Facts and ideas from anywhere

William C. Roberts, MD

FAT ATTRACTS FAT

To stay thin, it appears that one has to stay around thin people. The obese not only do themselves harm but can also harm their friends, especially close friends, by making it easier for them to overeat. That is what Christakis' and Fowler's data from the Framingham Heart Study show (1). They tracked 12,067 people over a 32-year period (1971 and 2003). The study found that those who have many friends who are fat are more likely to pick up bad eating habits. In such company, putting on an extra 30 or 40 pounds does not result in any social censure (2, 3).

TEN FOODS TO AVOID

A recent issue of Nutrition Action Healthletter, published by Michael F. Jacobson, PhD, listed 10 foods we should never eat (Table) (4).

Table.

Ten foods to avoid^∗

Food	Calories (number)	Saturated fat (g)	Trans fat (g)	Sodium (mg)
Pepperidge Farm Original Flaky Crust Roasted Chicken Pot Pie	1020	18	13	870
McDonald's Chicken Selects Premium Breast Strips (5 piece)	630	11	4.5	1550
The Cheesecake Factory's 6 Carb Cheesecake	610	29	—	410
Dove Ice Cream (chocolate)	300	10	—	80
Mrs. Fields Milk Chocolate and Walnuts Cookie	320	9	—	180
Starbucks Venti (20 oz) Caffe Mocha (with whole milk/whip cream)	490	16	—	220
Burger King Quad Stacker	1000	30	3	1800
Campbell's Chunky, Select, and red-and-white-label condensed soup	—	—	—	2000
Chipotle Chicken Burrito	1189	18	—	3216
Mint Chip Dazzler at Häagen-Dazs	1270	28	—	—

∗From reference 2; some nutrition information also obtained from other sources.

HOT DOG EATING CONTEST

On July 1, 2001, Takeru Kobayashi, a 23-year-old man from Nagano, Japan, won his first Nathan's Famous Hot Dog Eating Contest (5), viewed by 3000 spectators. In the 2001 contest, the 131-pound Kobayashi consumed 50 hot dogs in 12 minutes, or one every 14.4 seconds, to beat the previous record of 25. He won the contest in each of the 5 subsequent years, until 2007 when he came in second to Joey Chestnut. In 2006, the contest attracted 30,000 and was watched by 1.5 million viewers on ESPN. The winner of the contest gets the Mustard Yellow Belt. The average American adult eats 65 hot dogs each year. That's still too many for a lifetime!

SCHOOL ABSENTEEISM AND BODY WEIGHT

Foster and associates examined the attendance records of >1000 fourth- to sixth-graders in nine inner-city schools in Philadelphia and found that obese and overweight children missed about 12 days of school a year compared with 10 days for normal-weight children (6). Thus, another adverse consequence of obesity in kids.

SMOKING AND TAXES

Congress is presently weighing the biggest federal cigarette tax hike in history. A recent USA Today analysis found that higher state taxes on cigarettes decreased cigarette consumption (7). Indeed, the amount of decline in smoking was inversely tied to the size of the tax increase. Cigarette sales decreased 18% in North Carolina in 2006 after the tax was raised from 5¢ to 35¢; in Connecticut, they decreased 37% when the tax was increased from 50¢ to $1.51 a pack; in New Jersey, smoking dropped 35% when the tax was increased from 80¢ to $2.40. In contrast, South Carolina has kept its state tax per pack at 7¢ since 1977, and cigarette consumption there has fallen only 5%. As Congress considers raising the federal cigarette tax from its present 39¢ to $1.00 per pack, the USA may be about to experience one of the biggest one-time declines in smoking. The number of cigarettes smoked in 2006 in the USA was 1293 per capita, a considerable fall from the peak of 2095 per capita in 1976. This is one national tax I favor.

MARIJUANA

According to a 2005 report on the budgetary implications of marijuana prohibition by Dr. Jeffrey Miron, regulating marijuana would save about $7.7 billion annually in government prohibition enforcement, $2.4 billion at the federal level and $5.3 billion at the state and local level (8). Although some may balk at the idea of legalizing pot, some remedy clearly is in order. Each year >700,000 people are arrested for marijuana offenses, at a cost of >$7 billion. If marijuana were legalized, regulated, and taxed at the rates applied to alcohol and tobacco, revenues would reach about $6.2 billion annually, according to an open letter signed by 500 economists who urged President Bush and other public officials to debate the marijuana prohibition. Among those economists were three Nobel Prize winners, including the late Milton Friedman. Miron argues that legalization would reduce crime by neutralizing dealers and eliminating the black market. Legalizing marijuana isn't an endorsement of underage or irresponsible use.

Efforts in the past few decades to relax marijuana laws have been moderately successful. Twelve states have decriminalized marijuana, which usually means no prison or criminal record for first-time possession of small amounts for personal consumption. Federal law enforcement agents still raid the homes of terminally ill patients who use marijuana for relief from suffering in states where medical marijuana use is not permitted. Beyond the medical issue is the practical question of criminalizing otherwise good citizens for consuming a nontoxic substance, one less harmful to health than alcohol or tobacco!

COCAINE

According to the 2007 United Nations World Drug Report, nearly half of all cocaine produced in the world is consumed in North America (9). Texas ranks among the highest-usage areas, along with New York, Florida, and New England. Although adolescent cocaine use in America is declining, casual use among young adults remains steady. In Europe, it is rising.

In countries producing cocaine and heroin, conflict rages: in Columbia, guerillas and military thugs fight for control of countrysides where base ingredients of cocaine and heroin are grown; they tear up families, kill adults, and turn children into warriors for the drug money. The Taliban in Afghanistan—the same group that hosted al-Qaeda—uses opium profits to fund its insurgency. In Mexico, rival cartels turn cities into war zones. Drug-related violence is at a record high. In Oak Cliff and East Dallas, the local enforcers and street directors for major drug cartels are the tattooed gang members.

The USA has 5% of the world's population and consumes 50% of the world's cocaine and heroin. The overdosed and infected users of these agents come to our emergency rooms and expect the best care in the world. The best care, of course, is cutting off the supply of these agents.

BREAST ENHANCEMENT AND SUICIDE

Lipworth and colleagues from three different medical centers analyzed data from 3527 Swedish women who got breast implants for non–breast cancer reasons between 1965 and 1993 (10). The women were followed up to 29 years after their breast implant operations. The authors found that the risk of suicide increased after time. There was no increased risk during the first 10 years after operation, but from 10 to 19 years after operation the suicide risk was 4.5 times higher and after 20 years, 6 times higher. The authors indicated that the study underscored the need for psychological screening of women seeking cosmetic breast enhancement.

ROAD FATALITIES

In 2006, 42,642 people died in traffic accidents, a drop of 868 deaths from 2005 (11). That 2% decline contributed to the historic low fatality rate of 1.42 per 100 million vehicle-miles traveled, according to the transportation secretary. Fatalities among occupants of passenger vehicles fell to 30,521, the lowest annual total since 1993. Injuries also were down, with passenger car injuries falling 6% and large-truck injuries, 15%.

Motorcycle deaths rose for the ninth straight year, by 5.1% to 4810. This was the first year that the number of motorcycle-related fatalities was higher than the number of pedestrian fatalities. I've always wanted a motorcycle, but the appeal of survival has always won.

Alcohol-related fatalities increased slightly in 2006. There were 15,121 fatalities involving a driver or motorcycle operator, pedestrian, or cyclist with a blood alcohol concentration of ≥0.08. That's a lot of families shattered by something that is preventable.

VEHICLE RATINGS AND DRIVING SAFETY

Tara Parker-Pope, writing in The Wall Street Journal, summarized a study by the Insurance Institute for Highway Safety (IIHS), which showed that safety improvements in passenger vehicles, not safer drivers, are the main reason motor vehicle death rates have been decreasing for the past decade (12). The study found that drivers are actually getting more careless about seatbelts, speeding, and driving while intoxicated and that if vehicle designs had not improved in the last 20 years, traffic death rates would be on the rise. There is a big difference in safety among cars. A good place to check cars’ safety ratings is www.iihs.org under “vehicle ratings.” The IIHS is supported by auto insurers and is viewed as one of the most credible resources for research on car safety. Another option is www.safercar.gov, the National Highway Traffic Safety Administration New Car Assessment Program. It gives five-star crash and rollover ratings. When shopping for a car, it's a good idea to look at both sites. The downside of both sites is that not every car has been tested.

WAR COSTS

Georgie Anne Geyer in a column (13) quoted William R. Polk on the cost of the war in Iraq: “Current costs are running at more than $7.1 billion a month—$10 million an hour—and are rising more than 20% a year. The direct costs of the war are expected to rise shortly to at least $700 billion.” If these costs were figured by standard accounting methods, it would be between $1 trillion and $2 trillion. And where is the money coming from? In 2001, foreign capital inflows into the USA totaled $780 billion; by 2005, nearly $1.5 trillion. In 2005, foreigners financed over half of the government's deficit. We are progressively putting ourselves at the mercy of those who do not like us.

US EMPLOYEES IN IRAQ

The recent troop surge increased the number of American soldiers in Iraq to 160,000, but the USA has about 180,000 civilians on its payroll working in Iraq under US contracts (14). These civilians include at least 21,000 Americans, 43,000 foreign contractors, and about 118,000 Iraqis—all paid by US tax dollars! The private contractors perform construction work, private security, and weapon system maintenance. Thus, the USA pays approximately 340,000 persons working in Iraq. No wonder the costs are so astronomical.

TERRORIST DOCTORS

They were all employees of the United Kingdom's National Health Service (15, 16). At least six were physicians, one a medical student, and one a medical assistant. They were originally from Iraq or Jordan or other Middle Eastern countries or from India. Two were successful in driving their bomb-laden jeep at full speed into the main airport terminal in Glasgow, Scotland, and when emerging from their burning crashed car screamed, “Allah! Allah!” The other car-bombing plot in London was unsuccessful. Similar suicide occurrences, of course, have taken place in Jordan, Morocco, Yemen, Spain, Britain, and the USA (New York City). As a consequence, hundreds of Muslims have committed suicide among innocent civilians.

As Thomas Friedman explains (17), “Islam's self-identity is that it is the most perfect and complete expression of God's monotheistic message and the Quran is God's last and most perfect word.” A frustration, however, for these Muslim men driving them into these acts of extreme violence is that many (non-Islamic) people in other parts of the world are generally living much more prosperously, powerfully, and democratically than those living under Islam.

Surely the young doctors did not learn this violent behavior in medical school.

MOSCOW, 1941–1945

According to Braithwaite (18), in World War II, for every one American lost, the Russians lost 85, the Germans 20, and the Japanese 5. The Russians lost 27 ± 5 million people in World War II! We have lost nearly 4000 in Iraq.

FOOTBALL TRAUMA AND THE 1977 SUPER BOWL CHAMPION DALLAS COWBOYS

Barry Horn described how some members of the 1977 Super Bowl XII Champion Dallas Cowboys are faring today (19). Now in their 50s and 60s, they are a beat-up crew.

Mel Renfro, a pro-football Hall of Famer with 14 stellar seasons as a Cowboy defensive back, now has memory problems, periodic depression, and an artificial left hip, and he needs a knee replacement. Arthritis afflicts his shoulders and ankles, and his damaged vertebrae prevent neck movement. Sunlight triggers headaches.

Charlie Waters, a defensive back, can no longer play a round of golf. He has permanent nerve damage in his left arm, with little feeling in three fingers in his left hand. His right knee has been replaced. He has had 17 operations for football-related injuries. During one season he played with a broken arm.

Hall of Fame running back Tony Dorsett was a rookie running back sensation in 1977. His knee injuries no longer allow him to jog. He has had three knee operations and is facing a fourth. He has nerve damage in both arms. Too many defenders’ helmets banged into them. Two many defenders tried to tackle him by pulling his arms out of their sockets. Surgery repaired his left arm, which he lost use of in the late 1990s. Recently, similar symptoms have appeared in his right arm. And lately, his left arm has been tingling again. Mr. Dorsett says, “I go to the Hall of Fame ceremonies every year and see the old-time greats limping and barely able to walk. … I see the guys in the early stages of Alzheimer's, and I think someday that's going to be me.”

John Fitzgerald, the center, had six operations to repair knee, shoulder, and elbow damage that he accumulated in 10 seasons as a Cowboys offensive lineman. He is certain he also suffered a series of concussions but, like most of his former teammates, he is unsure how many. He is not sure that the periodic depression he experiences is related to football. During games his dislocated shoulders and elbows were popped back into place so he could get back into the game as soon as possible.

Thomas Henderson, a starting linebacker in Super Bowl XII, ended his career with a broken neck <4 seasons later.

Randy White, a Hall of Fame 14-season defensive tackle, says, “My joints. My wrists. My back. My neck. When I hurt my neck, I was pretty much done. There was serious risk of permanent damage. People that never played the game don't realize they are watching collisions out there on every play. That's fine-tuned athletes going 110% at each other. … Nobody's body is meant for that.” In his third pro season as defensive right tackle in 1977, Randy White played half a season with a broken right foot. He didn't practice and was instructed to stay off his foot during the week. On Sundays, “they would shoot it up and insert a metal plate into my shoe to make sure the foot didn't bend … then they would give me more painkillers at half-time. … Nobody would play with that injury today. Most guys would be in a cast.”

Starting offensive tackle Ralph Neely and defensive tackle Jethro Pugh were in their 13th season in 1977. Mr. Neeley's right knee couldn't be straightened out during his last two seasons.

He finally had the long-needed surgery a month after the Super Bowl victory in 1977. He indicated, “We were the generation that played with injuries we shouldn't have played with. … We played because we wanted to keep our jobs.” They all feared for their jobs. They would stay on the field at any cost. Mr. Neeley stated, “Coach Landry … was a great man … but making you feel secure was not one of his fortes.”

Tom Rafferty, who was the youngest starter on the 1977 Super Bowl team, considers himself “lucky” for delaying surgery and having sustained “only” head trauma in his 14 seasons on the offensive line. “I'd say I was knocked out during games half a dozen times. … That means games where I regained consciousness, and I had no idea where I was. Once, I got knocked out, and when they asked me if I knew where I was I said, ‘Houston.’ I was back on the field for the next series.” Mr. Rafferty did not undergo his first surgery until just before his final season in 1983. Both shoulders had to be repaired.

Hall of Famer Roger Staubach had a dozen concussions during his 11 seasons. He had surgery on both shoulders and one knee after he retired 2 years after the 1977 Super Bowl XII season.

Well, that's National Football League football. Is it worth it? I prefer tennis, golf, basketball, and baseball.

UNIDENTIFIED HUMAN REMAINS

According to a piece by Richard Willing in USA Today, American medical examiners and coroners held at least 14,000 unidentified human remains as of 2004 (20). According to the Federal Bureau of Justice statistics, the backlog of unidentified remains—murder and accident victims and missing or homeless people who die of natural causes—grows by about 1000 each year. The Federal Bureau of Investigation's National Crime Information Center, the only other national registry of unidentified remains, has collected information on about 6200 John Doe or Jane Doe cases, but reporting to this center is purely voluntary.

There are roughly 2000 coroners and medical examiners in the USA, and they determine the cause and manner of suspicious or violent deaths or deaths without a physician in attendance. Medical examiners, often physicians, are usually appointed, while coroners, often lay persons, are elected. Medical examiner offices in New York, California, Ohio, and Texas held more than half of all unidentified remains. Some coroners and medical examiners dispose of remains rather than store them indefinitely. About 600 John and Jane Does were cremated in 2004. In about half of the cases, DNA or fingerprints were gathered before disposing of the remains. It takes a lot of refrigerators to keep 14,000 “human remains” “alive.”

TENUOUS BALANCE BETWEEN COSTS OF PRESCRIPTION DRUGS AND PHARMACEUTICAL INNOVATIONS∗

When President Kennedy was killed in 1963, the mortality rate for a heart attack in the USA was 28%. Today it is 8%.

In 1963, we didn't have most of the new medicines and technology that helped reduce mortality from heart attacks. There were no beta-blockers, no calcium channel blockers, no angiotensin-converting enzyme inhibitors, no alpha-blockers, no cholesterol-lowering drugs, no glycoprotein IIb/IIIa inhibitors; aspirin was not recognized as a cardioprotective drug; niacin was not recognized as a cholesterol-altering drug; super aspirin (clopidogrel) was not available; there were no coronary care units; coronary angiography was being done in only three hospitals in the USA; coronary angioplasty with or without stents did not exist; coronary bypass had not yet been done; and the defibrillator had not yet been invented. In other words, it is much better to have a heart attack in 2007 than in 1963.

These impressive innovations were expensive. Today, it costs nearly $1 billion to bring a new drug to market. By the time the average new drug arrives on the market, only about 10 years are left on the patent before the company that paid for all the research faces generic competition. That may be a relatively short time to recoup research and development investments and to make the profit that will feed the discovery of newer drugs.

The US House of Representatives recently passed a bill requiring Medicare to negotiate prescription drug prices directly with pharmaceutical companies, and a similar measure will be considered by the US Senate. In theory that sounds reasonable because it would allow the government to use its buying power to squeeze lower prices out of drug companies. In practice, however, direct negotiations with the government actually mean price controls, which produce unwanted side effects when applied to the research-dependent pharmaceutical industry. Cheaper prescription drugs may provide a short-term benefit for Medicare consumers but will almost certainly result in a long-term loss for our children and grandchildren as fewer prescription drugs are discovered and utilized.

Many consumers and governmental officials do not appreciate the cost and complexity associated with the development of new medicines. Nor do they understand our need for a productive pharmaceutical pipeline. New drugs require high-risk investment in research that often results in failure. For every new drug discovered and approved, thousands fail, even after huge investments in research.

Every 20 seconds, a person in the USA has a heart attack. Thanks to advances in pharmaceuticals and technologic innovations that prevent and treat arterial blockages, fewer people now die. The prescription drug industry that has contributed to this progress needs some protection. The cost of pharmaceuticals is now about 10% of total health care costs. The price of hospitalization is by far the largest health care expense, and good drugs help keep people out of hospitals.

THE MERCK MANUAL, 18TH EDITION: STILL THE BEST

The first edition of the Merck Manual came out in 1899, and 17 have followed subsequently, usually a new one every 5 to 7 years. This 18th edition (21) is nearly 3000 pages and, in my view, is the best general medical text available for the price ($65). The book includes the typical topics in internal medicine organized by organ systems, but it includes far more than just internal medicine. It includes pediatrics, psychiatry, obstetrics and gynecology, dermatology, critical care medicine, and emergency medicine, including injuries and poisons. The general editor in chief is Mark H. Beers, and he is assisted by numerous others, including approximately 300 contributors. The only downside I find to this book is that the authors for each particular section are not listed. The paper is very thin, but the print is easy to read. The tables and figures for the most part are excellent. Despite its length, the book can rest in one's lap without any discomfort, in contrast to the general medicine and general surgery and specialty books published elsewhere. As far as I am concerned, this book should be in the hands of every practitioner of medicine who can speak or understand the English language.

NEW GUIDELINES REGARDING PROPHYLACTIC ANTIBIOTIC THERAPY BEFORE DENTAL PROCEDURES IN PATIENTS WITH CARDIAC CONDITIONS

The American Heart Association's latest guidelines also were approved by the American Dental Association, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society (22). According to the new guidelines, patients with the following conditions no longer need to take prophylactic antibiotics before, during, or immediately after dental procedures: mitral valve prolapse, rheumatic heart disease, bicuspid aortic valve, aortic stenosis, and congenital heart conditions such as ventricular septal defect, atrial septal defect, and hypertrophic cardiomyopathy. Preventive antibiotics prior to a dental procedure are advised, however, for patients with artificial heart valves; a history of infective endocarditis; certain specific congenital heart conditions, including unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits; a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter, during the first 6 months after the procedure; any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device; and, finally, a cardiac transplant when a problem has developed in a heart valve.

DRUG-RESISTANT BACTERIA AND THE PITTSBURGH VETERANS AFFAIRS HOSPITAL

At the Veterans Affairs Hospital in Pittsburgh, nurses swab the nasal passages of every new inpatient to test them for methi-cillin-resistant Staphylococcus aureus (23). Those found positive are housed in isolation rooms. Every room and corridor is equipped with dispensers of foamy hand sanitizer. Blood pressure cuffs are discarded after use, and each room is assigned its own stethoscope to prevent the transfer of microorganisms. Using these and other relatively inexpensive measures, the hospital in the last 2 years has decreased from 60 to 17 the number of patients who developed these deadly drug-resistant infections. The 40-bed surgical unit that began the experiment in 2001 has cut its infection rate by 78%.

The Centers for Disease Control and Prevention projected this year that 1 in every 22 patients hospitalized will get an infection—1.7 million cases a year—and that 99,000 will die. The cost of treating infections amounts to tens of billions of dollars annually.

In the past 2 years, a few hospitals have demonstrated that simple screening and isolation of patients along with a relentless focus on hygiene can reduce the number of dangerous infections. Several European countries, the Netherlands and Finland, have all but eliminated methicillin-resistant Staphylococcus aureus infections through similar aggressive campaigns. Barely a quarter of American hospitals screen patients for bacterial colonies in any methodical way. A program similar to the Pittsburgh VA Hospital's was instigated at Baylor University Medical Center in September 2007.

WHERE THE USA RANKS AMONG OTHER NATIONS IN HEALTH CARE

In 2000, the World Health Organization made the first major attempt to rank the health systems of 191 nations (24). France and Italy took the two top spots; the USA was 37th. In May 2007, the Commonwealth Fund, through surveys of patients, physicians, and other data, ranked the USA last or next to last compared with Australia, Canada, Germany, New Zealand, and the United Kingdom on most measures of performance, including quality of care and access to care.

All non-US major industrialized nations provide universal health coverage, and most have comprehensive benefit packages with no cost-sharing by patients. The USA has some 45 million people without health insurance and many more who have poor coverage. People without insurance tend to postpone treatment until a minor illness becomes worse, potentially harming their own health and producing greater costs in the long run. Access to health care is best in Germany and next best in the USA. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery.

The USA ranks last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer vs poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a physician when sick, to fill prescriptions, or to get needed tests and follow-up care.

The USA ranks last among 23 nations in infant mortality rates. The USA ranks near the bottom in healthy life expectancy at age 60 and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care.

According to the Commonwealth Fund, in comparison with five other industrialized countries, the USA ranks first in providing the “right care” for a given condition (as defined by standard clinical guidelines) and for preventive care. Although our obesity epidemic is the worst in the world, the USA ranks #1 among industrialized nations in reducing cigarette smoking. The USA, however, scored poorly in coordinating the care of chronically ill patients and in protecting the safety of patients. Americans were the most negative in their attitudes toward their health care system, with 33% of those surveyed calling for rebuilding the entire system compared with 13% who feel that way in the United Kingdom and 14% in Canada. Nevertheless, Gallup polls in recent years have shown that 75% of the respondents in the USA, Canada, and Great Britain rate their personal care as excellent or good.

Compared with five other industrialized countries, the USA had the best survival rate for breast cancer, the second best for cervical cancer and childhood leukemia, the worst for kidney transplants, and almost the worst for liver transplants and colorectal cancer. In an eight-country comparison, the USA ranked last in years of potential life lost to circulatory diseases, respiratory diseases, and diabetes mellitus and had the second highest death rate from bronchitis, asthma, and emphysema.

The USA is behind other advanced nations in adopting electronic medical records or prescribing medications electronically.

Despite our poor showing in many international comparisons, most Americans, faced with a life-threatening illness, would rather be treated in the USA than elsewhere. We tend to think that our very best medical centers are the best in the world. Whether this is a realistic assessment, cultural preference, or fact will require better measures of clinical excellence.

As an editor of a major cardiology journal, I find that manuscripts submitted from many other industrialized countries are of a caliber equivalent to and sometimes superior to those submitted by our own brethren.

MEDICAL BLOGS

In July 2006, the number of US “bloggers” was estimated to be about 12 million adults (8% of the total Internet users), and the number of US blog “readers” was estimated at 57 million (25). During the past several years, a number of physicians have blogged about medicine. These medical bloggers discuss health policy issues, the health care system, personal and professional experiences, and general medicine, among other topics. Dr. Juan Rivera suggests the following as worthwhile medical blogs to peruse: www.kevinmd.com, medpundit.blogspot.com, drwes.blogspot.com, casesblog.blogspot.com, doctoranonymous.blogspot.com, www.docnotes.net, gruntdoc.com, and vegan-heartdoc.blogspot.com.

RATEMDS.COM

This site, according to Forbes, averages 1000 new reviews a day, and its page views have increased eightfold in the past year (26). Physicians are not particularly happy with RateMDs.com because some of the comments are apparently unethical and defamatory. Physicians can post rebuttals, though most do not, and federal privacy rules prevent discussing particular patients. Lawyers advise physicians to ignore the reviews. The website Yelp.com, where people can review anything with an address, says physicians are in the top 10 search queries it gets, right after brunch and massage. AOL has added a doctor-review feature to RevolutionHealth.com, a medical information site launched in April 2007.

NUMBER OF WORDS SPOKEN DAILY

Benjamin Franklin once wrote that the last thing that stops moving in a man is his heart and in a woman, her tongue (27). A popular view is that women talk more than men. Penne-baker and colleagues (28) in the psychology department at the University of Texas at Austin analyzed conversations recorded from 1998 to 2004 in 396 students in the USA and Mexico, 210 women and 186 men, aged 18 to 29 years. The study examined word count, not vocabulary or word use. Two thirds of the participants spoke 11,000 to 25,000 words a day. The average for both sexes was about 16,000 (29). The participants in this study spent an average of 17 waking hours wearing a lapel microphone attached to a recording device hidden under their clothes. Participants wore recorders from 2 to 10 days. The devices were programmed to record for 30 seconds every 12.5 minutes, so users didn't know when they were on or off and could not control them.

If the average survival in the USA now is about 78 years, a lot of spoken words are spoken during that time. I wonder what percentage of those words are good or useful ones.

LIVE TO WORK VS WORK TO LIVE

The first phrase characterizes Americans and the latter, Europeans (30). According to Arthur C. Books, who quoted data from the Organization for Economic Cooperation and Development, Americans work 25% more hours than the Norwegians or the Dutch. The average retirement age is 60.5 years for European men and even lower for European women. The average number of vacation days per year is 16 for Americans, 35 for Germans, 37 for French, and 42 for Italians. Why these differences? Americans have always believed apparently that hard work is good for the soul, a religious connotation. A high percentage of Americans like their jobs, nearly 90% according to the General Social Survey in 2002. Only 11% said they were not too satisfied or not satisfied at all. Similar responses were found in those with above-average and below-average incomes and those with vs those without college degrees.

For most Americans, work is a source of happiness. Happy people work more hours each week than unhappy people, and they also work more in their free time. Furthermore, people with more hours per day to relax outside their jobs are not any happier than those who have less nonwork time. In other words, heavy workloads do not decrease our happiness. Obviously, there is a point beyond which work is excessive and lowers life quality, but within reasonable bounds the American formula of hard work is associated with happiness. Americans tend to score better than Europeans on most happiness surveys: 56% of Americans are “completely happy” or “very happy” with their lives vs 44% of Danes, 35% of French, and 31% of Germans. Those 5-week vacations and 35-hour workweeks don't seem to produce more happiness than a good old-fashioned 50-hour workweek.

OLDER AMERICANS AND FINANCIAL POWER

In 2006 the first boomers—members of the generation born between 1946 and 1964—turned 60. Now there are 67 million Americans >55 years of age, and by 2014 the National Association of Homebuilders predicts there will be 85 million. Consumers aged 50+ already spend more than $1.7 trillion on goods and services each year, including heavy outlays at restaurants and travel. Collectively, the 78 million baby boomers are richer than any group in history. The 50+ crowd now controls 50% of all US discretionary income, accounts for 75% of all prescription and drug spending, and has 65% of America's household worth. And by 2030, boomers are predicted to control nearly 80% of private investments. The AARP now has 38 million members and expects that number to hit 50 million by 2012. The terms senior citizen, golden years, sunset years, Geritol junkies, retirees, and the aging are being replaced with older boomers (aged 50 to 61) or active matures (aged 62 to 75) or aging consumers. The word retirement is being replaced with unretirement, rehirement, and refirement. According to Leslie Norton, we should expect the following (31).

• People are working longer, partly because of living longer. Nearly 75% of boomers have no plans to stop working. They stay at their current jobs or find other ones after they “retire.” Even if the actual percentage turns out to be half of that, it represents millions of Americans who will have more money to spend than they would have had if they stopped working. Right now, half of AARP members are still on the job, and that figure is expected to surpass 70% in 5 years.

• Boomers’ expertise is rewarding. Several retailers recruit older workers because they know what good customer service is like. Physicians and lawyers like to continue to utilize their knowledge.

• Housing is shifting dramatically: 40% of all households will be headed by someone ≥55 by 2012. Many are altering their houses for their needs. A trend called “aging in place” turns kids’ rooms into dens, installing larger door handles and light switches, nonslip floors, and wider hallways. “Active adult communities”—complexes housing aging consumers whose apartments are wired to monitor their residence so that help can be sent if anything is amiss—are proliferating.

• Grandparent “discounts” are proliferating in retail stores.

• “Braintainment” helps maintain cognitive functions. Brain Age is now one of America's best-selling games. Other providers of Braintainment include Posit Science and Cognifit Science. (Also see web.mit.edu/agelab/, home of the AgeLab of the Massachusetts Institute of Technology, and www.aaas.org, home of the American Association for the Advancement of Science.) Technology will ease aging (see www.goldviolin.com).

MARRIAGE OF THE WORLD's TALLEST MAN

The world's tallest man finally got a mate, a woman two thirds his height and half his age. Bao Xishun, a 7-foot 9-inch herdsman from Inner Mongolia, married 5-foot 6-inch Xia Shujian, a saleswoman, also from his hometown of Chifeng. Bao is 56 and Xia is 28. More than 2000 people attended the wedding in July 2007 (32).

EDDIE “THE KING” FEIGNER

He died in February 2007 at the age of 81 (33). He barnstormed the country for 61 years as head of “the King and His Court,” a four-man softball team whose players included Eddie Feigner on the hill, launching his reportedly 103-mile-per-hour pitches from second base and between his legs; a catcher; a first baseman; and a roving shortstop. The Court played everywhere, from prisons to rodeos to Dodger Stadium, where in 1967 at age 42, Feigner struck out Willie Mays, Roberto Clemente, Brooks Robinson, Willie McCovey, Maury Wills, and Harmon Killebrew in succession. That's five Hall of Famers! Between 1938 and 1998, according to Feigner, Feigner pitched 11,125 games, winning 9743 and tying 310. He pitched 930 no-hitters and rang up 141,517 strike-outs, averaging 24 per game. Again, according to Feigner, while blindfolded, he struck out 8698 of the 16,600 batters he pitched to. According to golf great Chi Chi Rodriguez, the King could wallop a golf ball 300 yards down the center of the fairway and bowl a 225 blindfolded.

Though he spent a large chunk of time each year out on the road and pitched at least one game every day, Feigner never worked with a trainer and rarely did much in the way of stretching. His wife said, “Eddie treated himself like a fine thoroughbred horse. He'd always say: ‘What's the first thing you do to that horse after the race? You throw a blanket on him. You warm him down.'” In keeping with that unconventional approach, Feigner wore his warm-up jacket in all climates and made sure to keep a collar around this neck. Even after a stroke in 1978 and gradual physical deterioration thereafter, in 2000 he was tapped to throw out the ceremonial first pitch of the Women's Softball Competition at the Sydney Olympics. According to Anne Marie, his wife, Eddie, then 75, walked to the mound and did that crazy whirligig windup of his. The 100-mile-per-hour pitch broke 8 inches and cut down and dropped at the end. That pitch was his last. A day later he had a massive stroke.

MANNERS

Peggy Noonan, one of my favorite editorialists, has a column each Saturday in The Wall Street Journal. A recent column had to do with manners (34). She described walking into a couple of shops.

“Hi! Let me help you find what you're looking for!” She is a saleswoman, cracking gum with intensity, about 25 years old, and she has made a beeline to her mark. That would be me.

“Mmmm, actually—”

“We have summer sweaters on sale. What size are you?!” Her style is aggressive friendliness.

In another shop, as soon as I walk in the door, “How are you today? How can I help you?” Those dread words.

“Oh, I'm sort of just looking.”

“I like your bag!”

“Um, thanks.” What they are forcing you to do is engage. If you engage—“Um, thanks”—you have a relationship. If you have a relationship, it's easier for them to turn you upside down and shake the coins from your pockets.

She speaks of being in a local restaurant with a friend: 12. Parker-Pope T. Finding out how your car will hold up in a crash. Wall Street Journal, July 3, 2007.

We sat down 40 seconds ago and are starting to catch up when: “What do you want to drink? … We have specials this evening.” … The waiter stands there, pad in hand. “You ready?” If you ask for a minute, he'll nod and be back in exactly one minute. “Do you know yet?” Again, this is not a request. One is being told to snap to it. Get 'em in, get 'em out. Move 'em.

Noonan describes cell phones: “They empower the obnoxious and amplify the ignorant.” I love that phrase. She says, “BlackBerrys empower the obsessed.”

And Ms. Noonan concludes with the following:

It is possible that we are on the cellphone because we are lonely and hunger for connection, even of the shallowest kind; that we BlackBerry because we hope for a sense of control in a chaotic world; that we are frightened of stillness and must interrupt conversations; that we are desperate to make the sale in the highly competitive environment … and must aggressively pursue customers. It's also possible we have grown more boorish. I think it's that one. Many things thrive in the age of everything, including bad manners.

—William C. Roberts, MD

Executive Director, Baylor Heart and Vascular Institute Dean of Continuing Medical Education, Baylor University Medical Center Editor in Chief, The American Journal of Cardiology and Baylor University Medical Center Proceedings

24 August 2007