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As you might have noticed, this blog doesn't generate many comments. I can think of a number of possible reasons for that, including this blog's specialized nature, how busy medical professionals are, the lack of awareness of this blog and my suckitude at medical blogging.

But there's at least one other possible reason: [irony] Everybody who might otherwise gather here is blogging him/herself. [/irony] Via the Health Care Blog comes this report (*.pdf file) on the medical blogosphere, which apparently contains more than 13 million blogs. It focuses primarily on docs who blog and looks at such issues as patient privacy, blogger anonymity/psedonymity and whether medical bloggers are disclosing possible conflicts of interest.

There are all sorts of medical blogs, however, including those posted by hospital administrators, insurance folks, laypeople (patients or relatives of patients, particularly) and health journalists.

I've got a set that I look at daily for general news about the profession and its major issues, but that's perhaps a half-dozen. Looking them over takes some time, but the payoff is story ideas and invaluable background. I'm open to suggestions if you're familiar with a medical blog you think I would particularly benefit from reading.

Courtesy of colleague Sonja Elmquist, here's a chart created by The Economist showing the odds of an American dying in each of a variety of accidental ways. (So things that aren't, strictly speaking, accidents, such as heart disease and cancer, aren't on the list.)

The top one, poisoning, jumps out at me, and I'd like to know more about that. I wouldn't have thought poisoning would rank so high even if you included all manner of drug overdoses. Also, the list includes snake bites but not shark attacks, which I find a little disappointing inasmuch as during the summer cable news seems capable of talking about little else.

My analysis of the N.C. Justice Center's proposed universal health-insurance coverage plan for North Carolina is here. (The plan is here.)

I got a couple of responses yesterday after my deadline that I'm posting here.

One was from David Ward, a spokesman for U.S. Sen. Richard Burr, R-N.C.:

As health care costs continue to rise, it is important we look for solutions that can make health insurance more affordable for people and their families. I am pleased to see North Carolinians engaging in discussion and work to improve access to affordable and high quality health care in North Carolina.

When it comes to health insurance, Americans need choice, ownership, and control. By giving individuals choice and control over their plans, they will become smarter about their health care options. Our health system is the best in the world. It's time to ensure that American families have access to it.

In general, the NC Justice Center’s Health Access Coalition proposal for Guaranteed Affordable Choice of health coverage for all North Carolinians appears to be a good attempt at a solution for a very difficult problem. The major impediments to implementing such a plan would appear to be how to marshal the political will, as the proposal says, and how to guarantee that the federal government can and will provide the help that is “required in order to implement many of the proposed steps. . . “

The proposal suggests that we can have universal access without lowering choice or service quality. However, marshaling the political will means confronting, instead of skirting-around-the- edge of the trade-off decision. Do we North Carolinians want everyone to have access to affordable health insurance and/or affordable health care (and how do we define ‘affordable’), or do we want to contain the cost of health insurance and/or health care, or do we want the greatest choice of how health care is provided and by whom, or do we want health services of the highest quality? If, as the proposal argues, we want everyone to have access to affordable health insurance, then we must be prepared to accept either greater costs, or fewer health care services choices, or lower health care quality, or perhaps all three.

The proposal suggests that costs to the individual will not be increased because of system cost savings under a universal access program with emphasis on prevention, because of additional revenue from increased taxes on cigarettes, and because the federal government will make up for any differential. There is not (yet) a consensus that prevention decreases overall health services costs. Federal government help may also be an overly optimistic idea. Some recent projections suggest that the Centers for Medicare and Medicaid Services will most likely run out of funds to pay Medicare expenses sooner than anticipated. Under such a scenario, will there actually be funds for existing state programs, such as an expanded SCHIP program, let alone additional funding for universal insurance coverage?

The proposal’s ideas about increasing cigarette taxes, initiating research on health care cost increase drivers, providing more public health education, and consolidating the insurance markets are not new, but they may be areas upon which political consensus could be most easily reached. Requiring that insurance companies charge only so much or that they sell prescribed plans may mean that some companies quit the NC market, thus lowering choice. In short, it seems as though the NC Justice Center’s Health Access Coalition must be very politically savvy to enact such a proposal in North Carolina.

The Health Care Policy and Marketplace Review blog has a post up with links to detailed analyses of the proposed health plans of the two major candidates for president, along with a comparison.

Back in December, I wrote about how some (human) gynecologists, including Dr. Gerald Mulvaney of the Greensboro office of the N.C. Center for Reproductive Medicine and a colleague, Dr. Sameh Toma, from the practice's Cary office, performed surgery in November on Donna, a Western Lowland gorilla at the N.C. Zoo who had been suffering from severe vaginal bleeding.

A biopsy from the November procedure found endometrial cancer. So Drs. Mulvaney and Toma, joined by Dr. Fidel Vilea, a gynecologist and cancer specialist from Duke University Medical Center, performed a hysterectomy on Aug. 27. The zoo reports that Donna is doing fine after that surgery.

It is not uncommon for gynecologists to perform surgery on female gorillas because their reproductive systems are so similar to those of humans.

"For years, we have benefited from animal experimentation," Mulvaney said in a statement. "Now we have had the opportunity to give back."

This week's New England Journal of Medicine offers three publicly available full-text articles that raise thorny questions about the profession's relationship to government.

One addresses the considerations that must be balanced when a medical professional offers advice to a campaign or government. The advisers occupy:

... a role awash in ambiguity, opportunity, and risk. The adviser is the president's ally — in the lingo of organizational economics, an "agent" serving the interests of a "principal." Yet as a bearer of specialized knowledge, the adviser is also responsible to a larger profession, to its values and commitments, and ultimately to the ideal of expertise itself.

The adviser, in short, must both "speak truth to power" and aid in the exercise of power, both offering unbiased intelligence and acting as a very biased assistant. It is fashionable to pretend these two roles are the same, but they are not. An expert adviser has special knowledge, training, and skills — all of which are needed more than ever in the White House. The question is whether these talents can really be used, or be useful, in the bare-knuckles world of American politics — and, more important, whether the values they embody can be upheld when science, advocacy, and democracy collide.

Even higher stakes, affecting individual patients, are involved, when a physician serves in, or with, the military. Such doctors must deal with questions such as whether to help in the interrogation of prisoners (some of whom have died in U.S. custody); whether to force-feed prisoners who refuse to eat; what standards to use in certifying soldiers to be deployed, or re-deployed, for combat; and whether to use psychotropic drugs as a way to get psychologically damaged soldiers back into combat.

A third article examines in more detail the conflict between the military and the profession over the issue of physicians over interrogation. In some cases, the article says, what doctors are asked to do directly violates professional standards.

The timing of these articles, particularly the latter two, ties in with today's anniversary of the 2001 terrorist attacks as the profession and the military continue today to deal with consequences of those attacks. I welcome discussion on the issues and questions they raise.

After more than a decade and tens of billions of dollars, an electronic medical-records system for the Department of Defense called AHLTA is a huge bust.

And it didn't have to be that way. The Veterans Administration for decades has been using its own medical-records system, developed by and for health-care professionals, that's both effective and freely available.

Mother Jones magazine has the story, and it's disturbing reading for anyone interested in the quality of health care our service members receive.

UPDATE: The military publication Stars and Stripes was on this problem more than two years ago.

Do you have an ICE -- In Case of Emergency -- listing in your cell phone's address book? If so, and you wouldn't mind being quoted in a story, please e-mail or call 373-7088.

Via the Health Affairs blog, here are critiques of the health-care reform plans of major presidential candidates Barack Obama and John McCain. Health Affairs also links to an essay by an economist who sees potential areas of compromise in the plans.

Endorsement of the candidates' respective health plans, the critiques and/or the essay is neither expressed nor implied; I'm just passing these on for whatever they might be worth.

UPDATE: The articles will be freely available for only two weeks, so act now.

Holy cow. If you thirst for more information on how the respective major presidential candidates' health plans might work, thirst no more. Jaan Sidorov at the Disease Management Care Blog posts a huge roundup of links to analyses and opinion pieces. It's got to be at least a day's worth of reading, but then perhaps one day isn't too much to spend looking at the country's health care problems and the various proposals on the table for addressing them.

(Well, I say "on the table," but whether much of anything can get through Congress is a question for another day.)

I wrote in April about a Greensboro practice that offers CT scanning -- "virtual colonoscopy" -- as an alternative to traditional colonoscopy for detecting colon cancer or polyps that could become cancerous. A front-page wire story earlier this week cited a study reported in the New England Journal of Medicine that found virtual colonoscopy 90% effective in detecting large adenomas and cancers (those measuring 10mm or more in diameter). That rate is roughly comparable to that of traditional colonoscopy.

The article said Medicare is considering covering the procedure, and where Medicare goes, a lot of private insurers probably will follow. (We don't archive wire stories, but a similar story is here.)

I don't know whether the administration's proposed $700 billion bailout of Wall Street is a good idea, either straight up or with changes proposed by Democrats. But I can do a little math, and the math tells me that if we taxpayers are spending this kind of money on this initiative (which may end up costing a lot more than $700B), there's going to be roughly zero left over for any kind of major government initiative, whether it's health care, public works, economic stimulus or what-have-you.

UPDATE: There may not be any tax cuts for a while, either, and the sunsetting of the tax cuts of the early Bush 43 administration may now be a foregone conclusion, particularly if the Democrats strengthen their hold on Congress.

Back in August, I wrote about how a lot of drugs and procedures either aren't effective or address symptoms without treating the underlying cause. Such waste constitutes roughly a third of the more than $2.1 trillion we spend annually on health care, and it's almost ten times the highest estimate of what we could save with a national conversion to electronic health records.

The waste isn't just money, either. It's lives. The Institute of Medicine estimates that the number of annual U.S. deaths from preventable medical errors alone is between 44,000 and 98,000.

The biggest reason why the waste is so enormous is, of course, how common such wasteful drugs and procedures are. And how common is that? Via The Health Care Blog comes an article in Miller-McCune magazine that says your odds of getting the best evidence-based health care are roughly 55 percent -- barely better than a coin toss.

The figure differs according to the medical problem, the article says: Breast-cancer patients are likely to get the best evidence-based care about 76 percent of the time, but hip-fracture patients get it only about 23 percent of the time.

More disturbingly, patients receive a type of care they actually shouldn't receive about 20 percent of the time for chronic conditions (diabetes, say) and 30 percent of the time for acute ones (such as heart attack or stroke), a trend likely contributing to the numbers noted by the Institute of Medicine. And socioeconomic factors don't appear to make any difference, so even the wealthy at the best medical centers aren't immune, so to speak.

The article examines how doctors practice medicine as the basis for why the best evidence-based practices aren't followed. And it puts some blame on patients, who may insist on a type of care they don't actually need -- an insistence to which some doctors succumb rather than risk a malpractice suit.

Changing this approach will be an enormous project, but the payoff in lives and dollars makes such change essential.

Although this may be a purely academic exercise in light of recent events, the New England Journal of Medicine's Web site is chockablock this week with publicly available information related to the two major candidates' health plans.

At a forum Sept. 12, co-sponsored by the Harvard School of Public Health and the New England Journal of Medicine, health advisers to the two major presidential candidates offered their views. Links to video and the transcript are here.

Also available online:

• An examination of the role of campaign contributions and lobbying in U.S. health care.


• Statements from John McCain and Barack Obama on their respective health plans.


• Critical outside examinations of both McCain's and Obama's plans.

There's a lot to chew over, and given recent economic events the temptation is to give up on any sort of health-care reform at all for now. But I suspect whoever wins isn't going to give up, so we might as well get some idea of what the winner will be trying to do starting in January.