Home birth

Interesting article from NYT Magainze about the rise in home births.  It focuses on a woman, Ina May Gaskin, who is one of the few midwives in the country who will vaginally deliver a breech baby.  Now, I’m no expert on such things, but I’ve got to think that back when childbirth was often deadly to women, a lot of those births were breech births.  Is having a “natural” experience really worth risking your and your baby’s life for.  As for home birth, you can actually say the same thing.  Sure most home births are just fine, but when they’re not, there’s a huge downside to not actually be at a hospital.  We have a former neighbor across the street who lost her baby about a year ago during a home birth.  Of course, that could have also happened at a hospital, but a baby born “in distress” as this one apparently was, would have had immediate access to all sorts of high-tech medical care that quite likely could have saved it’s life.  I found this comment on the story from a paramedic particularly compelling:

I am a 15 year veteran firefighter/paramedic who has had to respond to some horrific incidents at birthing/midwifery centers and home births. I have seen babies die because of the choice the parents made to have out-of-hospital births–babies who would not have died if born in hospitals…

The bottom line is that if you choose to have a home birth, you better be prepared for your baby to die due to a lack of immediate neonatal advanced life support medicine if something goes wrong. And when things go wrong there is not a minute to spare.

As a result of my experiences, I urge all my friends and loved ones to give birth in a hospital. Sure use a midwife if you’d like–but have the necessary resources close at hand IF things go south. Why take even a small risk?

From a purely rational cost/benefit perspective, home birth is a horrible idea.  Sure you presumably have the event of this wonderful, “natural” childbirth in a comfortable environment, but if something goes wrong, you are greatly increasing the likelihood of the worst possible outcome any parent can face.

The end of the PSA as we know it?

So many men have really suffered from counter-productive prostate cancer screenings via the PSA.  The medical community has finally come around on this.  I long ago decided there was no PSA in my future unless the test were radically improved.  Here’s the latest:

Men should no longer receive a routine blood test to check for prostate cancer because the test does more harm than good, a top-level government task force has concluded.

The recommendation from the U.S. Preventive Services Task Force runs counter to some two decades of medical practice in which many primary care physicians routinely gave the prostate specific-antigen, or PSA, test to healthy middle-age men.

But after reviewing all available scientific evidence, the task force concluded that routine PSA screening will help save the life of just 1 in 1,000 men who get the test.  [emphasis mine] At the same time, the test steers many more men who would never die of prostate cancer toward unnecessary surgery, radiation, and chemotherapy, the task force concluded.

How’s this for a cost/benefit?

But after reviewing all available scientific evidence, the task force concluded that routine PSA screening will help save the life of just 1 in 1,000 men who get the test. At the same time, the test steers many more men who would never die of prostate cancer toward unnecessary surgery, radiation, and chemotherapy, the task force concluded.

An absolutely classic case of overtreatment creating far more harm than good.  It’s a shame that it took so long and caused suffering for so many men, but it’s nice to see that medicine can actually make a dramatic course correction on something like this.

Glue instead of stitches

My son Alex took a nasty fall on our deck while running around in the rain the other day (alas, one of his favorite activities).  We thought he had made a hole completely through his lower lip and was going to require stitches.  Since Alex’s special needs and history with medical treatments and dentists suggested he was not exactly going to cooperate with that, we left the (affordable) Urgent Care when they said he’d need stitches for the (oh-my-god that much just for some medical glue!) Emergency room next door, where they could sedate Alex, if necessary.  Turns out, the urgent care was a little too ready to get rid of Alex and his special needs.  He cooperated wonderfully at the ER and only needed some glue to close the would just below his lower lip.  Nothing to be done for the giant gashes on the inside (which you can see in all their glory below).

Anyway, I was relating the story to my dad and he had no idea that it was now quite common to use glue instead of stitches.  Now, in my childhood it was all stitches, but as a parent my kids have been glued many times and rarely stitched.  A little googling and I discovered that this approach took off just in time for my experience with lacerated children– the late 90′s (David was born in 1999).  Here’s a NYT story from 1997:

THROUGH the ages, a wide range of materials have been used to close deep cuts and other wounds, including cobwebs, the jaws of leaf-cutting insects and, in modern medicine, stitches and staples. But now another material is showing promise: glue.

Rather than put patients through the long, painful ordeal of sewing their wounds and in many cases removing the stitches a week or so later, doctors are finding that they can simply glue the edges together and send their patients home. The adhesives being used are chemical relatives of the kinds of glue found in factories as well as around the house, but they have been sterilized and modified for medical purposes.

Several recent studies involving children and adults show that certain wounds closed with glue heal just as well as those closed with stitches, and that the cosmetic results up to a year later are comparable. In the newest study, doctors were so pleased with one kind of medical glue that they predicted that it could replace stitches for about one-third of the 11 million wounds treated in hospital emergency rooms in the United States each year. The study is being published in today’s issue of The Journal of the American Medical Association.

So, there you go.  As I said, Alex cooperated beautifully while he was glued.  Not sure that would have been so much the case with somebody pulling a needle and thread through his skin.

Stop stretching!

Listened to an absolutely fascinating Fresh Air interview about the latest science on exercise yesterday (via podcast, while exercising, in fact).  So many fascinating tidbits.  Among others– the whole idea of stretching before exercise is actually counter-productive.  Don’t I feel vindicated– I’ve never stretched before exercise a day in my life.  Always struck me as a waste of time.   Also talked about the silly myth of all that water you are supposed to drink before you are even thirsty.  Nope– just listen to your body.  And lots of interesting tidbits about not sitting down too long.  Apparently just standing up every 20 minutes can make a huge difference in basal metabolism, etc.   I was also quite intrigued to learn that having tight muscles actually leads to faster running.  My son David has super-tight muscles– he’s been in physical therapy– and he’s a really fast runner.  So there you go.

I don’t buy a lot of books, but I’m not waiting for the library for this one.   The whole interview is so worth your time, but the link also has a nice summary.

 

Overtreated. Again.

Came across this story when a physician FB friend posted that he read it the day after getting a steroid injection for his back.  Sadly for him, he won’t even get the placebo effect now:

A randomized trial of steroid injections for back pain has shown that they are no more effective than a placebo.

Because the long-term benefits of surgery remain unproven and pain medicines often have serious side effects, doctors have increasingly turned to steroid injections to treat lumbosacral radiculopathy, a common cause of back pain. The condition stems from damage to the discs between the vertebrae that often leads to sciatica, numbness or pain in the legs.

Researchers tested 84 adults with back pain of less than six months’ duration, dividing them into three groups. They received either steroids, etanercept (an arthritis medicine) or an inactive saline solution in two injections given two weeks apart.

At the end of one month, they were assessed for pain.

Leg and back pain decreased in all three groups, but there were no statistically significant differences among them. The researchers conclude that steroids may provide some short-term analgesic effect, but that the improvement in all of the patients was mainly due to normal healing.

If only people realized how often doctors are just guessing without any research to back up what they are doing.  Unfortunately, when they are not sure whether something will work, it’s safe to say the very often err on the side of what may well be an unnecessary treatment.   This is actually a pervasive and serious problem in our overall medical system and culture in this country.   Alex has several great doctors whom I especially appreciate as they are so honest about how much they don’t know.  When in doubt, treat, may be great for doctors, hospitals, etc., bottom lines, but not necessarily for patients.  And, oh, for that back pain, this conclusion confirms what I’ve been hearing for years:

But for now, he said, “the strongest evidence for back pain relief is with exercise.”

Free, but hard (relative to getting a shot or popping a pill, that is).  In my case, I actually found that simply sleeping with a pillow under my hips (while sleeping on my stomach) was all the cure I needed for the back pain I developed a couple years ago.   Had that not worked, I was planning on working through the exercises in the Back Pain Book.

Post Prozac Nation

Fabulous and fascinating article on anti-depressants and depression in the NYT magazine today.  Siddhartha Mukherjee nicely summarizes the evidence and controversy about whether and how SSRI’s work.  I think he goes by a little too breezily the fact that the best evidence suggests that anti-depressants actually do very little, if anything, for mild to moderate depression beyond the placebo effect (but a powerful effect it is).  That said, it’s a really interesting look at evolving theories on the neurobiology of depression.   Short version: it seems that SSRI’s in some way actually help to stimulate the growth of new brain cells in a key area of the brain.  Here’s the complicated, but succinct, explanation of what may be going on:

A remarkable and novel theory for depression emerges from these studies. Perhaps some forms of depression occur when a stimulus — genetics, environment or stress — causes the death of nerve cells in the hippocampus. In the nondepressed brain, circuits of nerve cells in the hippocampus may send signals to the subcallosal cingulate to regulate mood. The cingulate then integrates these signals and relays them to the more conscious parts of the brain, thereby allowing us to register our own moods or act on them. In the depressed brain, nerve death in the hippocampus disrupts these signals — with some turned off and others turned on — and they are ultimately registered consciously as grief and anxiety. “Depression is emotional pain without context,” Mayberg said. In a nondepressed brain, she said, “you need the hippocampus to help put a situation with an emotional component into context” — to tell our conscious brain, for instance, that the loss of love should be experienced as sorrow or the loss of a job as anxiety. But when the hippocampus malfunctions, perhaps emotional pain can be generated and amplified out of context — like Wurtzel’s computer program of negativity that keeps running without provocation. The “flaw in love” then becomes autonomous and self-fulfilling.

We “grow sorrowful,” but we rarely describe ourselves as “growing joyful.” Imprinted in our language is an instinct that suggests that happiness is a state, while grief is a process. In a scientific sense too, the chemical hypothesis of depression has moved from static to dynamic — from “state” to “process.” An antidepressant like Paxil or Prozac, these new studies suggest, is most likely not acting as a passive signal-strengthener. It does not, as previously suspected, simply increase serotonin or send more current down a brain’s mood-maintaining wire. Rather, it appears to change the wiring itself. Neurochemicals like serotonin still remain central to this new theory of depression, but they function differently: as dynamic factors that make nerves grow, perhaps forming new circuits. The painter Cézanne, confronting one of Monet’s landscapes, supposedly exclaimed: “Monet is just an eye, but, God, what an eye.” The brain, by the same logic, is still a chemical soup — but, God, what a soup.

On a quasi-related note, Mukherjee is the author of one of my favorite books I read last year.  The Emperor of All Maladies: A Biography of Cancer.

Big picture on health care

A little easy this week to get caught up in arguments about limiting principles, Wickard v. Fillburn, and broccoli, so I especially appreciated this post by Jonathan Cohn that puts this in a bigger picture about what the Court appears to be up to:

Think about that for a second: If the justices strike down the Affordable Care Act, they would be stopping the federal government from pursuing a perfectly constitutional goal via a perfectly constitutional scheme just because Congress and the Preisdent didn’t use perfectly constitutional language to describe it. Maybe labels matter, although case law suggests otherwise. But do they matter enough for the Court to throw out a law that will provide insurance to 30 million people, shore up insurance for many more, and help to manage one-sixth of the American economy? It wouldn’t seem so.

Of course, the conservative justices who would invalidate the Affordable Care Act may not hold the law in especially high regard. Samuel Alito, in particular, suggested during oral argument that he had serious problems with younger, healthier people subsidizing, via their insurance premiums, the medical expenses of older, sicker people—which just happens to be the defining feature of Medicare, Social Security, and every other social insurance scheme on the planet.

Alito is entitled to his opinion about what makes for good legislation. But he’s not entitled to impose that opinion on the country and his colleagues aren’t, either. Their job is to determine whether a law is constitutional, not whether a law is wise. And the more significant the law, the more unambiguous their judgment ought to be.

 

 

http://www.tnr.com/blog/jonathan-cohn/102204/supreme-court-roberts-kennedy-health-mandate-legitimacy

A penalty vs. a tax

This whole Supreme Court mess (at least the individual mandate) portion could have been entirely avoided if the mandate simply functioned as a tax credit instead of a penalty.  Basically, you raise everybody’s rates by some fixed amount and then give a tax credit/rebate of $XXX to everybody who purchases health insurance.  Simple.  And the constitutionality is beyond questions– we do this all the time for all sorts of things.  Instead, by trying to avoid the necessary changes to the tax code, i.e., “raising taxes” (heaven forbid) or by claiming that you have to pay a “tax” rather than a “penalty” for failure to purchase insurance, this line of attack is left open.  Functionally, of course, these matters are basically identical, as Ezra explains:

By now, you should know how the individual mandate works: Starting in 2016, those who don’t carry insurance will be assessed a $695 fine, per year, or 2.5 percent of their income, whichever is higher. There are exemptions for those who can’t afford health-care insurance, but that’s the basic gist of it.

Here’s how Paul Ryan’s health-care plan works: Individuals who purchase insurance will get a $2,300 tax credit. Individuals who don’t purchase insurance forgo the tax credit. There’s no affordability clause such that, say, someone who can’t afford health insurance nevertheless gets the tax credit.

If anything, Ryan’s plan might be a little harsher on those who choose to go without insurance. There’s no actual enforcement mechanism behind the individual mandate. The IRS can’t dock your pay or throw you in jail. If you choose not to pay it and you simply ignore the letters the government sends your way, nothing actually happens.

Conversely, under Ryan’s plan, if you don’t buy insurance, you really don’t get the tax credit, and so you do, in effect, pay a large tax penalty compared to a world in which you did buy insurance — larger, in fact, than the penalty under the individual mandate.

To an economist, there’s no difference between these two policies. Just to be sure, I asked William Gale, director of the Tax Policy Center, just to be sure. “It’s the same,” he shrugged. “The economics of saying you get a credit if you buy insurance and you don’t if you don’t are not different than the economics of saying you pay a penalty if you don’t buy insurance and you don’t if you do.”

Now, various conservative legal minds have argued that there is a profound difference between these two policies: One is penalizing a particular form of economic inactivity, while the other is encouraging a particular form economic activity. And perhaps that’s so. But it’s not a difference very many Americans would notice when it came time to pay their taxes.

Thus, even if the mandate were struck down, it’s actually a very simple  policy fix.  The problem is that due to the anti-tax jihadism of the Republican party, that simple policy fix is an untenable political fix.

Broccoli and slippery slopes

I was listening to the NPR story about the Supreme Court and health care yesterday and they played a clip from a health reform opponent who went right to the broccoli argument, i.e, if the government can make you buy health insurance what’s to stop the government making you buy broccoli.  Here’s a thought: the government can make you buy health insurance because it is an entirely necessary part of an overall health care reform law and health care is clearly a vital aspect of interstate commerce.    The government could, in fact, make you buy broccoli (certainly it’s not philosophically far at all from regulating your home-grown farming).  There’s clearly an interstate market for broccoli.  It’s just that it would be really stupid and there’s no logical reason at all for it to do so.  Slippery slope arguments have their value, but I think the over-use in this case helps to show their limits.  There’s all sorts of things that government has the power to do but doesn’t, because they are just plain stupid.  Having an individual mandate for health care doesn’t change that.

Visualizing health care expenses

Student sent me this link from a nice Atlantic post, “10 ways to visualize how Americans spend money on health care.”  There’s some very good ones here.  I’m most fond of this:

1) U.S. AGAINST THE WORLD: SPENDING VS. LIFE EXPECTANCY
We spend much, much more per person than the rest of the world … but we don’t live much longer than some eastern European countries that spend much less than us. As a result, when you plot the United States against similarly advanced countries based on life expectancy and medical spending, we’re all alone on our little island.

I’m sure of we repealed the Affordable Care Act and simply allowed health insurance competition between states this would all be remedied.

No wonder I never get anything done

Via Wonkblog (where I was just reading when I ought to be working on a PS conference paper):

The less sleep you get, the more easily you can get distracted from work by reading Wonkblog (or watching cat videos, or whatever). From a new study in the Journal of Applied Psychology:

As predicted, the less students had slept the night before, the more they were likely to wander off from their assigned task. Conversely, every minute of sleep meant .05 fewer minutes surfing. The connection with disturbed sleep was also strong: “An hour of disturbed sleep would on average result in cyberloafing during 20% of the assigned task.”

Not to mention, I hate feeling tired.  Though, I have recovered from my low point where I was consistently falling asleep while reading to my son each evening.

The price of health care

This cool graphic of relative health care expenses has been making all the usual rounds.  Kevin Drum takes the step of highlighting Switzerland so that we can see that the country that takes the most market-based approach– after the US, of course– consistently has the 2nd highest prices:

Of course, don’t let that distract you from the US dots in red.  Damn are we getting ripped off.  Anyway, this reminded me of a graphic I recently used in my health care policy lecture:

As you can see, Switzerland and it’s 2nd highest prices comes closest to the US by far in the portion of its health expenditures that are private (i.e.,, free markets) rather than public.  Now, of course, this is just correlations and not causation, but a more comprehensive study of the issue pretty clearly indicates that this is no coincidence.  Markets are great when and where they work, but until people do price comparisons when they have a broken arm of failing kidneys, health care is just not the place where they prove to be effective for doing anything except getting providers quite rich.