Critics are accusing Aussie medical schools of cutting back too much on basic science education including anatomy (link via the basic science Nazis at Fark.com).

[Senior attending physicians] have been “horrified” to encounter final-year medical students who do not know where the prostate gland is, or what a healthy liver feels like.

When asked by a cardiac surgeon during a live operation to identify a part of the heart that he was pointing to, one group of final-year students thought it was the patient’s liver.

The critics claim that too much time is being devoted to “touchy-feely” subjects such as “cultural sensitivity”. The medical schools counter that there is so much medical knowledge to learn and only a limited amount of time to do it. Who’s right? Both are.

But such controversy begs the question; Do most of our doctors really need a liberal medical education? Do patients really give a crap whether or not their physician knows the basic structure of every type of amino acid or where the ligament of Treitz is? I’d take a wild guess and say no. Patients want something to help them sleep at night or to find out what’s causing their stomach pain. Knowing the chemical structure of an amino acid is not going to help one bit.

Physicians traditionally get a liberal education because we have this sense that we should create a well-rounded doc as physician-scientist. In decades past it was believed that physicians should not only be practitioners but investigators on the forefront of a mysterious new field. However, these days physicians are more often seen as “providers” who toil away following practice guidelines. The attitude these days seems to be “leave the science to the scientists. Let them find new diseases and develop new treatments.”

Basic science courses take up two whole years in most medical school curriculums before the student gets to see their first patient. But in the US there are alternative models of education and training of health care professionals.

The training programs of physician’s assistants (PAs) and nurse practitioners (NPs) dispense with much of the medical school minutia filled intense basic science courses and provide more direct practical clinical training in less than half the time it takes to train most MDs. In most states PAs and NPs are allowed to do almost as much as an MD with minimal supervision and in many states NPs are allowed to practice without a supervising physician and can make as much as an MD!

There is a lot of talk in this country of having PAs and NPs take over the basic patient care duties of many primary care providers (partly to alleviate shortages and to decrease costs). And the jury is still way, way out on whether or not getting treated by professionals who have far less basic science training changes the quality of care (for better or worse). In the future your primary care provider may have no idea what frame-shift genetic encoding is and you won’t care less as long as you get something to help you sleep.

Welcome to a new century and a new era of immigrant bashing. The latest round saw its genesis in a new Senate bill cosponsored and written by John McCain (R-AZ). The bill would overhaul the immigration process by creating a temporary worker program that would allow in 400,000 foreign workers per year and change the citizenship process for an estimated 8-12 million undocumented resident aliens in this country provided that they work here for 6 years, pass criminal background checks, learn English and pay fines and back taxes” (the bill authors deny that this is “amnesty”).

Naturally and expectedly the conservatives in the House essentially freaked out and proposed their own immigration bill that would make it an automatic felony to enter the country illegally thus permanently blocking any opportunity to become a legal resident or citizen. Under current law entering the country illegally is a misdemeanor while subsequent entries are felony offences. However about 40% of the total illegal resident population is made up of people who overstay their visas and this is currently only a civil offence.

The sheer idiocy of the House bill is evident when you realize that in order to become a felon one needs to go through the court system and either plead guilty or be convicted by a jury. It’s highly unlikely that the courts would strip non-citizens of the right to trial by jury. And then what do you do with 12 million felons provided the overwhelmed court system does not collapse prior to convicting them all? Do we send them back to Mexico? Waiting for them all to go through the court system would delay deportation for years. As it is now deportation is much speedier.

Or do we throw them in prison? Currently the US prison population is about 2 million and overcrowding is chronic and sometimes severe. Where would we put 12 million more felons? Would we put them into “concentration camps” specially built at massive cost to house them all? Would families be torn apart? Even if we don’t jail them all we would still be creating a permanent underclass of 12 million people who would be prevented from working, prevented from becoming citizens or legal residents and who would have no choice but to live off the taxpayer. Realistically these new felons would simply be forced further into a shadow existence and this would probably increase and extend their impoverished situation.

Hell! Why don’t we just deport all these illegals! Not including the insanely massive cost and effort of finding and processing 12 million illegal aliens (estimates range from $206 to $230 BILLION over 5 years) John McCain, citing the columnist George Will, noted that it would take 200,000 buses in a line 1,700 miles long to deport 11-12 million people in what would probably be the largest mass deportation in history. The numbers boggle the mind! It’s one thing to act like a retarded carnival barker while pandering to your electorate and sounding tough on immigration. It’s quite another to face the reality of the situation.

The commonly held belief that the majority of the 12 million aliens are here to live off welfare is a complete fantasy. Because they are illegal and it is illegal to hire them exact figures on the employment status of illegal aliens is hard to come by however, there is one source that has data that indicates that illegal residents are not only employed in vast numbers but they are also generating enormous amounts of taxable income!

In 1986 Congressed passed the Immigration Reform and Control Act (IRCA) that made it a crime to knowingly hire illegal aliens. The key word here is “knowingly”. But the IRCA had minimal effects on hiring practices. Beginning in the late 80’s the Social Security Administration started getting increasing numbers of W-2 employment tax forms with incorrect or fictitious social security numbers on them. During the 90’s the total amount of taxable income recorded under “bad” SS numbers had grown to a staggering $189 BILLION. The taxes from these “bad” numbers amounts to $6-7 Billion in SS revenue and $1.5 Billion in Medicare revenue each year!

Where are these “bad” SS numbers coming from? The data shows that the majority of these filings are from employers in Texas, California, and Illinois. A third of these filings were from restaurants, construction companies, or farms. This looks like the residence and employment demographics of undocumented aliens! Apparently forged green cards and SS cards are relatively cheap and easy to get and this gives employers plausible deniability if confronted by INS.

In 2002 there were 9 million filings with bad SS numbers. Assuming that the vast majority of these are from undocumented foreign workers and assuming that millions more are employed in jobs that pay direct cash and report no wages then the vast majority of illegal aliens are employed. Known employment rates of illegal immigrants are actually only slightly lower then the national average. In fact, recent employment data indicate that the employment rate for unskilled immigrants in low paying jobs has increased while the rate for unskilled Americans has decreased.

Of course this is another fear mongering point from the House conservatives. Illegal aliens are taking jobs from American workers! Right? Yes and no. The picture is far more complex then just saying that American workers are losing jobs to immigrants. Over the last few decades the percentage of young Americans with a high school diploma has grown from 75% in 1970 to 86% in 2004. Presumably these graduates are more likely to go after higher paying skilled jobs. Who then is taking the unskilled jobs? Take a wild guess.

Less than half of new immigrants have a high school diploma. In 2001 despite making up only 13% of the US worker population, immigrants (legal and illegal) held 35% of the unskilled jobs. Despite the influx of immigrants during this same time the national unemployment has remained steady. What is going on is a change in worker demographics and not just a simple displacement. In addition, the fact that illegal immigrants must work to feed their families while unskilled American workers have access to all kinds of benefits including unemployment and welfare probably has something to do with the higher unemployment rates of unskilled Americans compared to unskilled immigrants.

Yet one critique of unskilled foreign labor is valid. It holds down wages. But it also holds down costs to consumers. If an unskilled American worker loses a job to an unskilled foreign worker then it is more than likely that this was because the unskilled foreign worker will work harder for less. But to call for the deportation of the illegals and their cheap labor is similar to calling on tariffs to protect American workers! But that’s anti-capitalistic and that’s un-American!

The status quo.

The reason why we have the current immigration policy boils down to economics and practicality. The cost of either constructing an impenetrable barrier to immigration from Mexico and/or deporting most or all illegal resident aliens is prohibitively expensive and likely not very feasible. Businesses that benefit from cheap foreign workers need those workers (very few employers are prosecuted under current immigration laws). And it remains to be proven that illegal immigrants significantly harm this country more than they benefit it. So the current system lumbers on.

The debate from the conservative viewpoint.

However, for conservatives, the debate over illegal immigrants appears to boil down to two non-economic issues. The first is the “inertia of illegality” i.e. the conservative fixation on the fact that once something is made illegal it should remain illegal (or get even more illegal). Thus the idiots in the House shun anything that resembles “amnesty” or leniency for illegal immigrants and propose tougher penalties for immigrants no matter how impractical.

The other issue, I hate to say, appears to be a good bit of underlying ethnocentrism and isolationism among conservatives towards Hispanic immigrants. This is consistent with a long tradition in this country of open hostility towards immigrants that appears to be indirectly proportional to the similarities in ethnic makeup of the immigrants compared to our own. Apparently anti-immigrant hysteria is so bad that California Rep. Dana Rohrabacher, unable to avoid the obvious economic consequences should 3 million illegal aliens be deported from his state, suggested that we could simply have “prisoners” pick up the slack. Never mind that this moronic suggestion would involve moving the entire US prison population to California and they would still be a million short. One has to wonder how different the reaction would be if instead it was 12 million mostly impoverished white Canadian citizens living here illegally.

It appears that the simple fact that Hispanic (non-white, non-black) population growth in the US has exploded in the last 20 years is “a priori” a major concern to conservatives. Ironically the majority of this growth is from native births rather then immigration. In 2000 there were 35 million Hispanics in the US of which only about 40% were foreign born. In 2001 over 50% of all births in California were Hispanic! In 2003 the national Hispanic population grew to 37 million and surpassed the black population as the biggest minority ethnic group in the country. It is projected that by 2050 over 50% of the US population will be non-white. This does not seem to sit well with some anti-immigrant conservatives.

“The combination of the 1965 Immigration Act, which accidentally unleashed mass immigration after a four-decade pause, and Washington’s abject failure to defend the borders against illegal immigration, has resulted in an extraordinary situation.

Basically, because of the perverse selection process built into the current system, the U.S. population is going to be vastly larger, much more non-white and much less skilled than would otherwise be the case.

By 2050, there will be 400 million people living in the U.S. instead of maybe 280-290 million. And whites, 90 per cent of the population in 1960, will be on the verge of becoming a minority. This is an ethnic transformation without precedent in the history of the world. It is happening for one reason only: the federal government is making it happen.”

Yea. So? The author Peter Brimelow can’t seem to come up with any compelling reason why this would be of concern other then the fact that cheap immigrant labor keeps wages low. But that should make conservatives happy. Huh? And there is no reason to believe that the Hispanic population would remain “less skilled” as it grew and integrated into American life, especially our robust economic system.

The common critique of Hispanic immigrants is that they are less educated, more impoverished, and less skilled than the American norm. Yea. So? This has been true of almost every immigrant group to come to this country. It is also true that they are hard workers, productive, and very entrepreneurial just like almost every other immigrant group and there is every reason to expect that the educational and skill levels of Hispanics will increase and reach parity as their numbers grow and 3rd and 4th generation Hispanics are born . . just like every other immigrant group.

In fact, the only reason that I can think of that would hold down Hispanic education, income, and skill levels would be because of continued institutionalized less-than-pluralistic attitudes represented by people like Mr. Brimelow when it comes to hiring practices and business and educational opportunities (it’s kind of a self fulfilling prophecy). However, such massive projected population growth should significantly reduce this risk as more businesses are Hispanic run and owned and “white” businesses will find that their survival depends more and more on serving and pandering to the non-white population. Ahh, parity.

All of this talk and worry among the conservatives is kind of amusing because it far too little and far too late. They can complain and fear monger all they want but the fact is that the Hispanic genie is out of the bottle and there is not a dam thing that Mr. Brimelow nor the republican majority of the House of Representatives can do about it. Even if all 12 million illegal aliens were sent home and not a single Hispanic immigrant were allowed to cross the border ever again (i.e. if we think magically) the “native” and legal immigrant Hispanic population would continue to increase dramatically (remember, most of the growth is from US births). Instead of pandering to their mostly white and conservative audience to win political points and sell books maybe these guys should consider learning a little Spanish!

The real isues.

Regardless, all of this discussion about useless and impractical proposals like building border walls, and deporting or criminalizing 12 million people detracts from some real issues that need fixing. Remember those billions of dollars in taxes that illegal immigrants produce? Few if any of them are eligible for benefits like Medicare or Medicaid because they are not in this country legally! Their taxes go into the general Federal fund to be distributed to other things like the war in Iraq. Not only do illegal immigrants get the royal screw but private hospitals which are forced by Federal law to treat anyone and everyone who comes to their ER don’t get anywhere near enough funding to offset the costs. There is no reason to believe that illegal immigrants are sicker than the rest of us. They just have nowhere but the ER to go to when they get sick! This injustice needs to be corrected and the proposals included in the McCain bill are a step in the right direction.

What is a problem is not from tax paying resident illegal aliens but from foreign nationals who do NOT reside in this country or who are only “visiting” who cross the border with the specific intent to be treated in an American ER knowing fully well that they cannot be refused emergency treatment nor do they have any intent on paying for such treatment. Either the EMTALA law needs to be changed or there needs to be some sort of tax on foreign entry to help offset these costs.

Amend section 1 of the 14th amendment to the US Constitution. It says, “All persons born or naturalized in the United States and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside.” Originally the intent of this post civil war amendment was to protect the rights of former slaves but these days it has become a massive loophole for illegal immigrants to try and become de facto citizens. These new citizens are automatically eligible for social services independent of their parent’s employment status and contribution to the tax base. This is not and was not the intent of the amendment and few other western countries have such naturalization laws.

The risk.

Republican representatives are sure taking quite a political risk considering the fact up to half of the future electorate will be non-white and considering that the usually politically tepid Hispanic population suddenly found its voice last week. Hispanics were marching not in support of illegality but in protest of what they saw as an attack on their cultural identity. That this cultural attack is seen to come from conservative Republicans is not a good thing. The GOP lost significant support from the black community in the 1960s and never recovered it. Now they seem hell bent on repeating history.

*About the author: Dr. Rangel is half Hispanic, was born in a town that is 90% Hispanic, practices in a city that is 78% Hispanic and that will see a net loss in white population over the next 5 years, and is mad that he didn’t learn more Spanish as a child.

Imagine you need a life saving cardiac operation for your severely diseased and failing heart. Then imagine your surprise when you find out that your Medicare government health insurance pays less than 40% of what private insurances reimburse anesthesiologists for the same procedure! Now imagine your concern when you learn that because of such poor reimbursement rates only a scant few anesthesiologists in your area will provide services for cardiac surgical cases when the insurer is Medicare!

The anesthesia services provided during these long procedures can be ridiculously complex and challenging even for the most seasoned “sandman”. Open heart procedures require that the heart be literally stopped (cardioplegia) and the patient is kept alive by use of an artificial pump (bypass). During the procedure the patient often requires multiple invasive monitoring modalities like swan-ganze catheterization and the anesthesiologist is required to interpret complex real-time clinical data and apply combinations of multiple medications based on this data in order to keep the patient stabilized.

Does it bother you that Medicare pays less for this life saving procedure then most private insurances will pay for anesthesia services for a knee replacement!?!?!? Well it should. This is what I was stunned to discover while talking to a good anesthesiologist friend of mine. He is an excellent gas-passer (and physician) only a few years out of residency who loves cardiac surgical cases for the challenges they bring (and he’s young, enthusiastic, and hungry).

But he recently he expressed his frustration when he realized that while private insurance paid him well over $1,000 for his services during a basic knee replacement he got only about $600 from Medicare for a cardiac bypass procedure. Since these operations can take up to 6-8 hours this meant that he was earning less than $100/hour. In order to find anesthesiologists to staff open heart cases many hospitals have resorted to subsidizing their reimbursement. It’s another example of cost shifting in our heterogeneous payer system.

The declining or flat Medicare reimbursement rate for anesthesia services is hugely ironic given the remarkable safety record of modern anesthesiology. Beginning in the mid 1980s it was found that the risks of death or injury from anesthesia could be reduced significantly if anesthesiologists and CRNAs adopt standardized checklists and maintenance for equipment and procedures. The study of individual adverse incidents as well as the reasons for liability claims lead to safer equipment design, training, and standardization of procedures and along with improved intraoperative monitoring techniques as lead to an estimated 25 fold decrease in anesthesia related deaths!

And for all this remarkable work on patient safety (almost 15 years before the current focus on hospital patient safety) Medicare “rewarded” the anesthesia industry by cutting reimbursement rates by 25% in 1992. Despite repeated calls and recommendations to correct this error, reimbursement rates continue to be 40% or less than that paid by private insurance which means that in absolute dollars the reimbursement rates for anesthesia are 80% below the 1991 rates! No good deed goes unpunished!

Not helped by an erroneous assumption that CRNAs could fill the gaps, the result of Medicare’s cost saving effort was a 75% drop in anesthesiology residency graduates per year and the closure of 25 out of 125 anesthesiology residency programs. Now there is talk of an anesthesiologist shortage and delays in elective surgeries. Ironically these Medicare cuts combined with anesthesiologist shortages may lead to increased salaries as hospitals, desperate to find someone to staff surgical procedures, increase subsidies and provide recruitment incentives. Most of this added cost will be passed on to private insurers and some to tax payers as increased medical care costs. Way to go Medicare! Their motto should be “We cut costs now and pay for the consequences later!”

So we may be facing a paradox of falling reimbursement rates and rising health care costs. Apparently no one at the Centers for Medicare and Medicaid Services (CMS) has faced up to this possibility. Of course we can simply change to a nationalized single payer system in which every doctor will be reimbursed at 40% below current levels or less! Oh joy! I’d love to see what that system would look like! Oh wait. This is the Canadian system.

When I told my friend that he was earning up to 4 times less per hour than I am (an internist) when he does Medicare open heart cases he got that look that people get when they realize that despite years of extensive (and expensive) training the government considers his skills to be of 60% less value than what the market (private insurance) values them. This is a sad realization that is being faced by more and more physicians as CMS cuts rates and we begin to slowly creep toward socialized medicine.

When the media begin operating with a mob mentality it’s easy to understand how this skews the public’s perceptions of the reality of these stories. Media swarms or clustering and over-reporting on stories is one side of the problem. On the other side is selective reporting that is a hugely practiced but little known phenomenon. For example, in the late 80’s and early 90’s the media was swarming over reports that silicone breast implants were being linked to autoimmune diseases but when several epidemiological studies were published that found no links what-so-ever, hardly anyone in the media noticed.

But what about media hype contained within a specific article? Jack Shafer from Slate takes a look at the latest media swarm; the “epidemic” in methamphetamine abuse and picks apart the “reporting” by the Washington Post. Apparently poor reporting tends to cherry pick from the statistics buffet, use broad terms that are open to interpretation like “epidemic” without being more specific, and avoids details and exact information (”Health officials say 75 percent of patients in some clinics have abused the drug, a big increase from a few years ago” - Which health officials? How many clinics? What clinics? An increase of how much? How many years ago?).

Best of all is the use of sources who at first glance should be “experts” on this topic but at best have only anecdotal data and at worst have a conflict of interest in saying something that contradicts the slant of the story! The use of law enforcement personnel as sources for stories on drug abuse trends is about a useful as a sports announcer who informs us that the team that scores the most points is going to win. Have you ever met a police officer who actually knows national or regional crime rates (or a doctor who knows national shifts in HMO enrollment rates)? And what department spokesperson is going to admit to a trend that would result in lower funding for their department?

Best of all is the habit of “reporters” in assuming that their “expert” sources are actually experts who get their ideas and opinions strictly from data, independent of previous media hype! All of this likely results in the following; Law enforcement official reads about the latest “epidemic” in drug abuse –> this article focuses his/her attention on relevant cases in the department –> reporter interviews official about these cases and asks opinion on trends –> official confirms that these cases are increasing without providing hard data or only partial statistics or anecdotal data –> reporter reports that official confirms that these cases are on the increase –> official reads this story that confirms the latest “epidemic” in drug abuse. And so on and so forth. Chicken or egg? Are they creating the news or just reporting it?

(Via Fark). An Indiana public school superintendent has axed plans to publish an article about oral sex in the school paper of Nobelsville High. What? Huh? What is an article on Lewinskyism supposed to be doing in a public high school student newspaper in the first place?

Then again, why not? After all, a high school newspaper is for the students (or at least for the cliquish students to publish stories about themselves and pad their college applications). According to the CDC about half of high school age teens are sexually active ergo an article on fellatio should be of interest to at least 50% of high school students (actually about 100% in reality since nothing quite captures teenager’s attentions like sex).

So what’s all this about an article on oral sex not being appropriate for high schoolers when so many are already doing the deed? Our puritan sensibilities often lead to odd juxtapositions. Our society continues to remain in massive denial about teen sexual activity despite the numbers and the biological sexual maturity of teenagers. We continue to believe in and adhere to the idea that sexually naive childhood can and should continue until a definitive and arbitrary cut off point (i.e. 18 years old or high school graduation).

Don’t get me wrong. Avoidance of unintended pregnancy is a great and rational reason for delaying sexual activity until after high school but this is an historical aberration. Throughout history adolescent pregnancy has been the norm but beginning in the ladder half of the 19th century we decided that everyone should get an education and that marriage and reproduction should be delayed until afterwards. However, what this also led to was a concept of delayed adulthood and extended childhood. The societal taboo of childhood sexuality was extended well into adolescence as a moratorium on all things sexual despite the fact that this makes little sense from either a biological or societal perspective.

What we end up with is a morass of mixed messages to our teens. Rather than emphasize the importance of avoiding pregnancy and finishing their education our simplified puritanical cultural elements kicked in and this message became the avoidance of all things sexual at all costs! And why not? A complete moratorium on anything sexual in high school avoids a lot of awkward parent-child or teacher/councilor-student moments when the newly sexually mature and curious teen looks for answers and guidance from the adults in their lives. What they get is either avoidance, silence, or something like the following from the 1986 movie “Peggy Sue Got Married”;

“Peggy, you know what a penis is? Stay away from it!”

Oh and this strategy has worked so dam well! Despite similar rates of sexual activity, the effective use of contraceptives by American teenagers is much lower than teens in other industrialized nations and as such our teen pregnancy rates are much higher. And yet such failures have only spurred policy makers even further in the wrong direction as if convinced that they will ultimately find the fabled Shangri La of sex-free teenage existence.

Instead of just saying “no” as we did in the 1980’s (to sex and drugs), in the 90’s some asshats came up with the idea of abstinence only education and signed pledges of virginity until marriage (what I call the ostridge head in the sand or the “see no evil, hear no evil, do no evil” approach). The result; No change in pregnancy rates or attitudes towards sex and while virginity pledgers 12-18 years old delayed the start of sexual activity by an amazing 18 months and had fewer partners than teens who did not pledge there was no or little statistical difference in sexually transmitted diseases rates between the two groups.

What? How can that be? Well it turns out that not only were pledgers less likely to use condoms (especially at first coitis), they were also more likely to engage in oral or anal intercourse in the belief that this is not “sex”. Pledgers appear to be less likely to be educated about sex and have less access to contraception.

Despite these poor outcomes (and the fact that it appears to confirm that the stick your head in the sand approach is at the root of the problem) it was the “successes” of this data, i.e. delayed sexual activity and fewer partners, that conservative groups crowed about. The message from these groups is that it is adolescent or premarital sexual activity that is bad rather than the consequences of adolescent pregnancy, STD transmission, and harm to educational opportunity and career advancement. So it’s the premarital sex act itself and not necessarily the consequences that concern conservatives. No wonder American teenagers are confused.

And yet ironically abstinence has played a role over the last several decades. The teenage pregnancy rate has declined gradually since a high in the 1950s (believe it or not) along with a similar decline in abortion rates in teenagers. The recent declines started in the late 1980s and early 90s and coincides with a decline in teenage sexual activity in this same time period. According to the Guttmacher Institute increased abstinence among teens accounted for about one-forth of the decline in the teen pregnancy rate from 1988 to 1995.

However, the frequency of sexual activity among sexual active teens appears to have increased slightly from 1988-95. What is to account for the rest of the decline in teen pregnancy rates? While the percentage of teens using a form of contraception at first coitis increased 65-75% (from an increased use of condoms at first coitis of 15%), overall compliance with contraception use continues to be suboptimal (about 78-83% where optimal is as close to 100% as possible).

It appears that while condom use has remained about constant more teens adopted the use of longer acting hormonal contraceptive methods like Depo Provera injection and this has contributed to a 9% decline in the teen pregnancy rate. Yet it is the overall inconsistent use of contraceptives (particularly condom use) that continues to keep the rate of teenage pregnancy in this country much higher than other industrialized nations despite similar rates of sexual activity and hormonal contraceptive use.

But how do we account for the decline in sexual activity? Does teaching teens abstinence and isolating them from the reality of their existence as sexual beings (or ignoring such reality) really work? Unlikely. Abstinence only programs and virginity pledges do not appear to be effective enough nor nearly wide spread enough to have influenced the activity of millions of teens and most of these programs became trendy only after the decline in teen sexual activity had started.

Moreover, sexual activity and teen pregnancy rates are significantly tied to socioeconomic status. In this country both of these rates are higher in black and Hispanic teens who tend to more disadvantaged*. There are many reasons for this trend but probably a big contributor is that the perceived negative consequences of pregnancy are less for a teen who is disadvantaged. I.e. they believe they have less to lose from early pregnancy and this contributes to a callous and more reckless attitude towards sexual activity. It is possible that the prolonged economic growth of the 1990s (including reductions in unemployment) contributed significantly to the decreased rates of both of these rates though direct causative evidence is lacking.

What is clear is that this decline in teen sexual activity and pregnancy occurred during a time of unprecedented expansion in modalities of mass media including cable and satellite television, digitally recorded media (DVDs, CDs, digital cameras), and most importantly, the Internet (or the “Internets” if you are a republican). All of these modalities allow teenagers to be exposed to more sexually explicit material (much of it very graphic) than ever before and yet national trends continue to conflict with commonly held delusions about sex in media increasing teen sexual activity. A 0.16 second Google search for “fellatio” yields 4.5 million web pages on this topic and yet an article about oral sex from a human health/sexuality from a non-pornographic perspective is not allowed in a high school newspaper. Hear no evil, see no evil, read no evil?

This belief in the myth of the asexual adolescent and the inherent badness of teenage sex is so ingrained in our culture that it continues to influence policy decisions that go counter to the evidence. Bush II has continued to push for funding for abstinence only public education programs despite the lack of evidence for effectiveness (apparently being a born-again Christian also means believing that you are permanently stuck in the year 1955).

What works? As bad as abstinence only education is, pure sex education is not much better. What appears to work is more comprehensive programs that include not only information on reducing risky behavior but also information on communication skills, obtaining contraception and protection, the values of delaying sexual initiation and pregnancy, and taking pride and a sense of empowerment in making decisions on personal sexual behavior. Just as important is data that suggests that providing contraceptives to students via high school health clinics improves compliance without increasing sexual activity (sexual activity among teens has never been proven to be connected to the level of their access to contraceptives - another myth). However, only a minority of high school student health clinics provide access to contraceptives and those that do have not been proven to be responsible for any decrease in STD or pregnancy rates. Less studied is the option of providing long-term hormonal contraceptives at school clinics on pregnancy rates (although this may increase STD risk).

Why we continue to treat our public high schools as sex-free zones to the extreme of censoring student publications when half of its students are sexually active is beyond me. This squeamishness about intentionally exposing teenagers to anything sexual is just another symptom of how the majority of our school administrators, teachers, councilors, parents, and even students (many of who adopt the same avoidance of sexual discussion that their parents display) are reality challenged. Regression to a 1950s style of abstinence only education is simply another way of increasing our common avoidance of the issue of teenage sexuality. Until we wake up and stop being so dammed puritanical we are never going to be able to deal with this effectively.

Perhaps a little clarification would be useful. Now repeat after me;

• Sex itself is not bad and it is part of being human.
• Risky sexual activity is bad because it has consequences.
• Education is good.
• Abstinence is also good and never wrong.
• Taking responsibility and being empowered in your decisions about your sexual behavior is always good!

If we can just agree to start with these basic principles then maybe we can start to raise generations of educated, mature, informed, and sexually responsible young adults rather than pretending that teenagers are just children with bigger clothing sizes.

*A disadvantaged teen = “Living in poverty; being poorly educated; having poorly educated parents; being raised in a single-parent family or in an economically struggling neighborhood; and lacking educational and job opportunities.”

As you know, 42.7% of statistics are made up on the spot! Seriously though, it is at times almost bizarre how the lay media slants coverage of the side effects of medications. For example, the once a week estrogen birth control patch is made by Ortho-McNeil and has recently been linked to increased rates of potentially fatal blood clots.

In 2005 the Associated Press reported that 12 young women had died in 2004 from thromboembolic complications (blood clots) thought to be related to the use of the patch. This was not a scientific study (the data was obtained by the AP from “Federal death and injury reports” using a freedom of information request) and no information was provided as to other associated factors such as smoking or autoimmune diseases that may have contributed to these deaths.

Last November the FDA and Ortho warned patients about the possibility of increased blood clot risk and the fact that users of the patch are exposed to up to 60% more estrogen than patients who take oral birth control (this is because estrogen from the patch is released directly into the blood steam and unlike birth control pills is not subjected to “first pass” metabolism by the liver).

This week Ortho-McNeil reported the results of two ongoing studies to the FDA which show a very mixed picture. While one of the studies (which I have not seen) found no increased risk, the other study suggested a risk of thromboembolic phenomenon of two times above normal for uses of the patch.

Every medication has risks and the problem here is one of perceived risk. Thromboembolic disease is very rare especially in the female population most likely to be on hormonal birth control. The risk of nonfatal blood clots in women on hormonal birth control is about 3-5 cases per 10,000 per year. If we assume that the patch increases the risk twofold then it is 6-10 cases per 10,000 per year.

But these are nonfatal cases! Let’s further assume that the Federal data obtained by the AP is true and that 12 women died in 2004 because of blood clots caused by the Ortho patch. According to CDC data from 1999 on maternal mortality there were 12 deaths per 100,000 live births. According to Ortho since going on the market in 2002 4 million women have used the patch. If we further assume that only 2 million were on the patch in any given year from 2002-2006 we can calculate that there were only about 1-2 deaths per 100,000 users from blood clots in any given year. What this means is that the risk of death from pregnancy is about 10-12 times more than the risk of death of someone using the Ortho patch!!!!

Since the purpose of the Ortho patch is ostensively to prevent pregnancy the benefits from a statistical context obviously still outweigh the risks and yet this fact is totally lost on the lay media (and the lawyers representing women who died or suffered blood clots). A big part of this misperception comes from the common misperception that prescription medications are supposed to be 100% safe. This is the problem with statistics. When analyzed in isolation they provide a very skewed picture of risk.

The criticism of this perspective is that this is simply a spin on the numbers. What about the fact that oral hormonal birth control is safer than the patch? In this case we have to consider the that there is evidence that use of the patch is more effective in preventing pregnancy then the pill (95%-99% for the pill compared to 98%-99% for the patch) and so the risks of the use of the patch should still far outweigh the risks of the pill by virtue of better compliance with dosing for the patch.

Yet even if the effectiveness was the same for the pill and the patch we can’t discount the value of the convince that the patch provides. This value in convince that we place in products is something that Americans do every day without thinking about it. Despite the fact that it is statistically three times more deadly to drive to work rather than walk we continue to be an automobile based nation. And yet we don’t commonly see news articles about the deadliness of the car.

No single medication comes without risks but you have to weigh the benefits with the risks. This simple concept is something that continues to elude most “journalists” and almost all trial lawyers and continues to cause the FDA fits. Statistics cannot be considered in isolation. To do so is intellectual laziness or manipulation of the story of which there is a-plenty in today’s society.

Remember the movie “The Blob” (any version), about an amorphous pile of alien Jello that got a bad case of the munchies? It wandered around town eating people and being a general nuisance and all the while it got bigger and bigger every time it had a meal! I get this image of “The Blob” in my head whenever I think of state Medicaid programs.

Beginning in the late 1980’s Congress expanded Medicaid eligibility to all pregnant women, infants, and children under age 6 who had incomes of up to 185% of the Federal poverty level. Other expansions of coverage including qualified Medicare beneficiaries and Supplemental Security Income (SSI) lead to 22% growth increases each year in the early 1990s.

The rate of Medicaid growth slowed in the mid 1990s when a strong economy and managed care held down enrolment growth and costs. Then by 2001 Medicaid growth was at 11% and was growing even faster than increases in total state spending. Part of this was due to the post 9/11 economy. Part was due to the collapse of managed health care and its artificial suppression of health care costs and part was due to increased costs of health care itself, a huge slice of which was the rising costs of prescription drugs.

But perhaps the biggest cause of soaring Medicaid spending has been an ever increasing movement to expand Medicaid to cover as many as possible of the 40 million or so Americans (under age 65) who lack health insurance each year. Just from 1999 to 2004 the Medicaid rolls increased from 34 to 47 million Americans! From 1998 to 2004 Medicaid spending almost doubled from 160 to $300 Billion/year! Some of this was due to soaring health care costs during this time BUT the increase in Medicaid spending was twice the rate of increased Medicare spending! The obvious conclusion is that huge expansions in Medicaid rolls were primarily responsible for the increases in Medicaid costs. For example; Medicaid is not just for impoverished families with children or the disabled anymore.

Today, a family of four can earn as much as $40,000 a year in most states and get government health insurance for children. The nation’s median household income was $43,318 in 2003

With relaxed eligibility requirement like this, I’ll be willing to bet that much of the increase in Medicaid rolls was from families who dumped their expensive private insurance to enroll in their state’s far cheaper Medicaid program. Not only that but some of these revamped programs also expanded coverage of services well beyond even private insurances. The TennCare program, Tennessee’s disastrous attempt at universal coverage through Medicaid expansion, was the latest extreme example of this but many other states have been slowly trying to expand their Medicaid coverage well beyond the initial design.

All of this massive increased state spending of Medicaid (even with matching Federal funds) is now starting to bump up against the “Law of unintended consequences“. For the first time state spending on Medicaid programs has exceeded state spending on public education as a percentage of state budgets. While it’s too early to show that this has had a negative impact on public education it is never-the-less a very disturbing trend.

Educational opportunity and access is directly proportional and closely tied to socioeconomic status (SES) which itself is directly proportional to the overall and long-term health of the individual (even to the point of being independent of genetic factors).

Part of the reason why democratic industrialized nations spend so much of their GDP on health care than less wealthy nations is because 1. they can and 2. the people believe it to be a top priority (even if it is expensive). But should health care spending automatically take priority over education spending especially when educational opportunity as such a huge impact on SES and health?

Some may counter that the reason for the differences in health status between people of different SES is that those with lower education and lower SES have less access to health care and receive poorer quality care. Ergo universal health insurance coverage and/or increased Medicaid converge should solve this, right? Wrong. McGinnis et al (2002) looked at SES and premature mortality and found that “behavior” and “social circumstance” accounted for 55%, while “deficiencies in medical care” contributed to only 10% of premature mortality!

And unhealthy behavior (particularly smoking) has been shown to be inversely proportional to education level. Several diseases, in particular cardiovascular disease, have been shown to be directly tied to the education level of the patient.

People with lower education levels also appear to spend more on health care. In particular, literacy rates significantly affect how much health care dollars are spent and resources are consumed across the board! Data from 1998 shows that functionally illiterate adults spend much more on health care and this increased spending appears to be independent of health status or income!! Low literacy adults were 1.5 times more likely to visit a physician and use 3 times more prescription medications than higher literacy adults.

In the US 44 million are functionally illiterate and another 53 million have marginal reading and computational skills. These numbers far exceed the number of Americans without health insurance (at any given time) and yet states have spent the last 15 years building up the Medicaid rolls and slowly encroaching (now exceeding) spending on education. This boggles the mind! Not only is our public education system failing (”. . is our children learning?”) but states are rushing headlong to expand and fund a program that shows no signs of slowing in it’s cost increases and is starting to gobble up education funds.

Unlike the Federal government, state governments do not have the ability to build up massive deficits without severely hurting their bond ratings and their ability to barrow for infrastructure improvements. Therefore the largest program in any state budget is inevitably going to start consuming funds from other programs. Our country can’t afford to cut education funding (not until we massively reform the public education system and try to get something for the massive amounts of money we pay for it).

As if this trend is not troubling enough there continues to be an amazing number of proponents of nationalized universal health care and most of the proposed plans for such a system look very much like Medicaid i.e. publicly funded, with few cost controls, and an abundance of covered services. And just how will such a nationalized massive program not suffer from the same spiraling cost “blobism” that is now happening to Medicaid? They have yet to come up with a plausible answer.

A few hard partying English type persons took a look at this issue and published their results in The British Medical Journal (BMJ). Despite Billions spent on alcohol each year in the US and UK and Billions more in lost productivity and “sick days” from over indulgence in happy juice, very little research has been done on causes or cures for this very neglected condition.

What the BMJ review did find is that there is no definitive evidence that any of these cures makes any difference and even though some treatments (linolenic acid, dried yeast preparation, and tolfenamic acid) did show promising results, the studies were small and not well designed. In many studies the actual amounts of alcohol and food consumed were not monitored and physiologic changes were not measured. Only eight studies of various hangover “cures” were evaluated in this review.

So just what is a “hangover” and why does one feel overhung after consuming too much alcohol? The reason appears to be multifactorial. First off there is some experimental evidence that dark or colored drinks (wine, bourbon, scotch, and brandy) are more likely to cause a hangover because they contain impurities called congeners produced as a byproduct of the fermenting process. Red wine contains tyramine which can induce particularly bad headaches in the post-party period. Ergo, clearer spirits may reduce your hangover symptoms.

Eating just before consuming alcohol helps to reduce the rate of absorption and can reduce the peak blood alcohol concentration by 9-23%. Food causes the pyloric valve at the bottom part of the stomach to close in order for digestion to start. Since alcohol is mostly absorbed in the small intestine, eating delays and significantly reduces the absorption rate. In addition, since alcohol is eliminated by the body using zero order kinetics (a constant rate of reaction independent of the concentration) even small amounts of absorbed alcohol are quickly and effectively metabolized and removed (this is why it is important to imbibe slowly - about one drink per hour). The type of food does not make a difference but larger meals will delay absorption even more.

Since alcohol has a high affinity for water (i.e. it dissolves much better in water than fat), people with more body fat (i.e. those who are obese, female, older) will have lower blood alcohol levels even if the same amounts of alcohol are consumed as a person with low body fat. In addition to having higher body fat percentages, women may be able to absorb more alcohol because they tend to have lower levels of a stomach enzyme (alcohol dehydrogenase) that normally breaks down alcohol before it reaches the small intestine. Chronic alcoholics also appear to have lower levels of this enzyme.

Once absorbed alcohol causes several physiologic changes (other than intoxication). Ethel alcohol is metabolized (mostly by that poor suffering liver you too often abuse) into acetaldehyde, which may be responsible for many symptoms of hangover. Alcohol also elevates levels of chemicals called cytokines, which are known to be elevated by viral infections (or administration of alpha-interferon) and cause symptoms like nausea, headache, and diarrhea.

Every bar had a bathroom and for good reason. Alcohol blocks the effect of antidiuretic hormone (ADH) on the kidneys. ADH is normally produced by the pituitary gland and causes the kidneys to secrete less water (i.e. when the patient is dehydrated). Without the ADH effect the kidneys secrete large amounts of water that may exceed the amount of fluid consumed in the alcoholic beverages. This often leads to dehydration in the post-party period with symptoms of light-headedness, weakness, and “cotton mouth”. Most hangover therapies recommend liberal consumption of water and avoidance of caffeine that itself induces fluid loss and may worsen the condition. However, rehydration alone has not been shown to completely eliminate all hangover symptoms.

Alcohol may cause lower blood sugar levels when chronic use induces liver damage and alcohol itself may inhibit glycogen breakdown by the liver. However, the most common cause of lower blood sugar levels appears to be in alcoholics with poor nutrition or when someone is on a drinking binge during which they eat little and the liver exhausts it’s supply of glycogen which it breaks down into glucose for use by the body. However, low blood sugar levels have not been proven to be a main cause of hangover symptoms.

Alcohol causes the intestines to speed up. Gastric emptying is increased and transit time of food and fluid through the bowels is increased. In addition, alcohol impairs the absorption ability of the intestines. The end result is that diarrhea is a common component of the hangover (and of chronic alcoholism). Ironically many hangover cures include recommendations for a big breakfast with plenty of carbohydrates, grease, and fat. While this will help with nutrition, fatty meals actually increase intestinal mobility and thus will make a bad situation even worse.

The intoxicating effect of alcohol can be seen by a slowing of brainwaves on an electroencephalogram (EEG). What this causes during sleep when one is intoxicated is that less time is spent in REM (the dreaming and refreshing part of sleep) and more time is spent in what is called slow wave sleep. In addition, alcohol relaxes the throat muscles during sleep leading to greater snoring and possibly sleep apnea in susceptible individuals. The result is sleep that is not effective and leads to excessive daytime fatigue.

As many have already said, the best hangover cure appears to be prevention. I.e. avoid over indulging. Short of this, a few common sense pointers may work. Eat shortly before you drink. Try to stick to clear liquors or low alcohol drinks. Consume liberal amounts of water. Avoid caffeine and fatty foods. Try and get as much sleep as you can and remember “hair of the dog” (drinking some more alcohol the day after) is just a way to delay the unavoidable.