Archive | February 2011

No Good Link Between Cell Phones and Brain Cancer

Recent reports have surfaced noting that cell phones appear to cause increased brain activity due to the non-ionizing radiation that they emit.  This has rekindled the debate of whether or not cell phones are a causative factor for primary brain cancer.  The official word on this can be found here, and suffice it to say that so far there has been no definitive proof.

I wanted to take a 30,000 foot view of the problem, by comparing primary brain cancer rates with cell phone usage in the United States.  Note that “primary” means a central nervous system tumor that is not a metastasis from another site.

Below is a composite graph I created demonstrating the relationship. (Click for larger version)

It is a little confusing but I will explain.  The blue line indicates the takeoff of cell phone subscribers in the U.S. over time.  The scale for this line is on the left of the diagram.  It reaches upwards of 200 million by 2007.  The red sawtooth line is the incidence of primary brain cancers in the U.S. for the period 1975-2007.   The scale for this line is on the right, and it shows that the incidence has varied between 5.8 and 7.  This is the number of new cases of brain/central nervous system cancers per 100,000 people, and is age-adjusted.

Naturally, this question requires more detailed epidemiological analysis, but the early indication is that there is no obvious increase in brain cancer during the period that cell phone use became widespread.  Rates could increase in the future if there is tissue damage that occurs over time, but to date that does not seem to be the case.

Like most other expert opinions in medicine, links such as “cell phone use and brain cancer” have to be taken with a grain of salt.  The link between lung cancer and smoking was an epidemiologic triumph, but since that time, many other links have been discredited.  Consider these:

Pancreatic cancer and coffee (No)
Hot dogs and childhood leukemia (No)
Vaccines and autism (No)
“Western diet” and cardiovascular disease (No)
Silicone breast implants and autoimmune disease (No)

For more, check out the book:   The Rise and Fall of Modern Medicine.

But before real science discredits the link, public impressions can be formed and can be very difficult to reverse through education.  Often, representing the question with a simple graph can be easier to understand.

National Cancer Institute (SEER)
Cell phone subscriber data

Subscriber data for 2007 was not available, so was estimated based on 2006/2008 data.
Cancer incidence from 2008-2010 not available, but data from the American Cancer Society estimate new cases of CNS malignancies at 22,000 for each of these three years, remaining stable when cell phone use has only increased.


Direct Primary Care: Affordable Concierge Medicine

The Hartford Courant showcased two primary-care physicians on page one.  Drs. Jane Walker and Kathleen Mueller offer two concierge pricing options at their Windsor office (Holistic Health Partnering, LLC.)  Patients can elect to a $55 fee for each visit, or a $30 monthly fee plus $15 per visit.  Most think of concierge medicine as requiring annual retainer fees in the $1000+ range, but this plan offers similar access at a lower price point.  (Holistic Health does participate with Medicare, but not with other insurance plans.)

Patients get enhanced physician access, and may get a level of care and attention beyond that of a typical primary-care practice.  Physicians  relieve themselves of much of the costly support operations of billing and administration, chasing accounts receivable, and the like.

Assuming a non-concierge practice administrative cost of 33%, the $55 visit charge corresponds to a $73.15 insurance payment.  A non-cash benefit to the doctor is easier documentation for the concierge visit.  The note can be “whatever the doctor thinks it needs to be”, rather than fulfilling bullet-point billing criteria corresponding to various levels of office visit under the insurance plan.  I am disregarding the minor-but-not-zero monetary advantage to the doctor of getting cash up front (concierge)  rather than cash later (insurance).

Which plan should a patient choose?  The answer depends on how many visits one anticipates in a given year.  Annual costs are the same under both plans at 9 visits per year ($495).  Above that number, the retainer plan offers better value.

Concierge medicine continues to evolve, and represents a method for primary-care physicians to find a business model that works for them as well as for patients.  This plan shows that concierge medicine can be an affordable method of obtaining primary-care access.

Disclaimer:  Although I am not personally familiar with the above physicians, I am a graduate of the same medical school.

Dale Earnhardt 10 Years Later

NASCAR champion Dale Earnhardt, taken by offic...

Dale Earnhardt

Ten Daytona 500s ago, we lost Dale Earnhardt.  It was February 18, 2001, and I was on-call as a 4th year surgery resident.  No, Dale did not present to our trauma room that day, since we were over 1100 miles away.  But the accident taught me an important lesson regarding trauma:  looks can be deceiving.

The accident was replayed continuously, and those of us watching in the resident lounge were not very impressed.  It didn’t look like a devastating accident.  Sure, the car hit the wall and slid, but it didn’t seem the same as a full head-on impact.  I was shocked to later learn that The Intimidator was gone.  In retrospect, and in light of the findings that he had suffered a massive and unsurvivable basilar skull fracture, it seems obvious.  When the car hit at around 160 mph, the impact subjected him to giant rotational forces.   On repeated views of the crash, one can picture what happened inside the car upon impact.

In trauma, its amazing how small changes in the mechanism of injury can make a huge difference in severity of the injury.  People sometimes crash cars, fall from great heights, and encounter all sorts of mayhem, walking away with a few scratches, as is apparent from watching any “amazing videos” television program.  But sometimes, seemingly small traumas can have terrible results.  Slipping on ice, falling off stepladders, initially innocuous head injuries, and the like can all prove dangerous or deadly.  Dale Earnhardt and the 2001 Daytona 500 underscored an important lesson in trauma:  looks can be deceiving.

The Digital Mammography Debate and Medical Inflation

National Naval Medical Center, Bethesda, Md. (...

Newsweek reported on the emergence of digital mammography in a recent article.  Scathingly titled “The Mammogram Hustle”, it discussed how new digital mammogram (DM) technology challenged film mammograms despite a lack of evidence that it is better at detecting cancers.  The authors describe how digital mammogram manufacturers lobbied Congress to increase the reimbursements for DM in order to entice purchase of the new and more expensive system.  It states that in 2003-08, Medicare paid an additional $350M for DM, with no evidence that this improved cancer detection or lives saved over existing film technology.

The article illustrates two important contributors to increased health spending:

Using anecdotal evidence instead of real science
When Congressman Clay Shaw was shown a digital image compared to film, he was impressed enough to introduce a bill that increased Medicare payment for DM.  A radiologist pitched the digital machine at its launch.  Some patients demanded the digital imaging to make sure they were getting the latest technology.

Wide introduction of new technology before proof of better outcomes
It took several years after the payment change for widespread implementation to take place.  After 2005, DM became more widely implemented in response to an article showing benefit of DM in certain populations of women.

New technology is critical as medicine strives for progress and improvement, and systems that encourage more women to get mammography screening are positive.  It is impractical for most facilities to have both types of imaging systems.  There are many good reasons to change to digital imaging, and there may have been ways to encourage facilities to implement DM without committing Medicare to overpay for the same net benefit.

Top 5 Winter Health Hazards

Single-stage Simplicity snow thrower in use on...

With 2 months or so left to go before escaping into spring, its worthwhile to run down a list of five winter weather health hazards.

1.       Frostbite:  When you are exposed to cold for too long, certain parts of the body begin to hurt.  Then, they stop hurting.  Once the hurt stops, things go from bad to worse.  Frostbite is treated similar to burn injuries, and can be just as significant.  Mild cases may leave only a blister.  Serious ones result in loss of appendages.

2.      Icy roads/walkways:  Sloppy conditions lead to cars sliding all over the place, causing anything from fender-benders to major crashes.  Slipping on iced-over steps and walkways can cause injuries ranging from minor to fatal.

3.      Snowblower injuries:  Although probably not part of high-school physics classes, schools in winter areas should review the potential energy remaining in a snowblower when it gets jammed with snow/ice.  Though the machine seems calm, once the clog is loosened that blade moves, fast.  Every hand surgeon covering ER call in a winter area has probably operated on the result, some several times in a season.  Unless you are Superman, you can’t possibly move your hand fast enough.  (And anyhow, Superman would have done the driveway using his heat vision)

4.      Falling off roofs:  The weight of rooftop snow can be a serious problem.  It is not as serious as what happens when one slides off the roof or the ladder collapses.  If you are worried about the roof coming in, do your local trauma room a favor and call a professional to clear it off.

5.      Shoveling snow:  Wet, heavy snow (the common Northeast variety) is about 20.8 lbs per cubic foot.  So for a 50’x20’ driveway, six inches deep with snow, you (and your back) are lugging over five tons of material if done by hand.  Everything from strained muscles to heart attacks can result.

Did I forget any?  If so drop a line.  And if you are tired of winter weather, click here for a more permanent solution.