitamins and nutrients are included. By getting a variety of different colored fruits and vegetables, you are guaranteed a diverse amount of naturally created essential vitamins and minerals. Choose grains, fruits and vegetables that are grown in deep mineral rich, alluvial soils without the use of pesticides, herbicides and fungicides…there’re grown as mother-nature intended.
The Choice is yours
110 companies sell vitamins in the United States. Less than 5 of them use whole food vitamins. The reason is simple: whole food vitamins are expensive to make. A few of the largest pharmaceutical firms in the world mass produce synthetic vitamins for the vast majority of these 110 “vitamin” companies, who then put their own label on them, and every company claims theirs is the best! Americans spend over $9 billion per year for synthetic vitamins and our health is worse now than it’s ever been…something is wrong….it’s called synthetics!
Don’t you think it’s time for a change?
by: Denise McKinley
Exercising In Heat
Summer is officially here. Finally you can pack away your jackets and get outside. Summer offers extras hours of daylight and with it the opportunity to spend even more time enjoying outdoor activities. For many, this means more time doing physical activities and playing sports. So, it’s important to remember the potential dangers that also come with exercising in hot conditions. As long as you know the dos and don’ts of working out in the heat, then you can fully take advantage of all the fun of summer.
What you should do:
* Drink plenty of fluids. It’s extremely important to stay hydrated. If you’re thirsty then you are already dehydrated; drink before you feel a need to. Be sure to drink throughout the day (stick to non-caffeinated beverages, preferably water). Also, drink 15-20 minutes before beginning your workout and every 15 minutes throughout the exercise.
* Eat regularly. The heat can decrease your appetite, but it’s important to eat normally. Try to eat small meals 5-6 times per day. Include lots of fruits and vegetables. Aside from being nutritious, fruits also tend to help with hydration.
* Wear light, loose fitting clothes that can breath. Cotton is always a good choice. If your outdoor activity produces a lot of perspiration, consider clothing that is designed to wick the sweat away.
* Wear sunscreen. Even if you exercise early in the morning or late in the evening, if the sun can reach you then you can get burned. Not only is a sunburn bad on the skin and potentially dangerous but it also hinders your bodies ability to stay cool.
* Use common sense and don’t attempt strenuous activities that your body is not accustom to. Stick to exercises that you are very familiar and comfortable with.
* Check the weather forecast. It’s best not to participate in intense outdoor exercise sessions when the heat index registers in the dangerous zone.
What you should not do:
* Don’t try to diet by sweating. Excessive perspiration is not the key to permanent weight loss. Any decrease in the scale would simply be a result of water loss, not fat reduction.
* Don’t adapt the "no pain, no gain" motto. Ignoring your body’s signals could be dangerous. Heat-related illnesses come with warning signs. Be sure to learn how to recognize them and what actions to take.
* Don’t forget to drink plenty of liquid when swimming. Just because your body is surrounded by water does not mean that you are well-hydrated. As with any land exercises, you need to regularly replenish lost fluids when in the pool.
* Avoid physical activity during the hottest part of the day, which usually is between 10 a.m. and 3 p.m.
* If you want (or need) to be working in very hot temperatures, don’t do it until you become acclimated. Try to spend only a few minutes per day in the hot conditions for the first couple of weeks and then add time gradually each day.
* Avoid extreme changes in temperature. Don’t hop from being extremely hot and sweating excessively right into an ice cold, air-conditioned environment. Try to cool your body down slightly before exposing it to the extreme temperature variation.
Whether you have to work outside or do it for enjoyment, following the above tips will help you stay cool and safe during the dog days of summer. So, don’t spend the season cooped up, get out there and have some fun!
by: Lynn Bode
What you should do:
* Drink plenty of fluids. It’s extremely important to stay hydrated. If you’re thirsty then you are already dehydrated; drink before you feel a need to. Be sure to drink throughout the day (stick to non-caffeinated beverages, preferably water). Also, drink 15-20 minutes before beginning your workout and every 15 minutes throughout the exercise.
* Eat regularly. The heat can decrease your appetite, but it’s important to eat normally. Try to eat small meals 5-6 times per day. Include lots of fruits and vegetables. Aside from being nutritious, fruits also tend to help with hydration.
* Wear light, loose fitting clothes that can breath. Cotton is always a good choice. If your outdoor activity produces a lot of perspiration, consider clothing that is designed to wick the sweat away.
* Wear sunscreen. Even if you exercise early in the morning or late in the evening, if the sun can reach you then you can get burned. Not only is a sunburn bad on the skin and potentially dangerous but it also hinders your bodies ability to stay cool.
* Use common sense and don’t attempt strenuous activities that your body is not accustom to. Stick to exercises that you are very familiar and comfortable with.
* Check the weather forecast. It’s best not to participate in intense outdoor exercise sessions when the heat index registers in the dangerous zone.
What you should not do:
* Don’t try to diet by sweating. Excessive perspiration is not the key to permanent weight loss. Any decrease in the scale would simply be a result of water loss, not fat reduction.
* Don’t adapt the "no pain, no gain" motto. Ignoring your body’s signals could be dangerous. Heat-related illnesses come with warning signs. Be sure to learn how to recognize them and what actions to take.
* Don’t forget to drink plenty of liquid when swimming. Just because your body is surrounded by water does not mean that you are well-hydrated. As with any land exercises, you need to regularly replenish lost fluids when in the pool.
* Avoid physical activity during the hottest part of the day, which usually is between 10 a.m. and 3 p.m.
* If you want (or need) to be working in very hot temperatures, don’t do it until you become acclimated. Try to spend only a few minutes per day in the hot conditions for the first couple of weeks and then add time gradually each day.
* Avoid extreme changes in temperature. Don’t hop from being extremely hot and sweating excessively right into an ice cold, air-conditioned environment. Try to cool your body down slightly before exposing it to the extreme temperature variation.
Whether you have to work outside or do it for enjoyment, following the above tips will help you stay cool and safe during the dog days of summer. So, don’t spend the season cooped up, get out there and have some fun!
by: Lynn Bode
Cranberry Juice For Cavities? Be Careful Of What You’re Buying
Researchers at the University of Rochester have published information showing that the cranberry may be effective at preventing tooth decay. The research focuses on the inhibiting effect of some compounds found inside the cranberry against a key bacterium blamed in the formation of cavities.
“Scientists believe that one of the main ways that cranberries prevent urinary tract infections is by inhibiting the adherence of pathogens on the surface of the bladder. Perhaps the same is true in the mouth, where bacteria use adhesion molecules to hold onto teeth,” says Dr. Michel Koo, an oral biologist and food scientist at the university's medical center.
While this may sound like good news for those who are looking for natural ways to support their body, it’s very important to understand what’s in cranberry juice before making a purchase. Always remember to read the labels. Most cranberry juice is cranberry flavored apple juice. Sometimes it is also mixed with grape juice. Other ingredients may even include high-Fructose corn syrup. Towards the end of the ingredient list is found cranberry concentrate.
While, drinking apple juice and grape juice is probably a dietary improvement for most people, juices that are made with so much processed sugar are clearly little more than cranberry flavored juices. They’re unlikely to contain significant amounts of the compounds that make cranberries useful in the prevention of tooth decay and tend to contain large amounts of the compounds that are blamed on tooth decay.
Purer forms of cranberry juice have a very strong flavor. Some people can develop a taste for unsweetened cranberries, while other people can only handle cranberries when blended with some other juice. If choosing a cranberry blend, be sure to read the ingredient label and avoid juices that are sweetened with processed sugars and diluted with juices that are mostly the sugars that lead to cavities.
Further research will be necessary before cranberries can actually be promoted as a preventative for tooth decay. However others sugars such as Xylose, are already used in “sugarless gums” because of their proven ability to inhibit bacterial development on the surface of teeth. Such gums are of course called sugarless because they do not have sucrose and glucose which are the sugars associated with cavities.
Cranberries have also been shown to have beneficial effects for people with chronic urinary tract infections. The compound believed to be responsible for this is a simple monosaccharide sugar called Mannose. Identified in Harpers Biochemistry as one of eight sugars necessary for normal cellular function, Mannose has also been shown to prevent bacterial infection and development.
These necessary monosaccharide sugars can all be found in a single dietary supplement. It also contains the other sugars identified in Harpers Biochemistry, based of their importance in biological functions. This can provide a more convenient choice for people wishing to improve their diets by increasing their nutrient intake while limiting the intake of food compounds which are not beneficial to good health.
by: Dave Saunders
Dietary Recommendations After Gastric Bypass Surgery
When obesity gets out of hand, unresponsive to dietary, lifestyle and medical interventions, drastic measures are needed to cut down calorie intake. Morbid obesity with a BMI (body mass index, a measure of malnutrition) above 40 kg/m2 is an indication for surgical procedures such as gastric bypass surgery. Gastric bypass is now a well-trodden path to lower BMI’s and achieve healthier lives in 18 months or so. First used in the 1950’s, only the last two decades have seen safe and successful gastric bypass surgery with any consistency. Half a century of meticulous observations and patient follow-up has led to the formulation of strict guidelines to ensure desired results.
Gastric bypass is a series of steps initiated starting with the decision to undergo the procedure. Identifying existing nutritional deficiencies is the first step towards surgery. Vitamin and mineral deficiency often occur in obesity, and need to be addressed before the procedure. The surgery itself has two goals; to reduce the volume of the stomach and shorten the food transit time in the intestine. After surgery the stomach cannot receive large meals or participate in digestion. This by itself limits food intake. Food also bypasses a large part of the intestine and has little time to interact with liver and pancreatic enzymes. As a result, nutrition absorbed from diet drops drastically. In most types of gastric bypass surgeries done today only 50 cm of the intestine is allowed to function in normal fashion. Compare this to food absorption taking over 7 feet of small and large intestine before surgery.
With such a radical reduction in the capacity to assimilate food, the postoperative period can be rather tricky. Only clear fluids are advised for the first two days while waiting for gut to recover. The gut is then re-trained for about two months before it can go back to a normal diet. During the recovery period the limitations imposed by the gastric bypass procedure should be kept in mind. After surgery the stomach has become much smaller and can only hold approximately eight ounces at a time. The stomach has also lost its ability to pulverize food to initiate digestion. Consequently the appropriate diet for postoperative recovery would be a liquid to soft solid diet that can be taken six to eight times a day in small quantities. Nutrient fluids are preferable since they can provide hydration and energy at the same time. Non-nutrient fluids are best avoided or at least restricted to in-between meals.
The type of nutrient chosen also deserves due consideration. The chosen macronutrient should not affect the stomach emptying time while providing enough energy to recover from the surgery. In this regard carbohydrates and fats are at either end of a spectrum and neither is suitable. Carbohydrates pass through very quickly and produce very uncomfortable symptoms like vomiting, bloating, diarrhea and sweating. Fat slows the gut considerably, and it is oftentimes ruled out because of its direct link to obesity. Research suggests that the macronutrients of choice after gastric bypass surgery are proteins. Proteins do not change gastric transit time significantly. A high-protein diet can also provide enough amino acids for repair and growth after a major surgical procedure like gastric bypass.
Apart from these advantages, a high-protein diet has a special role in the treatment of obesity. Gastric bypass restricts excessive calorie intake to prevent weight gain. However, accumulated adipose tissue also needs to be expended to achieve the desired weight loss. The basal metabolic rate (energy expenditure) should be increased simultaneously to burn stored fat and reduce BMI. This can be achieved by a high-protein diet since proteins in diet increase the basal metabolic rate by stimulating protein synthesis. Observations made during the postoperative period also confirm this proposition. Unless a high-protein diet is provided, weight loss often ceases despite controlled consumption.
Currently, a protein intake of up to 90 grams per day is recommended in the post-operative period. Given the trauma and the limitations the gut is subjected to during the procedure, such a high protein intake can be difficult to maintain. The gut is hardly ready and often fails to assimilate proteins and energy from traditional foods and diets. Therefore, a sugar-free fluid protein concentrate with a high bioavailability, adequate essential amino acids, vitamins and minerals is the most appropriate diet in the post-operative period. Digestion is further facilitated if the protein concentrate is already pre-digested, or hydrolyzed. Such a nutrient fluid can simultaneously supply concentrated energy and hydration even when taken in small quantities.
After recovery and return to a normal diet divided over 3 to 4 meals per day, a high-protein concentrate is still a relevant supplement between or during meals. The protein supplement continues to provide thermogenic action necessary to lose weight essential to sustain weight loss. It also compensates for any amino acid deficiency in the diet and maintains nutrition on bad days not uncommon in the months and years after a major surgery.
REFERENCES
1. Kellum JM, DeMaria EJ, Sugarman HJ. The surgical treatment of morbid obesity. Curr Prob Surg. 1998;35:791-858.
2. MacLean LD, Rhode BM, Nohr CW. Late outcome of isolated gastric bypass. Ann of Surg. 2000. 231:524-528.
3. Nutritional Implications of Bariatric Surgery: Perspectives of Practitioners Audiotape/Handout packages available post-conference.
4. Weight management—Position of ADA. J Am Diet Assoc. 2002;102:1145-1155
5. Faintuch J, Matsuda M, Cruz ME, et al. Severe protein-calorie malnutrition after bariatric procedures. Obes Surg 2004; 14:175–181.
6. Alvarez-Leite J.I. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care 7:569–575.
by: Protica Nutritional Research
Intermune Executive Convicted of Fraud
From today's New York Times comes word of an unusual legal case,
This case is unusual because it involved the prosecution of an individual who appeared to be responsible for the allegedly unlawful conduct. In most cases of unethical or unlawful conduct alleged on the part of health care organizations, at most it is the organization itself that has paid the penalty, usually in the form of a fine, sometimes accompanied by a corporate integrity agreement or deferred prosecution agreement. (See relevant posts here.)
We have argued that such penalties applied to corporations do little to deter bad behavior. A fine can just be a cost of doing business. The cost of the fine may diffuse across the whole organization. For public for-profit corporations, the fine may finally be paid by stockholders (through lower dividends or lower stock appreciation), employees as a group (through lower pay), and customers, clients, or patients (through higher prices). So the penalty may ultimately be spread over a large number of people, hardly any of which were actually responsible for the bad behavior. The few people responsible, who could include people who implemented, directed, or approved the behavior, usually have suffered no consequences. So what is to deter such people from again behaving badly?
So this case seems to be a step forward. One may argue whether off-label marketing should be illegal, but it currently is illegal. Corporate leaders who do not like this law ought to strive to change it, not violate it. If the law is to be upheld, when someone within a corporation implements, directs or approved illegal off-label marketing, then that person should suffer the consequences.
In a verdict that could strike fear into pharmaceutical industry executive suites, the former head of a drug company was convicted of wire fraud Tuesday for issuing what federal prosecutors called a misleading press release that contributed to off-label sales of his company’s drug.
But the executive, W. Scott Harkonen, the former chief executive of InterMune, was acquitted by the federal jury in San Francisco of a related charge of off-label marketing itself, known as 'misbranding,' the Justice Department said.
The case was unusual because off-label marketing cases are often settled with the company paying a fine. It is rare for prosecutors to press charges against individual executives.
'Today’s verdict demonstrates that pharmaceutical executives will not be able to hide behind a corporate shield when they promote drugs using false or fraudulent information,' Thomas P. Doyle, a special agent in the Food and Drug Administration’s office of criminal investigations, said in a statement Tuesday.
InterMune’s drug, Actimmune, was approved for two rare genetic conditions. But the main sales of the drug, which peaked at $141million in 2003, came from an unapproved use: treating idiopathic pulmonary fibrosis, a scarring of the lungs that can be fatal.
InterMune conducted a large clinical trial testing Actimmune as a treatment for the lung disease. The drug did not achieve the goal of the trial, which was to improve lung function compared with a placebo. But InterMune found that if only the patients in the trial with mild or moderate disease were considered, those who got the drug lived longer than those who received the placebo. The company highlighted the 'survival benefit' in a news release, issued in August 2002. [Editor's note - if the primary study outcome was improvement of lung function, and the only 'positive' result was improvement of survival in one sub-group, that result may have been due to chance alone, due to multiple statistical comparisons. If one does analyses on multiple sub-groups and for multiple endpoints, the likelihood of finding a 'significant' result increases with the number of such analyses done.]
Prosecutors said the news release was part of a scheme to induce off-label sales of Actimmune, also known as interferon gamma, which costs about $50,000 a year.
[The company's attorney] Mr. Topel said interpretation of the clinical trial results was a matter of debate. 'One position in a scientific dispute has been criminalized — quite an astonishing thing,' Mr. Topel said in an interview.
Wire fraud carries a maximum sentence of 20 years in prison and a $250,000 fine. Dr. Harkonen, who remains free on bail, has not been sentenced.
A medical doctor by training, he was chief executive of InterMune from February 1998 until June 2003.
InterMune agreed to pay about $37 million in 2006 to settle charges related to Actimmune marketing. The company, based in Brisbane, Calif., also entered into a five-year corporate integrity agreement with the Department of Health and Human Services.
In 2007, a second big trial of Actimmune found that the drug did not prolong lives of patients with pulmonary fibrosis. Sales of the drug have dwindled year by year. [Editor's note - this suggests again that the result in the sub-group from the first trial might have been a false positive due to multiple comparisons.]
This case is unusual because it involved the prosecution of an individual who appeared to be responsible for the allegedly unlawful conduct. In most cases of unethical or unlawful conduct alleged on the part of health care organizations, at most it is the organization itself that has paid the penalty, usually in the form of a fine, sometimes accompanied by a corporate integrity agreement or deferred prosecution agreement. (See relevant posts here.)
We have argued that such penalties applied to corporations do little to deter bad behavior. A fine can just be a cost of doing business. The cost of the fine may diffuse across the whole organization. For public for-profit corporations, the fine may finally be paid by stockholders (through lower dividends or lower stock appreciation), employees as a group (through lower pay), and customers, clients, or patients (through higher prices). So the penalty may ultimately be spread over a large number of people, hardly any of which were actually responsible for the bad behavior. The few people responsible, who could include people who implemented, directed, or approved the behavior, usually have suffered no consequences. So what is to deter such people from again behaving badly?
So this case seems to be a step forward. One may argue whether off-label marketing should be illegal, but it currently is illegal. Corporate leaders who do not like this law ought to strive to change it, not violate it. If the law is to be upheld, when someone within a corporation implements, directs or approved illegal off-label marketing, then that person should suffer the consequences.
Tuesday, September 29, 2009
In the Patient's Interest
I spent the entire day in meetings today. One would think that is a boring or unproductive way for a physician to spend time, however these meetings made me proud to be a doctor and proud of my colleagues in medicine.The morning was spent with nurses, respiratory therapists and quality experts who came together to celebrate success with patient safety and quality initiatives that have saved at
Monday, September 28, 2009
The Kelo Case Redux: Pfizer's "Nice Place" Ends Up Covered with Weeds
Four years ago we posted (here, here and here) about the controversial US Supreme Court decision in the Kelo case. Most discussion of the case at the time focused on individual property rights vs the power of the government to promote economic development, but the case had an important health care angle.
Briefly, the case centered on the taking of private property, including a house owned by Susette Kelo, by a not-for-profit organization, the New London (Connecticut) Development Corporation (NLDC) given the power of eminent domain by the New London city government. While the ostensible rationale for the taking was economic development, the action appeared to have been at the behest of Pfizer Inc, the world's largest pharmaceutical company, which had built a research and development facility in the city, and wanted a suitably upscale and sanitized environment for its workers.
As we previously posted, the NLDC's leadership had multiple conflicts of interest that involved ties to Pfizer. One board member was a Pfizer vice-president. The board president was married to another Pfizer vice-president. Pfizer wanted the part of New London that included Kelo's house made more attractive to complement its new research facility. The husband of the NLDC president had said, "Pfizer wants a nice place to operate. We don't want to be surrounded by tenements."
Kelo's and other property owners' protest of the taking went all the way to the US Supreme Court. As we posted here, the Court decided against the property owners by a 5-4 vote. Justice John Paul Stevens wrote for the majority that the city's "determination that the area was sufficiently distressed to justify a program of economic rejuvenation is entitled to our deference. The city has carefully formulated an economic development plan that it believes will provide appreciable benefits to the community, including - but by no means limited to - jobs and increased revenues." This majority opinion is important, because the Fifth Amendment to the US Constitution provides "nor shall private property be taken for public use without just compensation." Many had interpreted this provision to mean that eminent domain could only be used to take property for public use, e.g., to build a road or a public school, but not for private purposes, like building upscale waterfront developments.
The Associated Press just published an ironic follow-up.
What happened?
So that was the result of the economic development plan the Supreme Court majority termed "carefully formulated." The lesson seems to be that when government makes policy to favor individual corporations, the results are bad policy and little public benefit. Government leaders often seem willing to favor specific health care organizations, rationalizing their actions in terms of economic development or promoting health and health care. Doing so may benefit the corporations involved, but rarely individual or public health.
Although US local and national government officials have have increasingly practiced such corporate socialism, they have neglected their regulatory roles. Instead of picking winners and losers, government would do better to act like a combination of an honest policeman on the beat, deterring and punishing dishonest behavior, and in impartial referee, trying to make sure everyone is playing the game honestly. But no doubt government officials used to mingling with the corporate superclass would not be comfortable in the roles of honest cop or impartial referee.
Briefly, the case centered on the taking of private property, including a house owned by Susette Kelo, by a not-for-profit organization, the New London (Connecticut) Development Corporation (NLDC) given the power of eminent domain by the New London city government. While the ostensible rationale for the taking was economic development, the action appeared to have been at the behest of Pfizer Inc, the world's largest pharmaceutical company, which had built a research and development facility in the city, and wanted a suitably upscale and sanitized environment for its workers.
As we previously posted, the NLDC's leadership had multiple conflicts of interest that involved ties to Pfizer. One board member was a Pfizer vice-president. The board president was married to another Pfizer vice-president. Pfizer wanted the part of New London that included Kelo's house made more attractive to complement its new research facility. The husband of the NLDC president had said, "Pfizer wants a nice place to operate. We don't want to be surrounded by tenements."
Kelo's and other property owners' protest of the taking went all the way to the US Supreme Court. As we posted here, the Court decided against the property owners by a 5-4 vote. Justice John Paul Stevens wrote for the majority that the city's "determination that the area was sufficiently distressed to justify a program of economic rejuvenation is entitled to our deference. The city has carefully formulated an economic development plan that it believes will provide appreciable benefits to the community, including - but by no means limited to - jobs and increased revenues." This majority opinion is important, because the Fifth Amendment to the US Constitution provides "nor shall private property be taken for public use without just compensation." Many had interpreted this provision to mean that eminent domain could only be used to take property for public use, e.g., to build a road or a public school, but not for private purposes, like building upscale waterfront developments.
The Associated Press just published an ironic follow-up.
Weeds, glass, bricks, pieces of pipe and shingle splinters have replaced the knot of aging homes at the site of the nation's most notorious eminent domain project.
There are a few signs of life: Feral cats glare at visitors from a miniature jungle of Queen Anne's lace, thistle and goldenrod. Gulls swoop between the lot's towering trees and the adjacent sewage treatment plant.
But what of the promised building boom that was supposed to come wrapped and ribboned with up to 3,169 new jobs and $1.2 million a year in tax revenues? They are noticeably missing.
What happened?
New London the city's prized economic development plan has fallen apart as the economy crumbled.
The Corcoran Jennison Cos., a Boston-based developer, had originally locked in exclusive rights to develop nearly the entire northern half of the Fort Trumbull peninsula.
But those rights expired in June 2008, despite multiple extensions, because the firm was unable to secure financing, according to President Marty Jones.
So that was the result of the economic development plan the Supreme Court majority termed "carefully formulated." The lesson seems to be that when government makes policy to favor individual corporations, the results are bad policy and little public benefit. Government leaders often seem willing to favor specific health care organizations, rationalizing their actions in terms of economic development or promoting health and health care. Doing so may benefit the corporations involved, but rarely individual or public health.
Although US local and national government officials have have increasingly practiced such corporate socialism, they have neglected their regulatory roles. Instead of picking winners and losers, government would do better to act like a combination of an honest policeman on the beat, deterring and punishing dishonest behavior, and in impartial referee, trying to make sure everyone is playing the game honestly. But no doubt government officials used to mingling with the corporate superclass would not be comfortable in the roles of honest cop or impartial referee.
Sunday, September 27, 2009
Shameless Corporation of the Week Award
Each week EverythingHealth will bestow its "Shameless Corporation of the Week Award" to a deserving health insurance company. Somehow I do not think it will be hard to find a recipient each week.Today's award goes to: Blue Shield of California HMO.When Rosalinda Miran-Ramirez awoke with bleeding from her left breast nipple she awakened her husband and had him drive her to the local emergency
Malpractices of the multitude revisited: "An outstanding job of educating themselves about clinical issues"
At numerous posts at Healthcare Renewal, we have pointed out what we feel to be a serious gap in the credentials of many in biomedical leadership roles.
The gaps are in the form of a near complete lack of any scientific or biomedical education and experience, except perhaps a high school chemistry and biology class or two.
We often receive comments back, usually from "anonymous" posters such as here to our opinions that this expertise gap impairs the judgment of such leaders on medical matters:
I feel this "anyone can be an expert" sentiment is an important issue to bring outside of the comments section of our posts.
I raised probing questions in response to such messages here in my post "More On Healthcare Management By Domain Neutral Generalists: CIO's Running Hospital Pharmacies and Home Healthcare Divisions?"
Here are my most recent questions to the above anonymous medical self-education proponent:
Re: "I've met individuals with management training who do an outstanding job of educating themselves about clinical issues."
Finally, I ask:
The critically thought-out answers to these questions expose the territorial invasion of medicine by ill-suited outsiders and dilettantes quite well.
Echoing an observation I wrote about once before in my eight part series on mission hostile EMR's, but addressing it to medical administration where it also applies:
Medical administration reminds me of dentistry in its early days, especially when medical administrators lacking biomedical expertise refer to themselves as "medical professionals."
B.T. Longbothom, author of the second dentistry book published in the U.S. ("A Treatise on Dentistry", 1802), gave an excellent description in his preface of problems at the time. His observations apply to medical administration in our present age:
Hardly anyone spoke out.
More than thirty years later, untrained practitioners were as prevalent as ever. One of the leading dentists of the time, Shearjashub Spooner, in his "Guide to Sound Teeth, or, A Popular Treatise on the Teeth" (1836) warned the public of a phenomenon I believe now applies to medical administration:
I understand that point of view.
-- SS
The gaps are in the form of a near complete lack of any scientific or biomedical education and experience, except perhaps a high school chemistry and biology class or two.
We often receive comments back, usually from "anonymous" posters such as here to our opinions that this expertise gap impairs the judgment of such leaders on medical matters:
... No. I've met individuals with management training who do an outstanding job of educating themselves about clinical issues. And I've met individuals with clinical training who do an outstanding job of educating themselves about management and business issues.
I feel this "anyone can be an expert" sentiment is an important issue to bring outside of the comments section of our posts.
I raised probing questions in response to such messages here in my post "More On Healthcare Management By Domain Neutral Generalists: CIO's Running Hospital Pharmacies and Home Healthcare Divisions?"
Here are my most recent questions to the above anonymous medical self-education proponent:
Re: "I've met individuals with management training who do an outstanding job of educating themselves about clinical issues."
What, exactly, is it that individuals with management training who do an outstanding job of "educating themselves about clinical issues" are professionally or even reasonably qualified to do?
Could they pass medical boards?
Could they reasonably interpret a complex medical article in, say, The Annals, and make truly informed, wise decisions based on that reading?
Could they reasonably evaluate therapeutic alternatives in complex cases, say, someone with a new heart valve who's just developed fever and a lower GI bleed?
In an emergency could they provide medical care? (mot in the legal sense, just in the skills sense.)
If not, why not, and what do you mean by "outstanding job?"
In comparison, I have no MBA or formal business training (other than working for years in my father's pharmacy as a stocker and cashier) but did a good job managing a department of 50+ and a budget of $13 million for an international pharma, solving severe business problems that had been impairing R&D and managing my budget consistently to within 0.5% of EA.
Is there perhaps an asymmetry between medicine and business?
Finally, I ask:
What percentage of a typical medical training curriculum (such as for a Pharm.D. here or a physician here) can a person with a management background absorb through self-education, and is the medical training curriculum therefore irrelevant? Should we just go back to the days of self-trained practitioners? If not, why not?
The critically thought-out answers to these questions expose the territorial invasion of medicine by ill-suited outsiders and dilettantes quite well.
Echoing an observation I wrote about once before in my eight part series on mission hostile EMR's, but addressing it to medical administration where it also applies:
Medical administration reminds me of dentistry in its early days, especially when medical administrators lacking biomedical expertise refer to themselves as "medical professionals."
B.T. Longbothom, author of the second dentistry book published in the U.S. ("A Treatise on Dentistry", 1802), gave an excellent description in his preface of problems at the time. His observations apply to medical administration in our present age:
The word "dentist" has been so infamously abused by ignorant pretenders, and is in general so indifferently understood, that I cannot forbear giving what I conceive to be its original meaning: viz, the profession of one who undertakes and is capable not only of cleaning, extracting, replacing by transplantation and making artificial teeth, but can also from his knowledge of dentistry, preserve those that remain in good condition, prevent in a very great degree, those that are loose, or those that are in a decayed state, from being further injured, and can guard against the several diseases, to which the teeth, gums and mouth are liable, a knowledge none but those regularly instructed, and who have had a long, and extensive practice, can possibly attain, but which is absolutely necessary, to complete the character of a Surgeon Dentist.
Hardly anyone spoke out.
More than thirty years later, untrained practitioners were as prevalent as ever. One of the leading dentists of the time, Shearjashub Spooner, in his "Guide to Sound Teeth, or, A Popular Treatise on the Teeth" (1836) warned the public of a phenomenon I believe now applies to medical administration:
One thing is certain, this profession must either rise or sink. If means are not taken to suppress and discountenance the malpractices of the multitude of incompetent persons, who are pressing into it, merely for the sake of its emoluments, it must sink, - for the few competent and well educated men, who are now upholding it, will abandon a disreputable profession, in a country of enterprise like ours, and turn their attention to some other calling more congenial to the feelings of honorable and enlightened men.
I understand that point of view.
-- SS
Saturday, September 26, 2009
Fertility Clinic Mistake Ends Up Good
It made me feel good to read that a mistake by a fertility clinic in Michigan ended with a happy ending. The biologic parents created an in-vitro embryo that was accidentally implanted into another woman at the clinic. A few days later the clinic notified Carolyn Savage that she was carrying Paul and Shannon Morell's embryo. She never considered terminating the pregnancy or trying to fight for
Congress expects physicians to implement EHR's when they can't post a PDF on the web?
Congress expects physicians to implement EHR's and review patient histories in detail, when they can't even review their own bills before acting, and post a PDF on the web?
This has to be the lamest, most inept, and/or most patronizing Congress in history (with approval ratings to match, 16% as of Sept. 25 according to Rasmussen):
Or, perhaps the "inability" to post the text has to do with text that appears at pages 80-81 of the bill:
As in the Washington Times:
No metrics on quality of care, outcomes, patient satisfaction, or other aspects of the complex process of medical care are apparently involved. Just an "aggregation of the physician's resource use."
May I use the words "capricious and arbitrary" to describe this metric?
Now, we should ask:
Where have I seen this before? (How about: biomedical dilettantes helping impair R&D at a pharmaceutical company, now in sale mode due to a poor pipeline of new drugs, through cutting drug discovery resources on the simplistic metric of "cost per user per database?")
Ultimately, this Medicare strategy is the end result of allowing medical dilettantes (no matter how well they've "self educated" themselves about medicine) to control the playing field. It is a poster example of a perverse incentive in direct conflict with the obligation of physicians to provide the best care.
In the end, patients and physicians get screwed.
-- SS
This has to be the lamest, most inept, and/or most patronizing Congress in history (with approval ratings to match, 16% as of Sept. 25 according to Rasmussen):
Washington ExaminerThis very same Congress is pushing physicians to implement EHR's under penalty of Medicare payment reductions, while they claim an inability to post a PDF or Word document online. Implementing EHR's is only several orders of magnitude more complex...
Baucus claims it's too difficult to put health care bill online
By: BARBARA HOLLINGSWORTH
09/24/09
A proposal by Sen. Jim Bunning, R-Ky., that would have required the Senate Finance Committee to post the final language of the $900 billion health care reform bill, as well as a Congressional Budget Office cost analysis, on the committee’s website for 72 hours prior to a vote was rejected 12-11.
... Chairman Max Baucus, D-Mont., himself admitted that “This probably sounds a little crazy to some people that we are voting on something before we have seen legislative language.” Indeed.
Baucus’ excuse - that it would take his committee staff two weeks to post the bill online – sounds a little crazy too.
Or, perhaps the "inability" to post the text has to do with text that appears at pages 80-81 of the bill:
"Beginning in 2015, payment [under Medicare] would be reduced by five percent if an aggregation of the physician's resource use is at or above the 90th percentile of national utilization." Thus, in any year in which a particular doctor's average per-patient Medicare costs are in the top 10 percent in the nation, the feds will cut the doctor's payments by 5 percent."
As in the Washington Times:
This provision makes no account for the results of care, its quality or even its efficiency. It just says that if a doctor authorizes expensive care, no matter how successfully, the government will punish him by scrimping on what already is a low reimbursement rate for treating Medicare patients. The incentive, therefore, is for the doctor always to provide less care for his patients for fear of having his payments docked.
And because no doctor will know who falls in the top 10 percent until year's end, or what total average costs will break the 10 percent threshold, the pressure will be intense to withhold care, and withhold care again, and then withhold it some more. Or at least to prescribe cheaper care, no matter how much less effective, in order to avoid the penalties.
No metrics on quality of care, outcomes, patient satisfaction, or other aspects of the complex process of medical care are apparently involved. Just an "aggregation of the physician's resource use."
May I use the words "capricious and arbitrary" to describe this metric?
Now, we should ask:
- Is this what our government means by "data driven healthcare?"
- Do they realize the likely adverse consequences of such half-baked measures?
- Are those who would propose such a bill friends of patients, and friends of physicians?
Where have I seen this before? (How about: biomedical dilettantes helping impair R&D at a pharmaceutical company, now in sale mode due to a poor pipeline of new drugs, through cutting drug discovery resources on the simplistic metric of "cost per user per database?")
Ultimately, this Medicare strategy is the end result of allowing medical dilettantes (no matter how well they've "self educated" themselves about medicine) to control the playing field. It is a poster example of a perverse incentive in direct conflict with the obligation of physicians to provide the best care.
In the end, patients and physicians get screwed.
-- SS
Friday, September 25, 2009
GHOSTING MATILDA
The fall season is upon us and the markets are filled with advertising for Halloween, so our thoughts naturally turn to the recent stories of ghostwriting in medical journals. Here is a lighthearted take on that topic. This parody began on Margaret Soltan’s blog a few days ago, and it has just kept growing.
GHOSTING MATILDA
Once a jolly bagman signed on to some articles.
Corporate ghosts even promised him a fee.
And he sang as he watched and waited till they were in print,
These will be grand right up there on my CV.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
And he sang as he watched and waited till they were in print,
These will be grand right up there on my CV.
This month it’s Janssen, next it’s Bristol-Myers Squibb.
Wyeth and Lilly soon might want to talk to me.
Novartis might sign me up, also AstraZeneca ─
Soon I’ll be famous like that guy at Emory.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
Novartis might sign me up, also AstraZeneca ─
Soon I’ll be famous like that guy at Emory.
Up came an editor, looking for the telltale signs.
Ghost writing’s hard to cover up, you see.
And he found them in the documents: metadata do not lie ─
Bagman just sold his name and passed these off on me.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
And he found them in the documents: metadata do not lie ─
Bagman just sold his name and passed these off on me.
Up jumped the bagman, pointing fingers right and left,
You’ll never prove that I lied, said he.
I will say that underlings failed to send disclosure forms;
Let them be blamed instead, while I get off scot-free.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
I will say that underlings failed to send disclosure forms;
Let them be blamed instead, while I get off scot-free.
Out! said the editor, you’re now persona non grata.
So, too, the Dean and the Provost agreed.
Bagman’s ghost may be heard now, sighing in the library ─
Could have been grand right up there on my CV.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
Bagman’s ghost may be heard now, sighing in the library ─
Could have been grand right up there on my CV.
GHOSTING MATILDA
Once a jolly bagman signed on to some articles.
Corporate ghosts even promised him a fee.
And he sang as he watched and waited till they were in print,
These will be grand right up there on my CV.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
And he sang as he watched and waited till they were in print,
These will be grand right up there on my CV.
This month it’s Janssen, next it’s Bristol-Myers Squibb.
Wyeth and Lilly soon might want to talk to me.
Novartis might sign me up, also AstraZeneca ─
Soon I’ll be famous like that guy at Emory.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
Novartis might sign me up, also AstraZeneca ─
Soon I’ll be famous like that guy at Emory.
Up came an editor, looking for the telltale signs.
Ghost writing’s hard to cover up, you see.
And he found them in the documents: metadata do not lie ─
Bagman just sold his name and passed these off on me.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
And he found them in the documents: metadata do not lie ─
Bagman just sold his name and passed these off on me.
Up jumped the bagman, pointing fingers right and left,
You’ll never prove that I lied, said he.
I will say that underlings failed to send disclosure forms;
Let them be blamed instead, while I get off scot-free.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
I will say that underlings failed to send disclosure forms;
Let them be blamed instead, while I get off scot-free.
Out! said the editor, you’re now persona non grata.
So, too, the Dean and the Provost agreed.
Bagman’s ghost may be heard now, sighing in the library ─
Could have been grand right up there on my CV.
Ghosting Matilda, ghosting Matilda,
Who’ll come a-ghosting Matilda with me?
Bagman’s ghost may be heard now, sighing in the library ─
Could have been grand right up there on my CV.
Spanking Linked to Lower I.Q.
A new study funded by the National Institute of Mental Health has found that children who are spanked end up with a lower I.Q. than children who are not spanked. The researchers looked at 32 nations (including the U.S.) that used corporal punishment and compared the I.Q. between children.They found that the children who were spanked the most fell behind I.Q. development scores. But even children
The Reappearance of a Ghost of Seasons Past
About a year after we started Health Care Renewal, in late 2005, we wrote multiple posts about the complex and unfortunate case of Dr Aubrey Blumsohn's attempts to keep a research project honest. The early posts were here, here, here, and here. In this post, we summarized the case thus:
So, after four years, this case has generated an official hearing of sorts. The hearing is obviously late, and seemingly will only be devoted to only one aspect of this case (ghost writing). However, at least our friends in the UK are doing something. I cannot recall a single case that resulted in any serious consideration of imposing negative consequences on anyone who was accused of suppressing research, manipulating research, endorsing ghost-writing, or intimidating a whistle-blower. In fact, many of the more troubling cases have never resulted in any sort of public discussion either at the institutions at which they occurred, or at any organization with relevant regulatory, or even just moral authority. So the GMC hearing is at least a step forward. Two cheers for the British GMC, and none for US universities, academic medical centers, professional societies, and government regulators.
(If anyone can remind me of a case in which there was a public discussion at the relevant institution, or some public consideration of the case by a regulatory agency, professional society, or some group with moral authority, please remind me of it, and I would be happy to post about it.)
- Dr Aubrey Blumsohn, a senior lecturer at Sheffield University, and Professor Richard Eastell performed a research project on the effects of the drug risedronate (Actonel, made by Procter & Gamble Pharmaceuticals [P&G]) under a contract between P&G and the University.
- Although the research contract designated Blumsohn and Eastell as "Investigators" under whose direction the project would be carried out, Blumsohn was not given access to the original data collected by the project.
- Despite numerous requests, (like this one), P&G refused access to this data repeatedly.
Blumsohn was concerned that he and Eastell could be accused of scientific fraud if they continued to make presentations and write articles and abstracts without access to the data which they were supposedly writing about. - Blumsohn became suspicious that some of the analyses done by P&G could be misleading, especially related to a graph shown to him that omitted 40% of patient data.
- Blumsohn objected to P&G arranging for papers and abstracts to be written by a professional writer, but with Blumsohn listed as first author. Blumsohn was concerned that such ghost-written documents were mainly meant to convey "key messages" in support of P&G's commercial interests.
- Eastell warned Blumsohn not to aggravate P&G, because the company was providing a grant to the University which "is a good source of income."
- After repeated failed attempt to get the data, Blumsohn complained to numerous officials at Sheffield University, including Eastell, medical school Dean Tony Weetman, University Vice-Chancellor Robert Boucher, and the Head of the University's Department of Human Resources, Ms R Valerio.
- Still unable to get the data, he spoke with news reporters about his case. At this point, Sheffield suspended him, but then offered him a severance agreement if he signed a contract binding him not to make any detrimental or derogatory statements about the University and its leaders.
So the case involved suppression and manipulation of research, ghost-writing, institutional conflicts of interest, and attempts to silence a whistle blower. It provides lessons about the downsides of letting commercial firms sponsor and hence control human research designed to evaluate the products or services they sell; and of academic medicine becoming dependent on research money from such firms for such research. Although Health Care Renewal, being US based, most often writes about such issues in the US, this case is a reminder that they are global. (Note that we posted more about this case in 2006, here, here and here, but since then it has not gotten much public attention.)
Last weekend the (UK) Guardian returned to it:
The Guardian has learned that one of Britain's leading bone specialists is facing disciplinary action over accusations that he was involved in 'ghost writing'.
The General Medical Council will call Professor Richard Eastell in front of a fitness to practice committee. Eastell, a bone expert at Sheffield University, has admitted he allowed his name to go forward as first author of a study on an osteoporosis drug even though he did not have access to all the data on which the study's conclusions were based. An employee of Proctor and Gamble, the US company making Actonel, was the only author who had all the figures.
Experts believe the practice is widespread in Britain.
In a letter published in the Journal of Bone and Mineral Research, which carried the original study, he stated: 'In the original paper one of the authors, a statistician working for P&G, Ian Barton, had full access to all the data.' The authors had full access to all the analyses of the data that they requested, he said – but those analyses were carried out by the company.
The letter, published in 2007, also acknowledged flaws in the study. A later independent analysis of the data 'identified some errors and poor practice', he wrote. The study was designed to show the strengths of Actonel which was in fierce competition with a rival bone-strengthening drug called Fosamax, made by Merck.
Eastell's paper concerned a study carried out on behalf of Proctor and Gamble, comparing the bone density of women prescribed Actonel with others who were not. Only the company knew which women were on the drug and which were taking something else.
Eastell's colleague, Dr Aubrey Blumsohn, wanted the codes which would say which of the patients who suffered fractures had been on the drug. The company refused. Blumsohn took his concerns to Eastell, but in a conversation which Blumsohn says he taped , Eastell said he was concerned that persistent requests might damage the relationship they had with the company. Eastell is said to have told him: 'The only thing that we have to watch all the time is our relationship with P&G. Because … we have the big Sheffield Centre Grant [from P&G] which is a good source of income, we have got to really watch it.' .
So, after four years, this case has generated an official hearing of sorts. The hearing is obviously late, and seemingly will only be devoted to only one aspect of this case (ghost writing). However, at least our friends in the UK are doing something. I cannot recall a single case that resulted in any serious consideration of imposing negative consequences on anyone who was accused of suppressing research, manipulating research, endorsing ghost-writing, or intimidating a whistle-blower. In fact, many of the more troubling cases have never resulted in any sort of public discussion either at the institutions at which they occurred, or at any organization with relevant regulatory, or even just moral authority. So the GMC hearing is at least a step forward. Two cheers for the British GMC, and none for US universities, academic medical centers, professional societies, and government regulators.
(If anyone can remind me of a case in which there was a public discussion at the relevant institution, or some public consideration of the case by a regulatory agency, professional society, or some group with moral authority, please remind me of it, and I would be happy to post about it.)
Wednesday, September 23, 2009
Seborrheic Keratosis, Common and Benign
Seborrheic Keratosis are common and they are raised dark papules that appear on the skin as a person ages. The are usually located on the face, chest, back or shoulders and can be rough to the touch. Some people develop quite a few and others are scattered.Seborrheic Keratosis are skin tumors that are benign. The cause is unknown but they seldom appear before age 40. They are mainly a cosmetic
Why Have Governing Boards Forsaken Their Duties? - Ideas from Silverglate and Malchow
We have posted frequently about the governance and leadership of academic medical organizations. While one would think that health care organizations, and especially academic health care organizations ought to be held to a particularly high standard of governance, we have noted how their governance is often unrepresentative of key constituencies, opaque, unaccountable, unsupportive of the academic and health care mission, and not subject to codes of ethics. How the governance of organizations with such exemplary missions and sterling reputations got this way has been unclear.
Now there are new insights from the ongoing discussion of one of the most interesting and controversial cases of disputed organizational governance. We have often come back to the example of Dartmouth College, of which Dartmouth Medical School is a significant component. We most recently discussed here an ongoing dispute about the extent that the institution's board of trustees ought to represent the alumni at large, or instead, ought to be a self-elected body not clearly accountable to anyone else. (For our take on this complex case, start here and follow the links backward.) The latest development in the case is a lawsuit filed by Dartmouth alumni challenging an increase in the number of self-elected, or "charter" trustees, which they charged broke an 1891 agreement that established numerical parity between alumni-elected and charter trustees.
Soon after this lawsuit was filed, an important article by Harvey Silverglate (one of the founders of FIRE, the Foundation for Individual Rights in Education) and Joseph Malchow appeared. For those interested in the case, the article includes extensive detail, with multiple citations, on all the twists and turns of the case, and is very much worth reading. (See this post on FIRE's Torch blog for more background and discussion.)
However, the article also features extensive scholarship on governance of US not-for-profit institutions, focused on academic institutions (including medical academia), and with relevance to other not-for-profit or non-governmental health care organizations. In particular, the article sheds light on how the governance of such organizations has become so degraded.
First, Silverglate and Malchow summarized the duties of governing boards:
So just to summarize, considerable discussion, scholarship, and I believe some some laws support the notion that the board of a not-for-profit organization is obliged to take reasonable care to make informed decisions free of conflicts of interest to uphold the organization's mission.
However, currently, many boards value deference to the organization's (usually hired) top managers and avoidance of internal conflict within the board more highly than these obligations:
Silverglate and Malchow have some important ideas about how we came to this.
Not-for-profits became more like for-profit corporations:
Top hired not-for-profit executives assumed more power at the expense of other constituencies, including the professionals who did the work:
Attempts at reforming governance were inappropriately based on a for-profit corporate model, and particularly the need to project unity and avoid confrontation among the leadership trumped transparency:
Emphasis on raising money rather than upholding the mission has lead to board deference to hired executives.
Boards are increasingly composed of executives of for-profit corporations, particularly in the finance field, who may grant the same deference to the organizations' leaders that they would like from their own board. That is, hired executives identify more with other executives than with the organizations they are supposed to be leading:
The article suggests some issues that need to be addressed to make governance more accountable, transparent, ethical and honest. Boards need to be reminded of their duties, and that their loyalty should be to the mission, not the organization's executives, or the views of the board's majority. Transparency and open discussion are more important than projecting the (sometimes false) impression of unity. New board members should be chosen for their loyalty to the mission rather than their similarity to and congeniality with current board members.
I strongly suggest that anyone who cares about how health care organizations are run ought to read Silverglate and Malchow's full article. It should be required reading for current and would-be board members of academic and health care not-for-profit organizations (but I will not hold my breath waiting for them to read it.)
Now there are new insights from the ongoing discussion of one of the most interesting and controversial cases of disputed organizational governance. We have often come back to the example of Dartmouth College, of which Dartmouth Medical School is a significant component. We most recently discussed here an ongoing dispute about the extent that the institution's board of trustees ought to represent the alumni at large, or instead, ought to be a self-elected body not clearly accountable to anyone else. (For our take on this complex case, start here and follow the links backward.) The latest development in the case is a lawsuit filed by Dartmouth alumni challenging an increase in the number of self-elected, or "charter" trustees, which they charged broke an 1891 agreement that established numerical parity between alumni-elected and charter trustees.
Soon after this lawsuit was filed, an important article by Harvey Silverglate (one of the founders of FIRE, the Foundation for Individual Rights in Education) and Joseph Malchow appeared. For those interested in the case, the article includes extensive detail, with multiple citations, on all the twists and turns of the case, and is very much worth reading. (See this post on FIRE's Torch blog for more background and discussion.)
However, the article also features extensive scholarship on governance of US not-for-profit institutions, focused on academic institutions (including medical academia), and with relevance to other not-for-profit or non-governmental health care organizations. In particular, the article sheds light on how the governance of such organizations has become so degraded.
First, Silverglate and Malchow summarized the duties of governing boards:
Traditionally, fiduciary duty [of the board of trustees] has been understood as having two components: the duty of loyalty and the duty of care. The duty of loyalty requires a fiduciary to act in a manner he or she reasonably believes to be in the best interests of the organization. The duty of care obliges directors to inform themselves of reasonably available information prior to making a business decision. More recently, courts have considered the duty to act in good faith [the duty of obedience] as a fiduciary requirement. This component, similar to the duty of care, is satisfied when a director makes informed decisions without conflicts of interest.
The question central to the dispute regarding Dartmouth governance is to what or to whom do fiduciaries owe their duty. Corporate directors have a relatively straightforward task of serving the corporation and its shareholders. In the case of a charitable trust, however, which generally does not have 'ascertainable beneficiaries who can enforce their rights,' the duty of fiduciaries is instead directed toward fulfilling or furthering the organization’s mission
So just to summarize, considerable discussion, scholarship, and I believe some some laws support the notion that the board of a not-for-profit organization is obliged to take reasonable care to make informed decisions free of conflicts of interest to uphold the organization's mission.
However, currently, many boards value deference to the organization's (usually hired) top managers and avoidance of internal conflict within the board more highly than these obligations:
Dartmouth, to be sure, is far from the only place where fealty to organizational leaders—and the notion of 'going along in order to get along' —has been placed before true fiduciary duty.
Silverglate and Malchow have some important ideas about how we came to this.
Not-for-profits became more like for-profit corporations:
During the 1980s, traditional nonprofit organizations supported by donations and governed by donors and volunteers became increasingly displaced by professionally staffed commercial nonprofits, supported by grants, contracts, and earned income, and governed by insider boards. The shift in governance was armored by progressively professionalized and entrepreneurial management, which was perceived to be more adept at control of the ebb and flow of funds in the American market.
Top hired not-for-profit executives assumed more power at the expense of other constituencies, including the professionals who did the work:
By the 1990s, with faculty power firmly institutionalized at colleges and universities, a notion that university presidents were bereft of power took hold. The AGB [Association of Governing Boards], in 1996, argued that university presidents needed to regain power with a pivotal document of its own: Renewing the Academic Presidency: Stronger Leadership for Tougher Times. Though this outlook was applied to varying degrees at colleges and universities, an imperative toward greater executive power in universities was thus established.
Presidential and professorial decision-making power, combined with the rise of the administrative bureaucracy in academia, have generally relegated trustees to a secondary role in campus affairs.
Attempts at reforming governance were inappropriately based on a for-profit corporate model, and particularly the need to project unity and avoid confrontation among the leadership trumped transparency:
Aligning academic boards with the cultural trends of increased critical oversight has obvious benefits, but some boards have moved to adopt the norms of for-profit corporate governance that are simply not applicable to the university context. Admittedly, this is a thin distinction when considered on a theoretical level. But in practical terms, misguided nonprofit reforms—some of which, upon close examination, actually violate an institution’s mission—are readily evident.
For example, some nonprofit boards have emphasized the adoption of formal nondisclosure pledges or confidentiality agreements that step well beyond nondisclosure of proprietary information. This is hardly uncommon in the business sector, where bottom-line strictures demand a certain degree of internal accord and non-transparency. And though there is evidence that nonprofit board directors have, from time to time, attempted to hush public dissent, only recently have dominant majorities of some nonprofit boards proposed and ratified binding pledges not to publicly air differences. According to a 2006 BoardSource publication, 'If a board member does not support a decision for whatever reason, [he or] she has a responsibility to remain silent or step down from the board.' (Recall the resignation offer made to Zywicki before his second term was denied.)
These directives, written in highly influential publications in the realm of university governance, disregard the important role that public discussion has on decision-making at universities and nonprofits in general. 'In the nonprofit context, nondisclosure agreements or the use of 'executive session' rules to curtail debates about policy and procedure depart from established norms. They shut down opportunities for public dialogue and for communication with other concerned and influential parties, including reporters,' nonprofit specialist Norman I. Silber wrote in the Oregon Law Review.
Emphasis on raising money rather than upholding the mission has lead to board deference to hired executives.
Fidelity to institutional leaders, rather than institutional mission, is now paramount in higher education, as deviation from accepted decisions is perceived as potentially shrinking the donor base. Administrators cringe at public disagreement; rather than focusing on the long-term likelihood that competing ideas will result in implementation of the fittest, they tend to focus on the short-term possibility that a particular alumni subset may be offended. This shortsighted outlook is not only an insult to the intelligence of alumni and other constituencies, but it is ultimately detrimental to the institution, as established ideas are enthroned and unchallenged. It is also based on false premises: as in the case of Dartmouth, there is no established correlation between public criticism and donor decline.
Boards are increasingly composed of executives of for-profit corporations, particularly in the finance field, who may grant the same deference to the organizations' leaders that they would like from their own board. That is, hired executives identify more with other executives than with the organizations they are supposed to be leading:
Judge Cabranes noted that trustees, especially business executives, tend to act toward university presidents as they wish their boards would act toward them—deferentially. And the phenomenon of board members believing they serve at the pleasure of the executive is what one nonprofit attorney and blogger, has termed 'upside down board.' The ascendance of the hedge-fund community, a peculiar province of graduates of elite institutions, has contributed to the prevalence of the upside down board....
The article suggests some issues that need to be addressed to make governance more accountable, transparent, ethical and honest. Boards need to be reminded of their duties, and that their loyalty should be to the mission, not the organization's executives, or the views of the board's majority. Transparency and open discussion are more important than projecting the (sometimes false) impression of unity. New board members should be chosen for their loyalty to the mission rather than their similarity to and congeniality with current board members.
I strongly suggest that anyone who cares about how health care organizations are run ought to read Silverglate and Malchow's full article. It should be required reading for current and would-be board members of academic and health care not-for-profit organizations (but I will not hold my breath waiting for them to read it.)
Monday, September 21, 2009
Health Insurance Denied
One difficult part about being a doctor is that I am part of a horrible, greedy, uncaring industry that I cannot influence. Ah, such strong words for American medicine, you say? Well, I have encountered yet another patient who is denied health insurance for underwriting reasons that are just plain unfair.Maryanne has run out of COBRA, the temporary continuation of health insurance that is
A "Safety-Net" Medical Center CEO Gets a Golden Parachute
From theBostonChannel.com comes this story on executive compensation in a not-for-profit health care organization,
Boston Medical Center was formed by the merger of University Hospital (the Boston University teaching hospital), and Boston City Hospital, the legendary municipal hospital. (Note: I served as an internal medicine intern and resident in the University Hospital program, and rotated through Boston City frequently.) Thus, as noted above, BMC is the city's primary "safety net" hospital for the care of the poor. BMC has for its mission:
Such generous pay seems inconsistent with this mission and the organization's not-for-profit status. Such a golden parachute seems inconsistent with the current threats to its finances.
Any worry about the CEO's retirement finances should further be reduced by her ongoing part-time work on the boards of directors of three public for-profit health care corporations, Hologic, a medical device company specializing in "womens' health," ThermoFisher Scientific, a manufacturer of laboratory equipment and supplies for health care and research, and Vertex Pharmaceuticals, a biotechnology company focusing on small-molecule drugs. For her work as a director of Hologic, she received $304,698 in total compensation in 2008, and owned 40,000 shares or equivalent of common stock (per the company's 2009 proxy statement). For her work for ThermoFisher Scientific, she received $275,319 total compensation, and owned 61,068 shares or equivalent (per the 2009 proxy statement). For her work for Vertex Pharmaceuticals, she received $337,480 total compensation, and owned 79,500 shares or equivalent (per the 2009 proxy statement). As Robert AG Monks put it, corporate directors are supposed to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] Therefore, Ms Ullian's directorships seem to pose conflicts with her primary employment as CEO of an academic medical center which must buy products used in womens' health, buy laboratory supplies, and implement basic and clinical research.
The BMC board chair's assertion that the CEO is "primarily responsible for the success" of the institution merits special comment. It seems obvious that the main determinant of the success of a medical center is the work done by its health care professionals and support personnel. A medical center cannot provide care, much less good care, without doctors, nurses, therapists and technicians, supported by supply, logistics, cleaning, maintenance, dietary, clerical, medical record, financial and yes, even health care information technology workers and systems (and if I left out an important group of support personnel, I apologize now.) The chair's assertion suggests the hubris central to the ethos of contemporary business managers, but is at odds with the clinical context. (Of course, if the CEO was primarily responsible for the organization's success, she should now shoulder primary blame for its current awkward financial situation, but such consistency may be the hobgoblin of minds too little to understand the gravitas of the C-level manager.)
A long time ago, in a galaxy far, far away, health care was a calling. Doctors once pledged to avoid all commercialization (see post here), and hospital directors or superintendents (not CEOs) did not earn riches, much less become "imperial." (See Ludmerer's Time to Heal.) But in the culture of wretched excess that spread from the financial world, hospital CEOs now seem to feel entitled to become wealthy, as they claim responsibility for all successes, while all failures are blamed on someone else. The current system has made hired managers into an ersatz aristocracy, entitled to fill their pockets while denying any responsibility for ever rising costs, declining access, poor quality and demoralized professionals. In my humble opinion, to achieve true health care reform, health care again must become a calling, lead by people who will put the mission ahead of the accumulation of wealth and power.
Boston Medical Center – a financially troubled hospital – gave its outgoing CEO a one-time, nearly $3.5 million payment, in addition to her $1.3 million annual salary, Team 5 Investigates reported Friday.
Elaine Ullian, 61, has led the city’s major 'safety net' hospital for the last 15 years. She recently announced she will retire when her contract expires in January.
The hospital's financial situation is such that hospital leaders say it could face closure in the years ahead. It is currently suing the Executive Office of Health and Human Services over how it gets paid for treating poor and uninsured patients.
Team 5 Investigates discovered, in a review of the hospital’s financial filings with the state, that Ullian was paid $3,466,458 'in recognition of exceptional performance over a period of 15 years.'
The nearly $3.5 million bonus was on top of Ullian’s 2008 compensation of $1,348,504 including salary and benefits.
In a written statement to Team 5 Investigates, Ted English, the chairman of BMC’s board said that Ullian’s 'compensation is set by a committee of the Boston Medical Center Board of Trustees who consult with independent compensation advisors. It is based on her performance evaluation and measurable goals that are reviewed annually.'
'The Board considers Elaine Ullian to be one of the most competent and successful hospital CEOs in the country and believes she is primarily responsible for the success of Boston Medical Center over the past 15 years,' English's statement said.
Boston Medical Center was formed by the merger of University Hospital (the Boston University teaching hospital), and Boston City Hospital, the legendary municipal hospital. (Note: I served as an internal medicine intern and resident in the University Hospital program, and rotated through Boston City frequently.) Thus, as noted above, BMC is the city's primary "safety net" hospital for the care of the poor. BMC has for its mission:
We will provide consistently excellent and accessible health services to all in need of care regardless of status or ability to pay – exceptional care, without exception.
Such generous pay seems inconsistent with this mission and the organization's not-for-profit status. Such a golden parachute seems inconsistent with the current threats to its finances.
Any worry about the CEO's retirement finances should further be reduced by her ongoing part-time work on the boards of directors of three public for-profit health care corporations, Hologic, a medical device company specializing in "womens' health," ThermoFisher Scientific, a manufacturer of laboratory equipment and supplies for health care and research, and Vertex Pharmaceuticals, a biotechnology company focusing on small-molecule drugs. For her work as a director of Hologic, she received $304,698 in total compensation in 2008, and owned 40,000 shares or equivalent of common stock (per the company's 2009 proxy statement). For her work for ThermoFisher Scientific, she received $275,319 total compensation, and owned 61,068 shares or equivalent (per the 2009 proxy statement). For her work for Vertex Pharmaceuticals, she received $337,480 total compensation, and owned 79,500 shares or equivalent (per the 2009 proxy statement). As Robert AG Monks put it, corporate directors are supposed to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] Therefore, Ms Ullian's directorships seem to pose conflicts with her primary employment as CEO of an academic medical center which must buy products used in womens' health, buy laboratory supplies, and implement basic and clinical research.
The BMC board chair's assertion that the CEO is "primarily responsible for the success" of the institution merits special comment. It seems obvious that the main determinant of the success of a medical center is the work done by its health care professionals and support personnel. A medical center cannot provide care, much less good care, without doctors, nurses, therapists and technicians, supported by supply, logistics, cleaning, maintenance, dietary, clerical, medical record, financial and yes, even health care information technology workers and systems (and if I left out an important group of support personnel, I apologize now.) The chair's assertion suggests the hubris central to the ethos of contemporary business managers, but is at odds with the clinical context. (Of course, if the CEO was primarily responsible for the organization's success, she should now shoulder primary blame for its current awkward financial situation, but such consistency may be the hobgoblin of minds too little to understand the gravitas of the C-level manager.)
A long time ago, in a galaxy far, far away, health care was a calling. Doctors once pledged to avoid all commercialization (see post here), and hospital directors or superintendents (not CEOs) did not earn riches, much less become "imperial." (See Ludmerer's Time to Heal.) But in the culture of wretched excess that spread from the financial world, hospital CEOs now seem to feel entitled to become wealthy, as they claim responsibility for all successes, while all failures are blamed on someone else. The current system has made hired managers into an ersatz aristocracy, entitled to fill their pockets while denying any responsibility for ever rising costs, declining access, poor quality and demoralized professionals. In my humble opinion, to achieve true health care reform, health care again must become a calling, lead by people who will put the mission ahead of the accumulation of wealth and power.
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