More and Less

Let me let you in on one of the basic facts of life, and no, you don’t have to be a doctor to know this one, everybody wants more- more money, more fulfillment from their lives, more love. If you need proof, look in the self-improvement section of any bookstore, or just turn on your television during the day and flip through the channels.
Why do we need more? Well, we need more money so we can get more stuff. Our society and our economy has been based on a simple principle…consume, consume, consume. When we hit a bump and consumer spending dropped the entire world economy stalled.
I hate to admit it, but I’m no different from anybody else. I fell hook, line, and sinker for the lure of “consumermania.” I can even believe that I need the newest two terabyte MP3 player… my crummy eighty gig is way too small, it only holds a thousand or so CDs. Who can put up with that? Unfortunately, as much as I delude myself to believe it is, my need isn’t a real need. I don’t have time to download a hundred CDs, much less a thousand. I have about thirty-seven CDs on my player, and yet I’m gullible enough to believe I need a newer, more technically sophisticated model. With the rapidity of technological evolution in the modern world, this cycle of need and fulfillment is never ending, as soon as I buy the new “two-T”, they’ll begin to advertise a newer model, one that comes with a cell phone in it, and as soon as I get that, there’ll be an even newer model with both a cell phone and a miniature computer in it, and so it goes ad infinitum.
In a lot of ways medicine is the same way, but instead of ego and vanity being the only driving forces, it may truly be that our lives are at stake. We want more and we want better, the heck with better, we want the best. Who doesn’t feel that they deserve the best health care? America is nothing, if not an egalitarian society, in this regard, everybody deserves the best health care, right? I don’t know. Let me pose a hypothetical question, what if there were a drug that was ninety-nine percent effective in preventing osteoporosis in post-menopausal women, and had no identifiable side effects, shouldn’t we give it to everyone that could benefit from it? Sure, that seems like a “no brainer”… but, what if it cost twenty thousand dollars a dose? Ok, well, that does seem a bit steep, but it really would make so many lives better, I guess we still should. The problem is, at that cost, for that many women, most of which will be sixty-five years old, or older, the cost of the drug will bankrupt Medicare in a single year. Now, should we make this wonder drug available to our Medicare beneficiaries? By the way, I hate the term beneficiaries, almost as much as I hate the term, health care provider. These are patients, sweet little grandmothers and mamas, wonderful women, and I am their doctor with this wonder drug that will make their lives so much better. No longer will they have to face the chronic back pain and the debility of nerve root compressions that are associated with the pathologic fractures of osteoporosis. Can I give it to them?
This isn’t a medical decision, medically, the answer is obvious. From a risk-benefit standpoint the drug is amazingly effective, so it’s all benefit with no risk. The only risk is to the solvency of the largest health care provider in the United States. So, this decision becomes not a medical decision but a social decision, a governmental decision, a legal decision, even a moral decision. If the recent financial downturn has shown us anything, it is that consumption has limits, and those limits are imposed by the availability of funds. We are currently in a position that requires that we make a decision on how we will impose limits so that our spending stays in line with the funding available to provide health care.
SGR stands for Sustainable Growth Rate and it's how our federal lawmakers have tried to limit the growth of Medicare costs in the past. They’ve tied the total amount of money that can be expended on Medicare to the United State's GDP or Gross Domestic Product. That means the value of all goods and services produced in the US during the preceding year.
Because our economy is, to say the least, less robust than it was a few years ago and the number of folks becoming Medicare eligible due to baby-boomers pouring in like a damn busted, things don’t work like they did when the law was enacted. The formula stopped working several years ago, and in the current economic environment would be a total disaster. Everybody knows it doesn't work; the lawmakers, the doctors, the hospitals, even the HHS folks who administer Medicare know. Guess who doesn't know? For the most part patients have no idea about the costly, intricate dance that goes on every year, with doctors and hospitals spending millions of dollars to convince the lawmakers to do what they know they are going to have to do anyway.
We need a better system. The nature of the system put in place to make decisions on health care will reverberate through the years, to effect, not just ourselves, but what type of a system our children have to look forward to.
The beginnings of legislation to establish a Federal Coordinating Council for Comparative Effectiveness Research was hidden by our newly elected president in the Economic Stimulus Package. The whole purpose of this council is to slow the development of new medications and treatment technology because they are driving up the cost of health care. This is similar to a board that governs who receives medical care and what care they receive in England and the United Kingdom. Medicare recipients will be judged on the perceived amount of useful life that they have left as to whether or not they will receive treatment for a given condition.
Will the egalitarian system we take as given, grant access to all to every technical step forward, or equally restrict access by all. Will equal access become a quaint naiveté` and give way to a two-tiered, or multi-tiered system of health care delivery, with the latest and best going to those who can afford it, and whatever’s left going to those who can’t? We would never stand for that, as a country, would we? We already do. There are forty-five million Americans without health insurance, the uninsured are now a sub-class, they don’t have access to the same preventative care and routine checks that the insured enjoy. As a matter of fact, even if they can afford health care, they may be afraid to seek it. There’s the big punch-a-roo, if they get diagnosed with a pre-existing condition, they may never get access to health care they can afford.
Do you know which segment of the population is the fastest growing pool of the uninsured? Poor people, right? Perhaps, the unemployed? Nope, on either count. That distinction goes to working males over fifty, that make over seventy-five thousand dollars a year. That can’t be right. That’s what I thought, until it happened to me. When a misrouted bill went unpaid, my insurance was cancelled without notification until sixty days after the action. And once you find out your policy has been cancelled, if you’ve gone more than thirty days without a bridge policy, you have to jump through hoops and throw around a good deal of loot to get any type of coverage. After several rounds of denials, and a total inability to get a private policy to cover either myself or my wife (every company was happy to cover our perfectly healthy children, for the same price we had been paying as a family). Thankfully, I have a good income and the cost of establishing a group policy and hiring my wife wasn’t an undue hardship, but it cost twice what I had been paying. Most families can’t absorb this.
In my opinion, any, health care reform has to deal with both of the issues; cost and access. Until there’s some type of insurance reform that actually reforms the practices of private insurers and provides a means for all Americans to obtain health care coverage in some form, any health-care policy we undertake is a mere band-aid. What is not intuitively obvious is that the elimination of the vast number of uninsured Americans will in and of itself drive down the cost of health care per capita. This is so because the cost of delivering health care to the uninsured is simply passed on to the insured. It is the only way hospitals and health care providers can survive in the current environment. Secondly, coverage of largely healthy younger people whose expenditures on health care do not exceed their premiums will help offset the costs of those individuals with higher costs.
If health care policy is going to be made in secret and obscured in the depths of legislation clearly intended for other purposes, any national dialog on how we as a country feel it’s best to address these issues, is subverted.
What is my message to those in power; the senators, congressmen, and the president? Stand up, be men, do not act in a secretive or cowardly fashion. America deserves the right to be included in deciding where our, and I repeat OUR, health care is going.

Where have I been?

It's Jan 2009, there haven't been any posts since November, what gives? I have been putting together a book based on the Una Voce columns. Am 3/4 of the way done. Will post more as we get closer to done.

Teary Sockets in Tucson

Teary Sockets will be showing at the Tucson Film and Music festival at 3:00 p.m. on Sunday October 12th at the Rialto Theater. If you can come see us. Jackson (the director, and co-writer) and I will both be there.

Risks?

One of the unfortunate aspects of letting someone like me loose with a column, is that, every once in a while I’m going to get up on a soap box and start preaching. This is one of those times. Cancer prevention is one of those things I take pretty seriously, because, of all the people I see every day I can be pretty sure that at least forty percent of them will die of the disease that I’m trying to cure them of. Some days that pisses me off. When I see my own colleagues acting like a bunch of nattering old ladies on an issue that has the potential to have a huge effect on reducing the number of young people that may have to walk through the doors of my cancer center, it really pisses me off.

In the August 21, 2008 issue of the New England Journal of Medicine they published a special article by Kim and Goldie titled Health and Economic Implications of HPV vaccinations in the United States that concluded that such a vaccination program may be cost effective. In the same issue there was a dire warning framed as an editorial by Haug that warned of the unknown adverse side effects of such a vaccination program. Unfortunately, I think the pundits from New England missed the boat. What we may unknowingly do by instituting such a vaccination program is that we may inadvertently prevent a whole bunch of cancers in other areas. The discussions that were presented limited themselves to discussing the value of vaccination against human papillomavirus (HPV) for the currently approved indication, the prevention of cervical cancer. This indication alone is a certainly sufficient to merit serious consideration of the benefits of such a program, cost effectiveness be damned, but when the discussion is expanded to include other malignancies associated with HPV the potential benefits are of a significantly larger magnitude.

An association of HPV and oral squamous cell carcinogenesis has been discussed since 1983 . Early studies which included all cases, and included leukoplakia, estimated that between 11 and 15% of these lesions had evidence of HPV DNA . In later studies looking at oral cancers in non-smoking individuals the percentage of those cases associated with HPV jumped to 60-78% . The increase that was seen was largely due to improved methods of detection of HPV DNA. When sub-type analysis was performed, it was shown that 70 % of oral carcinomas contained HPV 16 or 18 . Which are the same strains currently protected against by the commercially available vaccinations for cervical cancer.

In the United States in 2007 there were 11,150 new cases of carcinoma of the uterine cervix diagnosed, while there were 34,360 new cases of carcinoma of the oral cavity and pharynx. Carcinomas of the vagina, vulva, and anus have also been linked to HPV exposure, and when added together would account for another 15,000 cases of cancer that be impacted by a vaccination program. In my mind, the question we should be asking is not should adolescent females be vaccinated against HPV, but shouldn’t all adolescents be so vaccinated. Isn’t it worth considering the 14,507 cases of carcinoma that could be prevented in men by such a vaccination program?



Kim JJ, Goldie SJ. Health and Economic Implications of HPV Vaccination in the United States. N. Engl. J. Med. 359:821 Aug. 21,2008
2 Haug CJ. Human Papilloma Vaccination – Reasons for Caution. N. Engl. J. Med. 359:861 Aug. 21, 2008
3 Syrjanen, et al. Morphologic and Immunohistochemical Evidence Suggesting Human Papillomavirus (HPV) in Oral Squamous Cell Carcinogenesis. Int. J. Oral Surg. (6) 418-24 Dec. 12, 1983
4Gassenmaier A., Hornstein O. Human Papillomavirus DNA in Benign and Precancerous Leukoplakias and Squamous Cell Carcinomas. Dermatologica 176(5) 224-233.1988
5 Syrjanen, et al. Human Papillomavirus (HPV) DNA Sequences in Oral Precancerous Lesions and Squamous Cell Carcinoma Demonstrated by In Situ Hybridization. J. Oral Pathol. 17(6) 273-278 July 1988
6 Honig. Non-Radioactive In Situ Hybridization for Detecting Human Papillomavirus DNA in Squamous Cell Carcimona of the Tongue. Bull. Group Int. Rech. Sci. Stonatol. Odontol. 3-4(35) 107-115 Sept-Dec 1992
7 Woods, et al. Analysis of Human Papillomavirus DNA in Oral Squamous Cell Carcinoma. J. Oral Pathol. 22 (3) 101-108 Mar 1993
8 Barten, et al. [p53 alterations and HPV Status in Oral Squamous Cell Carcinoma]. Verh. Dtsch. Ges. Pathol. 78: 255-259 1994
9 Jemal, et al. Cancer Stastics 2007 . Ca Cancer J. Clin. 2007: (57) 43-66

HPV vaccination

See above for footnoted version, that replaces this post.

The lyrics to the opening anthem for Teary Sockets

The Me Who is Me



Homophobic, Surrealistic, Racist, Fascist, Soporific

You can hand me the phone, you can text me the truth.
Call me your names, but then cut me loose.
You can be sure I won't be taking your cure,
And I'll be drinking the poison I choose.

Cannibalized, Eroticized, Smoking, Joking, Super-sized

So hide all your flaws, push your secrets down deep.
Conceal all your scars with the clothes that you keep.
Keep a hat on your head and tin foil on your bed,
So they can't read all your dreams while you sleep.

(bridge)

Here’s your little valentine, cut out and stitched upon my sleeve.
It’s a small world after all, but it offers no reprieve.
Every cow is sacred, and every word a blade,
Careful as you tiptoe through the minefields that I’ve laid.

Murderer, Voyeur, Stupid, Vapid, Soul Destroyer

I have to be who I am, though I might look just like you.
A little less tan, different laces in my shoe.
Non-conformity, it’s said, the different thoughts in my head,
Make it me who is me and not you.

CERN/LHC is on but we're still here

They turned on the LHC over on the Franco-Swiss border, and the accelerated nuclei took their first trip around that thirteen mile test track, and guess what? We're still here. No black holes, no uncontrolled matter/anti-matter reactions, not even a strangelet phenomena, and I don't even know what that would look like. I'm happy we didn't all wake up dead Wed. morning, but I don't guess I would have even known if we didn't.

It reminded me of a story I read by Ray Bradbury in high school about a family that knew that the world was going to end that night, and they did all of the things that they did every other night, ate dinner, read, put the kids to bed kissed them goodnight, and went to sleep. Probably they were a little nicer than usual. No one screaming, "Get to bed!" or "Don't you know tomorrow's a school day?" It was all sweet and nice. The mom probably made a nice dinner, one everybody liked. I don't think it would be like that at my house, but maybe it would, we didn't lie awake waiting for them to light off the LHC, we just went to bed and went to sleep, just like the people in the story. I think it would be this way no matter what.

We can't conceive of a world without us, and we sure can't conceive of a universe without our world in it. Besides, what are you going to do? Drive all over the place trying to get off. Order a bunch of things on the internet on your charge card? Why? You're never going to have to pay for them, but you're never going to get them either. For me at least, just ordering stuff isn't good enough. I have to drive myself crazy trying to get whatever it is, out of the packaging. Then I look at it for a few minutes, savoring its specialness. Then I put it someplace safe, and promptly forget about it, until I trip over it three months later and wonder what I was thinking when I ordered this piece of junk.

Maybe you could get on e-bay and buy five Ferraris just for the joy of winning the auction.
"See, I got every one of them." You could say to yourself.

But, if everyone knows the world is going to end everybody's going to bid like there's no tomorrow. Because, there isn't. But what if you’re wrong?

You wake up late for work the next morning. You didn't set the alarm clock. Why? It wasn't supposed to be there. You're running around like a chicken with its head cut off trying to get the kids ready for school and you ready for work. The kids are wondering what in the heck is going on. "Boy, they were so nice last night. Now they're hollering like crazy. Dad cussed a blue streak because he forgot to put the garbage out last night (remember, it wasn't supposed to be there in the morning)."

Then you remember the five Ferraris, the ones you were bidding against all the other poor saps that didn't think the world was going to be here this morning. What was the final bid? Thirty-four trillion apiece? "Oh crap," you exclaim, watching the neighbor shoving his three kids still in their pajamas into his Suburban. “I put that on the American Express, the one with no limit."

Now that's the end of the world.