Faculty Bibliography

According to Fred Feit, director of interventional cardiology at New York University Medical School, the goal these days is to 'come with the treatment that is least invasive.' Feit said that over a recent two-day period, he catheterized 17 patients, snaking a tiny tube from the groin up into the coronary arteries. He sent only one for bypass; the rest received stents. Stents are tiny mesh cylinders are made of metal and coated these days with a drug that retards clogging. They are floated into the artery with a catheter and then snapped into place. With the latest technology, each stent appears to have less than a 10 percent chance of closing up over the first six months. Feit says stent placement is safer, with an in-hospital mortality rate of only 0.7 percent, compared with 1.4 to 2.1 percent for bypass surgery. In addition, bypass surgery poses other risks: heart attack immediately after surgery (3 percent), wound infection (3 percent), bleeding (3 to 5 percent) and heart arrhythmias (30 percent). After recommending surgery, [Craig R. Smith] had a second major decision to make: whether to operate on a beating heart. That was his initial preference because of the lower risk of complications. But after Smith opened [Bill Clinton]'s chest, he reversed his decision after discovering that one of the arteries he had to bypass was buried within a thickened heart muscle. Stopping the heart allowed him better access. Cooling and potassium-containing solution stops the heart, and the patient is kept alive by filtering the blood through a heart lung machine until the heart is restarted with a shock

At a recent AMA meeting in Chicago, some doctors said they were going to refuse to care for malpractice attorneys. But physicians' anger is not an effective tool for change. Besides, insurance companies, not lawyers, determine the prohibitive malpractice- insurance rates while ensuring their own profitability. No panacea exists for the malpractice dilemma, but a system of peer review in the courts and in hospitals would be a good start. Panels of experts in both venues could serve as a safeguard against frivolous lawsuits while ensuring that patients who have suffered true malpractice have their day in court. Current Michigan law shows how a panel can be a gatekeeper for malpractice actions. The law requires a review of all potential lawsuits before a mediation panel, which has two weeks to determine whether care has deviated from normal, accepted standards of practice. A patient may reject the panel's opinion, but then must pay the doctor's costs if the final verdict goes for the defendant. This disincentive helps to weed out frivolous suits

If Plan B ever does go over the counter, doctors will lose the ability to keep track of side effects such as nausea, vomiting, headache and bleeding. Perhaps more importantly, patients might be steered into leaving their doctors out of important medical decisions. When a patient asks me to prescribe a routine birth- control pill (which may contain lower doses of the same progesterone, levonorgestrel, that Plan B contains), she often uses it as an opportunity to discuss not only her fear of pregnancy but also sexually transmitted diseases or other issues. The FDA's track record is mixed. Last December, it bravely banned ephedra because of an acknowledged inability to regulate the dosage or effects of the potent over-the-counter herb. But cold medications, Tylenol and aspirin have shown the potential to damage livers and kidneys after they were already over the counter and beyond the FDA's ability to regulate them. Where should the FDA draw the line? Consider that Plan B is a hormone at least three times as powerful as the progestin found in many prescription-only birth-control pills. Why prescription-only? Because birth-control pills have the potential to cause blood clots and strokes along with other serious complications that increase if the medicine isn't used properly

Siegel comments on the new prescription drug coverage. The new plan creates a system whereby patients will have to pay top price for drugs they must buy themselves before the coverage kicks again. The new Medicare bill will bring the drug companies easy access to a group that can't afford to underwrite their fancy corporate schemes

Instead of worrying about the flu, government has been busy spending millions stockpiling more than a million doses of anthrax vaccine (with no use for it in the foreseeable future) and more than 200,000 doses of smallpox vaccine (without a single case occurring here since 1949). These actions were taken so that the Department of Homeland Security can look like it takes the threat of biological agents seriously. Fearing an anthrax attack since 2001, Congress has contracted for millions of dollars in vaccine production. Since the vaccine is perishable, and there is no anthrax, most of what is produced is thrown away. Similarly, panicked over smallpox in 2002 and 2003, the government bought 291,400 doses of the antiquated live virus vaccine, which was found to have significant side effects. Ultimately, only 38,549 people were vaccinated and more than 250,000 doses were discarded. Influenza kills about 40,000 people in the United States every year and hospitalizes more than 200,000

Siegel comments on the shortage of flu vaccines after the Centers for Disease Control announced that 50 million influenza vaccines from the British manufacturer Chiron won't be available in the US this year because of possible contamination. Among other things, he cites that the main reason of the shortage is that drug manufacturers are not eager to produce vaccines. Without a patent to insure high prices, the profit margins for 'generic' vaccines is narrow

ONE OF MY CALMEST PATIENTS RETURNED FROM HONG KONG LAST WEEK, AND OF COURSE HE WAS WORRYING THAT HIS MILD COUGH WAS FROM SEVERE ACUTE RESPIRATORY SYNDROME, OR SARS. HE NERVOUSLY STUTTERED OUT THE WORD SARS, BUT AFTER I EXAMINED HIM HE ACCEPTED MY REASSURANCE AND RETURNED TO HIS QUIET WAYS. HE EITHER HAD A COMMON COLD OR WAS JUST WORN DOWN FROM TRAVEL, AND TWO DAYS LATER HE WAS FINE. For SARS, fear is the central pathogen, where the risks of acquiring the new mutated cold virus are far secondary to the fear of being infected. Uncertainty about what the risk really is promotes the panic - seeing SARS in the news causes us to personalize it, especially at a time when everyone is already feeling vulnerable from the war. Of course, we do need to track SARS before the bug starts to spread like the hysteria it is causing. SARS is a serious health matter but may galvanize fear because of the sudden attention. Publicizing preventative measures beyond the proper context may make SARS seem worse than it is

'Harry' is one of my elderly patients who could have been helped by a comprehensive, Medicare prescription drug plan. But when he hears about the bill signed by President Bush last week -- with deductibles, co-payments and a large cash contribution coming out of his pocket -- he simply shakes his head and moves to my drug sample closet. Once the full benefit of the new plan takes effect in 2006, Harry will have to pay a $420 annual premium. After he pays a $250 deductible, Medicare would cover 75% of his annual drug costs up to $2,250 and 95% of expenses above $5,100, but nothing for drug costs between $2,250 and $5,100. Harry will continue to be charged top prices at the pharmacy, and the government, forbidden to negotiate or leverage for lower prices by buying in bulk, will also pay top dollar for what little coverage they do provide. In the meantime, I remain Robin Hood with my drug samples, brought by sexy salespeople who interrupt me in the hallway on my way to caring for Harry and others

I wasn't so sure. The sinus expert to whom I sent Mr. N reported no evidence of a sinus infection and didn't believe the patient needed antibiotics. The infectious disease expert with whom I shared my office concurred. The neurologist who treated Mr. N for his headache thought he had a life-threatening inflammation known as temporal arteritis, and she started him on steroids to keep him from going blind or having a stroke. The arterial biopsy for temporal arteritis was equivocal, but the neurologist said this was often the case and continued treatment. I left a message for Mr. N's family doctor in Florida, but he didn't return my call. When I telephoned Mr. N, he sounded edgy and told me his family doctor didn't believe he needed to see all those so-called experts in New York. This doctor also apparently thought that there were many intangibles to this patient's case that only he could know because of the long history together. I acknowledged the value of this; I merely saw the imperative to communicate the new findings. Afterward, he decided that he no longer was happy with his local doctor. I was able to recommend another doctor with an office nearby. This doctor had similar training to that of my own and Mr. N's old doctor and was known to be a good communicator

In my son's kindergarten class, a boy, whom I'll call Ira, was labeled as a behavior problem. The other parents were worried: Was this child's silly and impulsive behavior something that would rub off on their children? Would all the children in the class misbehave and try to be like this unfortunate child? As a doctor I wondered if the child had been given a diagnosis such as attention-deficit hyperactivity disorder or if he was simply troubled and undisciplined. Even though I thought Ira to be a sweet child, I found myself automatically joining the bandwagon of parents who protested to the school that this child should not be allowed to be in the same class as our kids. We lost that battle, and I was dismayed when my son listed Ira in the group of his favorite friends. From that day on, I asked my son if there was word about Ira. We suffered through it together, until the day when Ira and his special teacher returned to the class. My son said everyone was happy, including the children of the forbidding parents. None of the kids thought they could catch what Ira had