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Published letters
Displaying 1-10 letters out of 2654 published
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Re:Affordable Care Act- Article
Submit responseI cannot agree with this letter to the Annals more (see below). I as well commented on healthcare reform numerous times, in phone calls and letters to Obama, my Senators Kerry and Brown, and my Congressman Tierney. All my comments fell on deaf ears. I got patronizing letters back, 'thanking me' for my support of this important bill, when I clearly expressed my disapproval. Not a surprise actually, given the actions of this President.
Am I surprised at the Annals? The answer is "No" I am not. Just as the AMA has not represented physicians throughout the entire debate, the Annals has been happy to take my subscription money, support the so-called grass-roots program through the ACP, and on every mailing and blog support this movement without consideration for any disapproving thoughts. Just as the controlling party acts as if it knows better than the citizens, the Annals, and AMA, and other so-called representative organizations act as though they know better than the physicians. It must be nice to live up in the ivory tower and come down to the lowly practicing physician once in a while to tell him/her what is best for him/her and their patients, and then retreat up to the board-room to work on another policy without concern for the repercussions of your actions.
I have lost faith in the ACP as a representative organization for me, I have long ago lost faith that the AMA represents me, and fell most comfortable reacting to articles such as this and working hard to care for my patients and let you on the editorial board know of my displeasure. It is gratifying to see a letter such as the one below which bluntly can show you how wrong you are to publish an article such as the one you have, and how you have failed to read the pulse of the nation and the physicians in your editorial decisions.
Nicholas Mascoli, MD
TO THE EDITOR: The Hippocratic Oath states, "First do no harm." Unfortunately, this article does just that. It is truly disturbing that the peer-reviewed AIM has chosen to publish such a polarizing piece of pure political propaganda without an accompanying balanced editorial and no supportive references to verify factual claims. The congressional budget office may not need to confirm the factual arguments of the authors, but I would certainly hope that a scientific medical journal would. Throughout the entire healthcare debate, physicians shouted from the rooftops that PPACA would be the death of American medicine and private practice. This article finally acknowledges that our concerns were justified. The total disdain for physicians during the debate was obvious to all but those who did not want to see it. Physicians that publicly opposed the legislation found themselves ridiculed or under investigation. Now that it is clear that the public has not embraced this legislation and the true costs of it are being discovered, the government is calling on our sense of moral obligation to support this reform measure. The article reads like a veiled threat to those who disagree to either capitulate or be steamrolled. The authors write, "To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change." This unprecedented Orwellian intervention by the federal government is an intrusion into all we hold dear about American healthcare. They continue, "The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups." They tout the 10% payment increase to rural primary care doctors, however, they are the same doctors in rural small practices that will be made unsustainable by this Act. The failure to address SGR or tort reform, which are critical to today's practice of medicine, is the legislations Achille's heel, about which the authors tell us we should pay no attention. Unfortunately, this Act is the "final act" and is the death knell for the once noble practice of medicine in America.
Lee S. Gross, M.D. Family Medicine Member, D4PC
Conflict of Interest:
None- simply concerned about the direction of the country and effects of this Administration on the quality and cost of Healthcare
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You've jumped the shark
Submit responseThe enactment of the PPACA law has divided the American medical profession into three groups: the large majority who are inalterably opposed to it, the starry-eyed few who haven't a clue, and the cadre of apparatchiks who are scrambling to secure their position in the bureaucratic hierarchy of Obamacare. By publishing the recent infomercial written by Kocher, Emanuel, et. al., the Annals have identified themselves with that last group. Ethics and common sense require that you now publish a rebuttal to this article. George W. Marcom, M. D.Conflict of Interest:
None declared
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Care Planning and Goals of Care
Submit responseDrs. Sudore and Fried rightfully note the need to "prepare patients and surrogates to participate with clinicians in making the best possible in-the-moment decisions." They also emphasize a focus on goals of care and the often non-static nature of patients' preferences. In this process of decision making, physicians have several roles. One critical role is to clarify reasonably achievable goals of care. These goals are also non- static and evolve in tandem with the natural history of the patient's disease. Moreover, the degree to which particular goals are achievable, and the cost (in terms of burden to the patient) to achieve them, also change over time. Physicians must embrace the dynamic features of disease, preferences, and achievable goals of care, in providing sound counsel to patients and family members and in collaborating with them in generating optimal plans of care.
Conflict of Interest:
None declared
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Important to measure coronary heart disease, not just risk factors
Submit responseTo the Editor:
The authors concluded, "Successful weight loss can be achieved with either a low-fat or low-carbohydrate diet when coupled with behavioral treatment. A low-carbohydrate diet is associated with favorable changes in cardiovascular disease risk factors at 2 years."
It is important to measure coronary heart disease, not just risk factors, which can be misleading. A recent study found that an Atkins- type diet "promotes atherosclerosis through mechanisms that do not modify the classic cardiovascular risk factors" such as HDL" (1).
Other studies also showed that measures of heart disease, not just risk factors, worsened on an Atkins diet, including myocardial perfusion, flow-mediated vasodilation, and inflammation but improved significantly on a low-fat, whole foods, plant-based diet (2,3).
No published study has ever shown that an Atkins diet prevents or reverses the progression of coronary heart disease. In contrast, a whole foods plant-based diet much lower in fat than used in this study (10% vs. 30% fat) can reverse coronary heart disease,(4) beneficially affect the progression of prostate cancer, and even improve gene expression and telomerase despite reductions in HDL. It would be unfortunate if people are discouraged from making these diet and lifestyle changes because they incorrectly believe that an Atkins-type diet can provide comparable benefits (5).
The authors reported an overall significant decrease in LDL in the low-fat diet and a rise in HDL in the Atkins diet. Other risk factors were not significantly different. LDL is strongly linked with coronary heart disease, but not everything that raises HDL is beneficial.
HDL is part of reverse cholesterol transport. When you eat more saturated fat and dietary cholesterol, your body makes more HDL to remove it. Eating a stick of butter will raise HDL, but butter is not heart- healthy. Pfizer discontinued a study of its drug, torcetrapib, which raised HDL but actually increased risk of cardiac events. A low HDL in the context of a healthy low-fat diet has a very different prognostic significance than a low HDL in someone eating a high-fat, high-cholesterol diet.
It's not low-fat vs. low-carb. Atkins- type diets may have some benefits because the typical American diet, and many low-fat diets, are very high in refined carbohydrates. Even better is to consume a diet that is low in refined carbohydrates as well as low in saturated fat, trans fats, and animal protein, includes beneficial fats such as omega-3 fatty acids, and high in fruits and vegetables in their natural, unrefined forms.
References
1. Smith SR. A look at the low-carbohydrate diet. N Engl J Med. 2009;361:23,
2. Miller M, Beach V, Sorkin JD, et al. Comparative effects of three popular diets on lipids, endothelial function, and C-reactive protein during weight maintenance. J Am Diet Assoc. 2009;109:713-717.
3. Fleming R, Boyd LB. The effect of high-protein diets on coronary blood flow. Angiology. 2000;51:817-826.
4. Ornish D, Scherwitz L, Billings J, Brown SE, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of coronary heart disease Five- year follow-up of the Lifestyle Heart Trial. JAMA. 1998;280:2001-2007.
5. Ornish D. Was Dr. Atkins right? Journal of the American Dietetic Association. 2004;104(4):537-542.
Conflict of Interest:
Disclosure: I write general-interest books on health for which I receive royalties, receive lecture honoraria, and consult for Mars, Inc. to make healthier foods.
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Cancer and SCM: Possible confounders
Submit responseThe association of cancer with stress cardiomyopathy evidenced by Burgdorf et al is noteworthy. In our published large cohort of 114 patients with SCM (1), we described 5 patients (out of 114) with a recent diagnosis of cancer. One possible confounding variable that I intend to raise here is the emotional stress component of the relationship. The diagnosis of cancer is associated with a strong emotional trauma. In susceptible individuals (elderly females for example), it may be temporally associated with transient ventricular dysfunction. Neurogenic origin is the central component of most variations of the cardiac syndrome and makes most sense biologically. I do agree that other factors need to be looked into.
thank you
References:
1)Singh NK, Rumman S, Mikell FL, Nallamothu N, Rangaswamy C. Stress Cardiomyopathy: Clinical and ventriculographic characteristics in 107 North American Subjects. Int J Cardiol. January 19, 2009 <doi:10.1016/j.ijcard.2008.12.043>
2)Singh NK. Apical Ballooning Syndrome: The emerging evidence of a neurocardiogenic basis. Am Heart J. 2008 Sep; 156(3):e33.
Conflict of Interest:
None declared
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Rosuvastatin for Those with Intermediate 10-Year Cardiovascular Risk in JUPITER
Submit responseTo the Editor: We are pleased to see Ridker et al who reported that rosuvastatin 20mg significantly reduces major cardiovascular events among men and women with elevated hsCRP and intermediate risk (5% to 20% 10-year risk) based on Framingham risk score and Reynolds risk score in JUPITER which has been published in Circulation: Cardiovascular Quality and Outcomes.1 This is the first time the authors analyzed their data in conjugation with clinical practice and further implied the fact that rosuvastatin may not be used for those with 10-year cardiovascular risk <5% due to lack of statistic evidence. Certainly, supposed there are very low events rate in the population with low 10-year cardiovascular risk, the prophylactic use of rosuvastatin will not only be cost-ineffective but probably be harmful to persons. Another interesting finding in this report is that rosuvastatin seems to play a risk modifier of primary prevention in JUPITER cohorts and especially for men. In other words, the effectiveness of rosuvastatin equals to one major risk factor deletion in Framingham or Reynolds risk scores leading to the risk ladder downward. For example, the events rate on rosuvastatin arm for those with Framingham 10-year risk of 11% to 20% equals to that on placebo arm with 10-year risk of 5%-10% (0.95 vs 0.92 / 100 person years respectively). Here, we take Framingham risk score for men to calculate and exemplify. Assuming that there are the men aged 50-59 year-old ( 6-8 points), with HDL-cholesterol levels 40-49 mg/dl ( 1 point, the mean value of men in JUPITER) and with systolic blood pressure in normal range (120-129 mmHg) have current smoking status ( 3 points), the total points will be 10-12 that the 10-year risk probability is 6%-10%. However, if they quit smoking, the total points will be 7-9 that the 10- year risk probability is 3%-5%. Obviously, the benefit of rosuvastatin use is similar to the work of quit smoking, lower of blood pressure, elevation of HDL and "return to youth" in Framingham risk score for men. Further, the effect of lower of levels of hsCRP of rosuvastatin may be another direct risk reduction in Reynolds risk score. Finally we congratulate a good start for Ridker et al to elucidate the populations who really benefit from rosuvastatin in JUPITER. In the future, the issues of drug less or non-responders in JUPTER and the association between inflammation and obesity deserve to be emphasized and further discussed.
Reference 1. Ridker PM, Macfadyen JG, Nordestgaard BG, Koenig W, Kastelein JJ, Genest J, Glynn RJ. Rosuvastatin for Primary Prevention Among Individuals With Elevated High-Sensitivity C-Reactive Protein and 5% to 10% and 10% to 20% 10-Year Risk: Implications of the Justification for Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) Trial for "Intermediate Risk" . Circ Cardiovasc Qual Outcomes. 2010 Aug 24. [Epub ahead of print]
Conflict of Interest:
None declared
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Rural Areas Still Need the Small/Individual Medical Practices
Submit responseSome of the poorest people in the country live in rural areas. Not only can they not afford healthcare, they can't afford insurance. Many are self employed and lving without it. They rely on highly subsidized, rural clinics or government funded programs, when they do access the healthcare system, a reluctance becaue of their fear of the cost.
Add on top of that the expense of traveling to a urban/centralized area to receive healthcare may not even be an option for them. This is where small medical practices or nurse practioner offices shine. It provides these underserved and isolated areas with the healthcare. This healthcare is necessary to help decrease the disparities in health outcomes for these individuals.
I used to live in such an area and had limited to no healthcare while growing up. Now, as a healthcare provider in an urban setting, I am quite concerned about how my family who contnues to live in such a situation are going to benefit/hurt related to healthcare reform. I have my choice of specialist, the ability to pay for healthcare, when I don't have an employer sponsored plan.
I don't think even have to to get into the issue of how these rural individuals are to get emergent care in a timely manner, when the "city" is so far from where they live. Having small rural clinics/hospials will remain a medical must. It is a matter of life & death of the rural culture & the people whom raise the food that shows up on our grocery store shelves.
Conflict of Interest:
None declared
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Affordable Care Act- Article
Submit responseI read this article in the Annals and was disappointed. I'm sure the Annals has received many letters thus far from physicians expressing our frustration and disappointment with the current administration, politicians, and this article. Everything the current administration does, including this current letter posted by the Annals, continues to demonstrate that the administration has absolutely no idea how to truly lower healthcare costs, have irresponsible and ridiculous beliefs about what us doctors do on a day to day basis, and are making dangerous changes that threaten healthcare for the individuals in this country. Just passing a bill but no concrete plan on how to put everything in action- really- does NOT work. I won't repeat what my colleagues have already written, other than I am disappointed in the Annals, and the Obama Administration. Also, shame on Dr. Emanuel and the Annals for not fully disclosing all relationships the authors may have.
Karla R. Dick, D.O. Family Medicine
Conflict of Interest:
None declared
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Re:Editor's Response
Submit responseThanks you so much Dr. Laine for publishing this editorial piece by Kocher et al. Seems to me part of what a good journal does is publish points of view in the editorial section that stimulate interest and response this sure got me thinking and it sure got response -- so again thank. I really appreciate your taking seriously the Annals' mission to enable physicians and other health care professionals to be well-informed members of the medical community and society.
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Favorable cholesterol/HDL ratio
Submit responseThe Framingham Heart Study data (and Castelli, personal communication)suggest that a very favorable cholesterol/HDL ratio (ie in the range of 3.5-4.0) can lower risk so much that treatment of elevated LDL is unnecessary(no coronary heart disease in any Framingham patient with a ratio of 3.5 no matter what the LDL value). Please comment on whether this affects your treatment recommendations.
Conflict of Interest:
None declared