New report: Fixed-payment insurance policies decreasing in Washington state

Fixed payment insurance plans pay a specific amount -- $25 per doctors visit, say, or $200 a day for a hospital stay -- regardless of the bill. The patient pays the rest.

Plans like this allow employers a way to buy minimal coverage for employees. But it's not comprehensive health insurance. The medical bills may be much more than what the plan pays out.

Each year, we survey fixed-payment companies doing business in Washington state, and compile the results into a report on fixed payment insurance plans.

Here's what we're seeing:

• Sales for group policies have decreased significantly, as has the number of group enrollees. (Group enrollees decreased by 88 percent.)
• Among individual plans, the number of policies and enrollees both decreased.

The full report -- click on the link above -- includes a breakdown in the number of policies sold by each company.

Natural Allergy Relief

If you are one of the 35 million Americans that suffer each year during the pollen season, this article is for you! Seasonal allergies tend to occur during the spring and fall, when pollen and ragweed are at their peak. Each season, those who deal with allergies are often desperate for ANY solution to their suffering. Below is a more natural approach to relief instead of over the counter or prescription drugs.

Some of you may be familiar with Dr. Andrew Weil. He is one of the leading physicians in the health and wellness field right now. He is the author of several best-selling health and nutrition books including Spontaneous Healing, Eight Weeks to Optimum Health, Eating Well for Optimum Health and the cookbook The Healthy Kitchen. Dr. Weil is a graduate of Harvard College and Harvard Medical School, is Clinical Professor of Medicine at the University of Arizona and director of the Program in Integrative Medicine at that institution.

Being a proponent of holistic and integrative nutrition, Dr. Weil is not a great fan of antihistamines, which don't change the allergic process but merely block its expression. He says that steroid nasal inhalers used for treatment of hay fever and other seasonal allergies can be very effective, but some of the steroids are bound to get into the rest of the body and these hormones weaken the immune system. His preference among conventional treatments is the non-prescription drug cromolyn sodium (Nasalcrom Nasal Solution). It works and is nontoxic. If that doesn't help, you may have to try a steroid nasal spray such as Vancensae, preferably for a limited time.

Dr. Weil also recommends trying some lifestyle modifications. All allergies have the potential to disappear if you make changes in both lifestyle and your mental state. Here are some of his suggestions:

Skip on the milk. Follow a low-protein diet and try to eliminate milk and milk products. Excessive protein can irritate the immune system and keep it in a state of over activity. The protein in cow's milk is a frequent offender.

Get hypnotized! Try hypnosis, which can lessen or completely prevent allergic reactions and facilitate the immune system's unlearning of its pointless habits (in this case, an inappropriate response to pollen, dust, mold or animal hair or other substances that cannot really hurt us).

Chill out. Consider whether stress impacts your allergy and, if so, take steps to reduce it. Dr. Weil has seen long-standing, severe seasonal allergies disappear when people switched jobs, left a relationship or otherwise eliminated a source of stress.

Dust-proof your home. Dust-proof your bedroom by eliminating wall-to-wall carpets, down-filled blankets, feather pillows and other dust catchers. Encase your mattress in an airtight, dust-proof plastic cover; dust your furniture with a damp cloth; and damp-mop floors regularly to pick up dust.

Get a HEPA filter. Consider buying an air filter. Dr. Weil recommends a HEPA (high-efficiency particulate air) filter, which removes particles in the air by forcing it through screens containing microscopic pores. These devices work well and aren't too expensive. Get one for the main rooms in your house, or move one from room to room regularly. Avoid air-filtering equipment that generates ozone (HEPA filters don't).

Invest in a neti pot. What could be simpler than rinsing away allergens with saltwater? Neti pots have been used in India for thousands of years to flush the sinuses and keep them clear. It’s an idea that takes some getting used to for most Westerners, but it’s a bit like using nasal spray. A little douse of saltwater can rinse away those prickly pollen grains and help treat allergies and other forms of sinus congestion. Refer to my old blog post regarding the neti pot for more information.

Ask your doctor about quercetin. A natural plant-derived compound called a bioflavonoid, quercetin helps stabilize mast cells and prevents them from releasing histamine. Quercetin also is a natural antioxidant that helps mop up molecules called free radicals that cause cell damage, which can lead to cancer. Citrus fruits, onions, apples, parsley, tea, tomatoes, broccoli, lettuce and wine are naturally high in quercetin, but allergy sufferers will most likely need to use supplements to build up enough of this compound to prevent attacks. The recommended dosage is about 1,000 milligrams a day, taken between meals. It’s best to start treatment six weeks before allergy season. Those with liver disease shouldn’t use quercetin, so please consult your doctor before using this or any other supplement — especially if you are pregnant or nursing.

Eat allergy fighting foods. A recent health study found that participants who ate foods rich in omega-3 fatty acids were less likely to suffer allergy symptoms than those who didn’t regularly eat these foods. Omega-3s help fight inflammation and can be found in cold-water fish, walnuts and flaxseed oil, as well as grass-fed meat and eggs.

To help keep airways clear when pollen counts are high, add a dash of horseradish, chili peppers or hot mustard to your food — all act as natural, temporary decongestants. It’s also a good idea to avoid foods that you’re slightly allergic to until the air clears. Fighting off allergies can render the body hypersensitive to those foods, causing more severe reactions than usual.


Hopefully you will find some, if not a lot of relief from one or more of the suggestions above. My favorite thing to do during this season is to drink a cup of hot water first thing in the morning with nothing in it. The steam helps to relieve any congestion in my sinuses. Best wishes for a sniffle-free Spring for you!

Keep it fresh!
- Lauren

Interview with Jimmy Moore, and basics of intima-media thickness and plaque tests

Let me start this post by telling you that my interview with Jimmy Moore is coming up in about a week. Jimmy and I talk about evolution, statistics, and health – the main themes of this blog. We talk also about other things, and probably do not agree on everything. The interview was actually done a while ago, so I don’t remember exactly what we discussed.

From what I remember from mine and other interviews (I listen to Jimmy's podcasts regularly), I think I am the guest who has mentioned the most people during an interview – Gary Taubes, Chris Masterjohn, Carbsane, Petro (a.k.a., Peter “the Hyperlipid”), T. Colin Campbell, Denise Minger, Kurt Harris, Stephan Guyenet, Art De Vany, and a few others. What was I thinking?

In case you listen and wonder, my accent is a mix of Brazilian Portuguese, New Zealand English (where I am called “Need”), American English, and the dialect spoken in the “country” of Texas. The strongest influences are probably American English and Brazilian Portuguese.

Anyway, when medical doctors (MDs) look at someone’s lipid panel, one single number tends to draw their attention: the LDL cholesterol. That is essentially the amount of cholesterol in LDL particles.

One’s LDL cholesterol is a reflection of many factors, including: diet, amount of cholesterol produced by the liver, amount of cholesterol actually used by your body, amount of cholesterol recycled by the liver, and level of systemic inflammation. This number is usually calculated, and often very different from the number you get through a VAP test.

It is not uncommon for a high saturated fat diet to lead to a benign increase in LDL cholesterol. In this case the LDL particles will be large, which will also be reflected in a low “fasting triglycerides number” (lower than 70 mg/dl). While I say "benign" here, which implies a neutral effect on health, an increase in LDL cholesterol in this context may actually be health promoting.

Large LDL particles are less likely to cross the gaps in the endothelium, the thin layer of cells that lines the interior surface of blood vessels, and form atheromatous plaques.

Still, when an MD sees an LDL cholesterol higher than 100 mg/dl, more often than not he or she will tell you that it is bad news. Whether that is bad news or not is really speculation, even for high LDL numbers. A more reliable approach is to check one’s arteries directly. Interestingly, atheromatous plaques only form in arteries, not in veins.

The figure below (from: Novogen.com) shows a photomicrograph of carotid arteries from rabbits, which are very similar, qualitatively speaking, to those of humans. The meanings of the letters are: L = lumen; I = intima; M = media; and A = adventitia. The one on the right has significantly lower intima-media (I-M) thickness than the one on the left.

Atherosclerosis in humans tends to lead to an increase in I-M thickness; the I-M area being normally where atheromatous plaques grow. Aging also leads to an increase in I-M thickness. Typically one’s risk of premature death from cardiovascular complications correlates with one’s I-M thickness’ “distance” from that of low-risk individuals in the same sex and age group.

This notion has led to the coining of the term “vascular age”. For example, someone may be 30 years old, but have a vascular age of 80, meaning that his or her I-M thickness is that of an average 80-year-old. Conversely, someone may be 80 and have a vascular age of 30.

Nearly everybody’s I-M thickness goes up with age, even people who live to be 100 or more. Incidentally, this is true for average blood glucose levels as well. In long-living people they both go up slowly.

I-M thickness tests are noninvasive, based on external ultrasound, and often covered by health insurance. They take only a few minutes to conduct. Their reports provide information about one’s I-M thickness and its relative position in the same sex and age group, as well as the amount of deposited plaque. The latter is frequently provided as a bonus, since it can also be inferred with reasonable precision from the computer images generated via ultrasound.

Below is the top part of a typical I-M thickness test report (from: Sonosite.com). It shows a person’s average (or mean) I-M thickness; the red dot on the graph. The letter notations (A … E) are for reference groups. For the majority of the folks doing this test, the most important on this report are the thick and thin lines indicated as E, which are based on Aminbakhsh and Mancini’s (1999) study.

The reason why the thick and thin lines indicated as E are the most important for the majority of folks taking this test is that they are based on a study that provides one of the best reference ranges for people who are 45 and older, who are usually the ones getting their I-M thickness tested. Roughly speaking, if your red dot is above the thin line, you are at increased risk of cardiovascular disease.

Most people will fall in between the thick and thin lines. Those below the thick line (with the little blue triangles) are at very low risk, especially if they have little to no plaque. The person for whom this test was made is at very low risk. His red dot is below the thick line, when that line is extended to the little triangle indicated as D.

Below is the bottom part of the I-M thickness test report. The max I-M thickness score shown here tends to add little in terms of diagnosis to the mean score shown earlier. Here the most important part is the summary, under “Comments”. It says that the person has no plaque, and is at a lower risk of heart attack. If you do an I-M thickness test, your doctor will probably be able to tell you more about these results.

I like numbers, so I had an I-M thickness test done recently on me. When the doctor saw the results, which we discussed, he told me that he could guarantee two things: (1) I would die; and (2) but not of heart disease. MDs have an interesting sense of humor; just hang out with a group of them during a “happy hour” and you’ll see.

My red dot was below the thick line, and I had a plaque measurement of zero. I am 47 years old, eat about 1 lb of meat per day, and around 20 eggs per week - with the yolk. About half of the meat I eat comes from animal organs (mostly liver) and seafood. I eat organ meats about once a week, and seafood three times a week. This is an enormous amount of dietary cholesterol, by American diet standards. My saturated fat intake is also high by the same standards.

You can check the post on my transformation to see what I have been doing for years now, and some of the results in terms of levels of energy, disease, and body fat levels. Keep in mind that mine are essentially the results of a single-individual experiment; results that clearly contradict the lipid hypothesis. Still, they are also consistent with a lot of fairly reliable empirical research.

Cooling Summer Foods

The end of May means the beginning of Summer. Pools and beaches will be open and the weather will continue to warm up. The change of season means it is time to change up the foods we eat. We will want to start to eat foods that have a cooling effect on the body, to stay fresh during the coming months.

Instinctively there are certain foods that are more appealing to us in the summertime versus the winter months, but there is logic as to why. We tend to think of a food’s energy in terms of calories, but all foods were once alive and therefore have a living energy that effects our bodies’ response when we consume them. Therefore we can eat foods that have a cooling effect on the body during the warm months, and a warming effect on the body during the cold ones.

There are a few things to consider when choosing foods for these cooling effects. How it is grown, the color of the food, and how it is cooked. As a general rule, vegetables and fruits that take less time to grow, and grow above ground, have more of a cooling effect on the body, as well as a more uplifting and energizing effect. Some of these include, most leafy greens, lettuce, broccoli, tomatoes, cucumbers, celery, zucchini and yellow squash. Conversely, those that take longer to grow and grow beneath the soil have a more grounding and warming effect on the body. These include root vegetables such as potatoes and parsnips, onions, garlic.

Following what we know about cool colors and warm ones, the same general principle applies to foods. Foods that are blue and green in color are usually more cooling than those that are red or orange. Herbs can be considered as well. Spices such as cayenne, cinnamon and cloves are all warming, which is why we tend to crave them in the fall and winter months. Mint and cilantro have the opposite effect and are great in summer salads and salsas!

Cows, pigs, chickens etc are all warm blooded animals, so when we consume them they have a warming effect on the body. Fish are cold blooded and therefore seafood and seaweeds will have a cooling effect. But it is also important to consider the method in which all of the above foods are prepared. The closer a food is to its raw state, the cooler it will be. So the less it is cooked, the more cooling, and the more it is cooked, the more warming it will be. Therefore lightly steaming vegetables will keep them cool, while broiling, frying or baking will diminish their cooling properties.

Make your summer full of vibrant salads made from lots of fresh fruits and vegetables and you will keep healthy, cool and of course fresh all summer long!

Keep it Fresh (and Cool) - Jill

Living Gluten-Free

I seem to be getting a lot of questions lately about following a gluten-free diet. It seems to be something that is becoming more and more common, and I think that this is due to the fact that many of us have a sensitivity or allergy to wheat that goes undetected for many years. There has been some attention drawn to this fact lately and so it seems that people are getting more in tune with their bodies and beginning to become aware of these types of sensitivities. This can cause people to avoid gluten, the protein found in wheat (and therefore rye and barley as well) in their daily diet, or avoid it for a period of time to determine if there is in fact an allergy or sensitivity.

There are varying degrees of sensitivity, ranging from mild to full on allergy, to Celiacs disease. Sensitivities can cause symptoms such as headaches, bloating or stomach issues, yeast infections, weight gain or skin rashes. Celiac disease, however is a disease in which the body is incapable of breaking down gluten, causing an auto immune response in the body. A doctor can run blood tests to determine Celiac disease, but sensitivities to wheat can be more difficult to determine. If you suspect that wheat may be the cause of what ails you, the best way to do so is to avoid wheat and gluten for a short period of time, usually 7 days will suffice. Within this time period symptoms will subside and will return when wheat is reintroduced on the eighth day, if there is a sensitivity.

Avoiding gluten may seem like a daunting task. It can be overwhelming when you start to think about all of the foods that involve wheat. But once you know what to look for, I assure you that its not as confusing as it may seem. Gluten is found only in grains made from wheat, therefore all vegetables, fruits, nuts, seeds, legumes (beans) and meats in their natural state are gluten-free. The tricky part is determining what grains and flours to avoid and what foods contain these flours in some way or another. The following is a list of grains and flours that do and do not contain gluten:

Grains/flours that contain gluten:
Wheat (this includes the berry and the germ of the plant)
Rye
Barley
Kamut
Semolina
Barley
Spelt

Grains/flours that do not contain gluten:
Rice (all varieties, excluding those made with pastas such as pilaf)
Millet
Amaranth
Almond flour
Arrowroot starch
Buckwheat or kasha
Cassava or manioc flour
Chickpea flour
Corn and cornmeal
Flax
Quinoa
Potato starches and flours
Sorghum
Soy flour
Teff
Tapioca flours and starches

You may notice that oats were left off this list. Oats, oat bran, oat groats and oat flours do not technically contain gluten, but are derived from the wheat plant and therefore may cause sensitivity. Other foods to note: couscous is made from wheat flour and seitan, a protein popular among vegetarians, is made from wheat gluten.

Some common foods that contain glutenous flours are breads, pastas, cookies, cakes, crackers, and cereals. But it is easy to find gluten-free versions of these items. Look for pastas made from rice or quinoa or even black beans and lentils. There are many different types of breads and baked goods out there that are made with gluten-free flours. Most of these can be found well marked in health food stores, but can be found in main stream food chains as well. My favorite gluten free bread is Food for Life’s Millet bread. I also LOVE their brown rice tortillas, which are great for making wraps. Mary’s Gone Crackers crackers and twigs are also amongst my favorite gluten-free snacks. Tortilla and potato chips are generally gluten-free, but sometimes will contain wheat flours.

Usually health food stores and large supermarkets will shelve the majority of their gluten-free products together so that they are easy to find an identify, and are often accompanied by a gluten-free symbol (such as blades of wheat with a slash through it). Although some gluten-free breads and wraps can be found in this area, most are kept in the freezer case to prolong their shelf life.

There are a variety of options out there, but it is important to read labels carefully. A unsuspecting item, such as ice cream can contain gluten! Eventually you will become familiar with these foods and it will become second nature, I promise.

Keep it Fresh!
~Jill

Have a serious medical condition and need health insurance?

Do you have pre-existing condition and need health insurance? Here’s how the new federally-funded Pre-existing Condition Insurance Plan helped a local Olympia man:

Dusty of Olympia, is a 28 year-old with lymphoma. When he was 25 he started his own business. In order to save money he chose not to purchase health care insurance - like others of his age, he felt he could take the risk. Six months later he was diagnosed with stage 4a lymphoma. He received treatment and owes over $200,000 in medical bills. He hadn’t been to the doctor in months because he could not afford any treatment that may be recommended and didn’t want to add to his debt.

Dusty learned about the new Pre-Existing Condition Insurance Plan (PCIP-WA) from one of our employees who met his girlfriend. Today, he’s enrolled in PCIP-WA and finally receiving the care he needs. Here’s what he had to say about the plan:

“As of this July this year, I’ll have been in remission for three years. The
Pre-existing Condition Insurance Plan lets me get all of my tests and everything
is showing that I’m still clear. Life is going really well! My partner and I are
expecting a baby in August and we’re excited.”

If you have a pre-existing condition medical condition and need health insurance – or know of a family member or friend in need, tell them about PCIP-WA today.

Who can apply?
How much does it cost?
How does the plan work?

Apply today!

How to look up info on your agent or broker (plus the answer to the quiz)

Last week we posted a quiz question: How many agents and brokers are licensed in Washington state?

Out of three choices, about half picked the right answer: 118,415.

If you want to check your agent's credentials, find a broker in your area, look for past disciplinary cases, etc., take a look at our new online lookup for agents and brokers.

If you want to also look at company cases, check our insurance disciplinary orders search engine.

Food Reward: a Dominant Factor in Obesity, Part IV

What is Food Reward?

After reading comments on my recent posts, I realized I need to do a better job of defining the term "food reward".  I'm going to take a moment to do that here.  Reward is a psychology term with a specific definition: "a process that reinforces behavior" (1).  Rewarding food is not the same thing as food that tastes good, although they often occur together. 

Read more »

Physician Interview: Prevalence of heart disease in black community

View the full video interview on Rouge Valley’s YouTube channel.

Cardiologist Dr. Paul Galiwango is the medical manager of cardiac imaging at Rouge Valley Health System (RVHS). Here he discusses his particular interest and insights on the issue of heart disease and hypertension faced by the black community.

Q: What is hypertension?
A: Hypertension is high blood pressure. The heart pumps blood into vessels; and if the pressure is too high, the heart has to work harder to pump blood. Over the long term, it leads to damage of the lining of the vessels, and increases the chances of blood clots, strokes, and blood vessels bursting. There are usually no symptoms, which is why it’s important for patients to visit their physician regularly, so that we can try to detect it at that silent stage—before it wreaks any damage.

Q: Why are blacks more susceptible to hypertension, heart failure and stroke?
A: We certainly know that hypertension affects the black community more disproportionately. We see an increase in frequency, and we see it at younger ages. In addition to that, hypertension is often more resistant to treatment on patients in the black community. And it seems to have a particularly malignant vascular effect in terms of organ damage to the heart, kidneys, and brain. Why we see that is still a subject of fierce debate. I think it is multi-factorial. There are some genetic studies that suggest  there are some unique aspects in the way the kidneys handle the sodium load, which makes blacks more sensitive to salt. And salt affects the cause of high blood pressure—so we call it sodium-sensitive hypertension. And then there are also some lifestyle issues. For example, if you look to the American south, there tend to be some very high-sodium diets, and high prevalence of obesity. So this also contributes to the hypertension rates.

Q: Why do stroke and heart failure tend to present so young in blacks?
A: It certainly seems to be linked to the prevalence of hypertension coming at a younger age. There was a large study that came out last year that looked at a very diverse group–whites, blacks, Hispanics–and followed them for 20 years. What they found was the prevalence of heart failure at a young age (younger than 50 years old) was about 20 times higher in blacks than in the non-black participants. And the lion’s share of that contributed to hypertension. Researchers saw that for every 10 millimetre increase in blood pressure in a black person in their 20s, you double the risk for heart failure in their 40s.  It’s sobering, but what’s encouraging is that it’s a treatable condition.

Q: When you see black patients, how do you treat them? What sort of programs do you put them on? Is it particularly unique?
A: In any patient who I see with hypertension, I treat aggressively. Hypertension is silent, and it’s easy for it to progress without the patient even realizing it. With black patients, there are some nuances—we do know that they respond differently to certain classes of drugs that are commonly used for hypertension, like ACE Inhibitors, Beta Blockers. Data has suggested that medications such as these may be less effective in the black population. So I would tend to stay away from those, at least at first, and go to more effective drugs like Calcium Channel Blockers and Diacide Diuretics.
    I also really underscore the importance for everyone—particularly in the black population—of trying to avoid salt in their diet. People often recoil at that suggestion at first, but you do find that with time, the palate adapts, and you get used to it. There’s just so much sodium already in packaged foods, it’s best to try and cut out salt anywhere you can. I recommend just not adding it to table food, or when you’re cooking. In fact, I’ve learned to cut salt out of my own diet.

Q: What do we do at Rouge Valley to treat this population?
A: The cardiologists at Rouge Valley are all very cognizant of these issues, and can aggressively manage heart hypertension in all patients, and know what to do when they see anyone approach. We have a very diverse community in Toronto and Durham—blacks, South Asians, Asians, etc.—so we deal with everyone appropriately. But I’d also emphasize that the cardiac rehab program is an excellent one, and it gives all the patients the tools they need to live a healthier lifestyle—and aids in helping them to abandon some of the more harmful habits, like smoking, or a high-sodium diet. So we also refer a lot of our patients to that program.
    It’s important for physicians who are treating black patients whose hypertension has gotten quite difficult to treat, not to give up and refer those patients on to a specialist for evaluation. It’s possible that the medication might need to be tweaked, or replaced. A lot of times, it’s a bit frustrating to have a patient on medication for a while, and their blood pressure isn’t coming down. But if that’s the case, they really should be referred on. You can get there, but you just have to persist.

Healthy Skeptic Podcast

Chris Kresser has just posted our recent interview/discussion on his blog The Healthy Skeptic.  You can listen to it on Chris's blog here.  The discussion mostly centered around body fat and food reward.  I also answered a few reader questions.  Here are some highlights:

• How does the food reward system work? Why did it evolve?
• Why do certain flavors we don’t initially like become appealing over time?
• How does industrially processed food affect the food reward system?
• What’s the most effective diet used to make rats obese in a research setting? What does this tell us about human diet and weight regulation?
• Do we know why highly rewarding food increases the set point in some people but not in others?
• How does the food reward theory explain the effectiveness of popular fat loss diets?
• Does the food reward theory tell us anything about why traditional cultures are generally lean?
• What does cooking temperature have to do with health?
• Reader question: How does one lose fat?
• Reader question: What do I (Stephan) eat?
• Reader question: Why do many people gain fat with age, especially postmenopausal women?

The podcast is a sneak preview of some of the things I'll be discussing in the near future.  Enjoy!

Meeting Neighbors, by May blogger of the month Sarah Meyers

The children crowded near us, curious about the strange foreigners in their village.  I decided it was time to practice my arabic.  “Kif Halak?” (How are you?)  I asked one of the girls.  She just stared at me, and I realized along with my atrocious American accent, I had botched the grammar and used a masculine construct to address the girl.

More children gathered around and I tried again, asking one of two sisters in matching neon pink shirts “shu ismik?” (what is your name), and this time at least had the grammar right.  She too stared and did not answer, but I finally got a response from an older girl.  She told me her name was  “Shams.”  That sounded a lot like the Hebrew word for “sun” (shemesh) so I pointed to the setting sun and asked “shams?” That brought out a wave of laughter from the children, but also broke the ice a little.  One of them asked me my name, and repeated it back, trilling the ‘“r” beautifully as I have failed to do in multiple languages.  Emboldened, I used my basic Arabic to introduce my friends as well, although that was as far as the conversation got.

About a dozen of my classmates were spending an hour in an unrecognized Bedouin village about 12 kilometers from Beer Sheva.  Over the years, MSIH students have built up a few connections in the region, and one of those connections is a man named J, who works with one of our student groups to arrange English tutoring for the children in his village of Umm-Batim.  But during the day, J directs the Regional Council of Unrecognized Villages (RCUV,http://www.rcuv.net/online/en/), an NGO that represents the Bedouin villages in the Negev, or southern Israel, that lack government recognition of their land rights, and therefore do not have paved roads, running water, or connections to the electric grid.  J was interested in creating a partnership between MSIH students and the RCUV, and invited us to come visit a village to brainstorm on how we could be involved.

When we first arrived in Beer Sheva, many of us were startled by the dustiness, the bare and battered concrete buildings, and plumbing of a lower quality than we were used to.  Now, Beer Sheva has become normal to us, and we sat in the sitting room of a villages, with walls made of sheet metal and tarps, with water from tanks and trunks, and realized how lucky we were in Beer Sheva.  

We also realized just how hard it is to help.  Multiple languages were flying around, and only A, my Arabic teacher who had come as a translator, understood the Hebrew, English, and Arabic in which conversations were taking place.  I myself was humbled that after a year of weekly Arabic classes, I could communicate so little.  A third year student who had come along remarked on her regret that she had not learned Arabic while she was here, and I regretted missed homework, forgotten vocabulary, and poor skills at understanding spoken Arabic.  

I do believe that despite our lack of language skills, and lack of medical skills, this meeting with grow into a fascinating project.  

This meeting was one of many experiences that has underscored for me the importance of language skills in cross-cultural and international work.  That, while English is spoken widely around the world, the people we can both help and learn from the most are unlikely to speak it, that the more Hebrew and Arabic we learn here, the more we can learn from hundreds of small encounters.  

One time, at a hospital here in Israel, I watched a nurse try to communicate with a Arab woman who spoke no Hebrew.  “Woujya? Woujya?” the nurse asked, in very basic Arabic. (Pain? Pain?).  “Woujya ktir? Woujya Shwey?” (Big pain? Pain a little?) I respected the nurse’s attempts to communicate, yet realized that I wanted to one day be able to communicate better than that in Arabic, and that would take some serious study.  At the best, such communication can drastically improve diagnosis and care, and at the very least, I think it will bring out from the patient a smile.  - May blogger of the month, Sarah Meyers

The Key to High Survey Response Rates Revealed

In a poster, entitled “Strategies for Achieving High Response Rates in a Web Based National Survey: Care for patients with Acute Myocardial Infarction (AMI),” recently presented at the American Heart Association:  Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke 2011 Scientific Sessions meeting in Washington, D.C., Yale researchers outlined key factors that influence the response rates of organizational surveys.

According to the Yale team, there are six key factors that helped produce such a high (91%) response rate: procedure, contacts collaboration, tailoring, relationships, and motivation. “The key to good survey research is a high response rate, but the challenge is no one wants to complete surveys.  And, it’s especially hard to get busy senior hospital executives to reply to survey questions,” explains Marcia Mulligan, program coordinator at the Yale Global Health Leadership Institute and lead author on the study. For this survey the researchers kept their approach clear and succinct. Using pre-notify mail invitations and automated web servers they were able to reach a large sample as well as multiple contacts at hospitals. During the communications with potential participants the researchers tried to have a connection with them through personal messages and one-on-one conversations as a way to increase response rates.

Leslie Curry, Ph.D., research scientist at the Yale Global Health Leadership Institute,  “A 91% return rate is extremely rare and this higher rate contributes to stronger science. The experience and techniques of the GHLI Yale team is the secret to our success with survey participants.”

For further information on GHLI AMI-related research click here

Nina Gumkowski, GHLI Intern

The China Study II: Wheat may not be so bad if you eat 221 g or more of animal food daily

In previous posts on this blog covering the China Study II data we’ve looked at the competing effects of various foods, including wheat and animal foods. Unfortunately we have had to stick to the broad group categories available from the specific data subset used; e.g., animal foods, instead of categories of animal foods such as dairy, seafood, and beef. This is still a problem, until I can find the time to get more of the China Study II data in a format that can be reliably used for multivariate analyses.

What we haven’t done yet, however, is to look at moderating effects. And that is something we can do now.  A moderating effect is the effect of a variable on the effect of another variable on a third. Sounds complicated, but WarpPLS makes it very easy to test moderating effects. All you have to do is to make a variable (e.g., animal food intake) point at a direct link (e.g., between wheat flour intake and mortality). The moderating effect is shown on the graph as a dashed arrow going from a variable to a link between two variables.

The graph below shows the results of an analysis where animal food intake (Afoods) is hypothesized to moderate the effects of wheat flour intake (Wheat) on mortality in the 35 to 69 age range (Mor35_69) and mortality in the 70 to 79 age range (Mor70_79). A basic linear algorithm was used, whereby standardized partial regression coefficients, both moderating and direct, are calculated based on the equations of best-fitting lines.

From the graph above we can tell that wheat flour intake increases mortality significantly in both age ranges; in the 35 to 69 age range (beta=0.17, P=0.05), and in the 70 to 79 age range (beta=0.24, P=0.01). This is a finding that we have seen before on previous posts, and that has been one of the main findings of Denise Minger’s analysis of the China Study data. Denise and I used different data subsets and analysis methods, and reached essentially the same results.

But here is what is interesting about the moderating effects analysis results summarized on the graph above. They suggest that animal food intake significantly reduces the negative effect of wheat flour consumption on mortality in the 70 to 79 age range (beta=-0.22, P<0.01). This is a relatively strong moderating effect. The moderating effect of animal food intake is not significant for the 35 to 69 age range (beta=-0.00, P=0.50); the beta here is negative but very low, suggesting a very weak protective effect.

Below are two standardized plots showing the relationships between wheat flour intake and mortality in the 70 to 79 age range when animal food intake is low (left plot) and high (right plot). As you can see, the best-fitting line is flat on the right plot, meaning that wheat flour intake has no effect on mortality in the 70 to 79 age range when animal food intake is high. When animal food intake is low (left plot), the effect of wheat flour intake on mortality in this range is significant; its strength is indicated by the upward slope of the best-fitting line.

What these results seem to be telling us is that wheat flour consumption contributes to early death for several people, perhaps those who are most sensitive or intolerant to wheat. These people are represented in the variable measuring mortality in the 35 to 69 age range, and not in the 70 to 79 age range, since they died before reaching the age of 70.

Those in the 70 to 79 age range may be the least sensitive ones, and for whom animal food intake seems to be protective. But only if animal food intake is above a certain level. This is not a ringing endorsement of wheat, but certainly helps explain wheat consumption in long-living groups around the world, including the French.

How much animal food does it take for the protective effect to be observed? In the China Study II sample, it is about 221 g/day or more. That is approximately the intake level above which the relationship between wheat flour intake and mortality in the 70 to 79 age range becomes statistically indistinguishable from zero. That is a little less than ½ lb, or 7.9 oz, of animal food intake per day.

Fast Food, Weight Gain and Insulin Resistance

CarbSane just posted an interesting new study that fits in nicely with what we're discussing here.  It's part of the US Coronary Artery Risk Development in Young Adults (CARDIA) study, which is a long-term observational study that is publishing many interesting findings.  The new study is titled "Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis" (1).  The results speak for themselves, loud and clear (I've edited some numbers out of the quote for clarity):
Read more »

Quiz: How many agents and brokers are licensed in Washington?

We've posted a one-question quiz: How many agents and brokers are licensed in Washington state?

You can pick an answer in the poll box, which on the lower right-hand side of this web page.

Check back --we'll post the correct answer in a few days.

More than 1/4 of hospital emergency rooms in non-rural areas have closed in the past two decades

More than a quarter of urban/suburban hospital emergency rooms have closed in the past two decades, researchers have found.

The Journal of the American Medical Association published the study, titled "Factors Associated With Closures of Emergency Departments in the United States." The researchers found that the number of non-rural emergency rooms declined from 2,446 to 1,779 between 1990 and 2009. That's a decline of more than 27 percent.

Food Reward: a Dominant Factor in Obesity, Part III

Low-Fat Diets

In 2000, the International Journal of Obesity published a nice review article of low-fat diet trials.  It included data from 16 controlled trials lasting from 2-12 months and enrolling 1,910 participants (1).  What sets this review apart is it only covered studies that did not include instructions to restrict calorie intake (ad libitum diets).  On average, low-fat dieters reduced their fat intake from 37.7 to 27.5 percent of calories.  Here's what they found:
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Clarifications About Carbohydrate and Insulin

My statements about carbohydrate and insulin in the previous post seem to have kicked up some dust!  Some people are even suggesting I've gone low-fat!  I'm going to take this opportunity to be more specific about my positions.

I do not think that post-meal insulin spikes contribute to obesity, and they may even oppose it. Elevated fasting insulin is a separate issue-- that's a marker of insulin resistance.  It's important not to confuse the two.  Does insulin resistance contribute to obesity?  I don't know, but it's hypothetically possible since insulin acts like leptin's kid brother in some ways.  As far as I can tell, starch per se and post-meal insulin spikes do not lead to insulin resistance.
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May Healthy Happy Hour: The Downtown

Come join us this Friday, May 20th from 7-9 at The Downtown in Red Bank for healthy happy hour! We will have a table reserved.. just look for our logo. Hope to see you there!

Hungarian Highlights (with an attempted medical student focus) by blogger of the monthTalie Lewis

Hoping to accomplish a similar goal as Sarah did with her latest post, I am going to try to extract the experiences that seem the most directly relevant to medical students, in addition to a haikummary (a haiku summary), which highlights many of the daily activities that comprised our Budapest adventure. It can be found at the end.  

There are certain universal sights, symbols and sounds that one might expect to see and be familiar with in most European countries; extravagant places of worship, Starbucks, Addidas, local music artists covering U2 songs...and we saw all of these things. One surprise that we came across however, was when we saw a pair of medical students studying from a textbook we know quite well called "Microbiology Made Ridiculously Simple" (a book, which also made my mother a bit skeptical of my studying practices when she saw it on my desk...don't worry though, it is used by most, as a supplementary resource). Now, this seemed like an excellent opportunity to engage with some Hungarian medical students. However, as I started conversation with these two young men, it turned out one was Israeli and the other was Norwegian. Finding an Israeli medical student in Budapest was not a total surprise because most of us knew there is a program for Israeli students to study medicine in Hungary, but it was still quite exciting to find someone able to offer us advice about what to do in Budapest and Tel Aviv.

While we did not get to talk to Hungarian medical students on that occasion we had another opportunity. On Friday night, most of us went to the apartment of three twenty something Hungarians. The apartment is part of an organization called the Moishe House, which (according to their website) "is an international organization providing meaningful Jewish experiences to young adults in their twenties." There happened to be one of these in Budapest that one of our MSIH classmates got us in touch with. We went for a Friday night prayer service, which turned out to be pretty traditional in terms of the prayers, but extremely spirited, musical and modern in the way it was carried out.  There were probably between 30-40 locals there and thanks to some post-service mingling and soup eating time, we got the chance to talk with some of them. I found this experience to be pretty cool for a bunch of reasons, but the specific reason I'm bringing it up is because one of the three Moishe house tenants is in her fifth year of medical school (the program is 6 years long). Therefore we had the opportunity to learn a bit about how they do things.

And now, what I’m sure

you’ve been waiting some time for

the Haikummary

Day 1:

Self guided tour through

The part of Budapest near

Our hotel and dinner

Day 2:

Found a castle and

Church, got lost in a labyrinth for free,

And a biker’s bar

Day 3: 

Got bathed and massaged

Harikrishna meal in Pest

Played SET in Buda 

Day 4:

Toured the parliament

Ethnographized, strudelized

Opera-ized, cheaply 

Day 5:

Learned about Hungary’s

Past and present Jewish life,

And met some natives

Day 6

Thought provoking art

Vegan Hungarian food

And we departed

Main lessons learn-ed

Budapest is beautiful

And affordable 

- blogger of the month, Talie Lewis

Health insurance rates, by state

What's an average health insurance premium?

The Commonwealth Fund recently came out with a lengthy report summarizing state trends in health insurance premiums and deductibles from 2003 through 2009. (The upshot: premiums rose 41 percent nationally during those years, while per-person deductibles jumped 77 percent.)

In Washington state, the study found, the cost of premiums rose 38 percent between 2003 and 2009, with family coverage costing an average of $12,758 here in 2009.

How's that compare to everyone else? About in the middle. In a list of the 50 states plus Washington, D.C., from highest family premiums to lowest, we come in 28th.

Also, the Kaiser Family Foundation does an annual survey on employer health benefits. The most recent one -- based on data from January through May 2010 -- found that premiums had risen 114 percent from 2000 through 2010, to a national average of $13,770. Worker contributions during the same time rose -- brace yourself -- 147 percent. (Here's a link to the gigantic full health benefits report.)

Recent cases from our consumer files

Got an insurance question or problem and live in Washington? We may be able to help. (We're the state insurance regulator for Washington.) Give us a call at 1-800-562-6900 or e-mail AskMike@oic.wa.gov.

What kinds of things do we deal with? Here's a sampling of cases from last month:

• We convinced a health insurer to pay an additional $3,000 in surgery claims for a patient.
• We got another insurer to pay more than $10,000 in claims that had been denied due to what the company maintained was a pre-existing condition.
• We helped a Seattle consumer resolve claim delays on his mother's life insurance policy, leading to a $25,000 payment, plus interest.
• When a health insurer repeatedly refused to pay claims because the patient's birthdate on the claim forms didn't match what they (erroneously) had in their records, we got the situation resolved and the claims paid.
• And we helped mediate a dispute over a totaled vehicle's value, meaning that the consumer got nearly $1,000 more than originally offered.

Strikes and Struggles, by blogger of the month Sarah Meyers

I approached the Beer Sheva North train station, and saw two bored security guards standing in front of a locked door.  “Yesh Shvita Hayom”- there is a strike today.  No trains.  I realized I would have to call my friend and reorganize our travel plans according to the bus schedule.  Surprises like these are what happen if you don’t check the train website or the Israeli newspapers quite regularly.  Strikes are pretty frequent as well.

On my way to the bus station, I ran into A, my Arabic teacher outside of a coffee shop.  He told me how his office had wanted to send him up to Haifa that day, and without the train running, had given him the day off.  I later learned that the strike was called late the night before, shortly after my friend and I had checked the schedule, to protest the arrest of their union leader.

A little over a week ago, I came into Arabic class, and saw a classmate placing a bucket and a magev, the oversize squeegee they use for cleaning floors, against the wall.  I asked her what the magev was for, and she informed me that there was a “ma’avak” that evening.  “What does that mean,” I asked? She told me it was a “struggle,” a struggle for the rights of the cleaning workers on campus.  She explained that her student group was supporting the struggle of the campus janitors for better wages and rights, and because they were vulnerable in a strike, students were taking over their shifts that night, cleaning the campus, to educate other students and to show solidarity with the janitors.

A few months ago, as part of our Clinical and Global Medicine class, we were sent to interview geriatric patients at the hospital.  My group was under the supervision of a hospital social worker.  Her perspective was valuable: she critiqued me for not first building a strong enough rapport with a patient before proceeding to the medical history.  

At the end of the session, she told us to feel free to contact her any time we had any questions.  Except, she said as an afterthought, the social workers were all going on strike the next day, and she did not know when they would be back to work.  She told us how low their wages were, and how long it had been since they were given a raise.  For weeks after this, we saw protests across the street from the hospital, and social work students chanting and holding signs in intersection.  One day, everything was back to normal, except the social workers salaries, reported to be 25% higher.

Now it is the doctors’ turn to strike.  Periodically, they will strike for a single day affecting outpatients but not emergency care.  They say they are trying to minimize the disruption third year students rotations, and that the future of medicine is at stake.  - blogger of the month Sarah Meyers

Book review: Biology for Bodybuilders

The photos below show Doug Miller and his wife, Stephanie Miller. Doug is one of the most successful natural bodybuilders in the U.S.A. today. He is also a manager at an economics consulting firm and an entrepreneur. As if these were not enough, now he can add book author to his list of accomplishments. His book, Biology for Bodybuilders, has just been published.

(Source: www.dougmillerpro.com)

Doug studied biochemistry, molecular biology, and economics at the undergraduate level. His co-authors are Glenn Ellmers and Kevin Fontaine. Glenn is a regular commenter on this blog, a professional writer, and a certified Strength and Conditioning Specialist. Dr. Fontaine is an Associate Professor at the Johns Hopkins University’s School of Medicine and Bloomberg School of Public Health.

Biology for Bodybuilders is written in the first person by Doug, which is one of the appealing aspects of the book. This also allows Doug to say that his co-authors disagree with him sometimes, even as he outlines what works for him. Both Glenn and Kevin are described as following Paleolithic dieting approaches. Doug follows a more old school bodybuilding approach to dieting – e.g., he eats grains, and has multiple balanced meals everyday.

This relaxed approach to team writing neutralizes criticism from those who do not agree with Doug, at least to a certain extent. Maybe it was done on purpose; a smart idea. For example, I do not agree with everything Doug says in the book, but neither do Doug’s co-authors, by his own admission. Still, one thing we all have to agree with – from a competitive sports perspective, no one can question success.

At less than 120 pages, the book is certainly not encyclopedic, but it is quite packed with details about human physiology and metabolism for a book of this size. The scientific details are delivered in a direct and simple manner, through what I would describe as very good writing.

Doug has interesting ideas on how to push his limits as a bodybuilder. For example, he likes to train for muscle hypertrophy at around 20-30 lbs above his contest weight. Also, he likes to exercise at high repetition ranges, which many believe is not optimal for muscle growth. He does that even for mass building exercises, such as the deadlift. In this video he deadlifts 405 lbs for 27 repetitions.

Here it is important to point out that whether one is working out in the anaerobic range, which is where muscle hypertrophy tends to be maximized, is defined not by the number of repetitions but by the number of seconds a muscle group is placed under stress. The anaerobic range goes from around 20 to 120 seconds. If one does many repetitions, but does them fast, he or she will be in the anaerobic range. Incidentally, this is the range of strength training at which glycogen depletion is maximized.

I am not a bodybuilder, nor do I plan on becoming one, but I do admire athletes that excel in narrow sports. Also, I strongly believe in the health-promoting effects of moderate glycogen-depleting exercise, which includes strength training and sprints. Perhaps what top athletes like Doug do is not exactly optimal for long-term health, but it certainly beats sedentary behavior hands down. Or maybe top athletes will live long and healthy lives because the genetic makeup that allows them to be successful athletes is also conducive to great health.

In this respect, however, Doug is one of the people who have gotten the closest to convincing me that genes do not influence so much what one can achieve as a bodybuilder. In the book he shows a photo of himself at age 18, when he apparently weighed not much more than 135 lbs. Now, in his early 30s, he weighs 210-225 lbs during the offseason, at a height of 5'9". He has achieved this without taking steroids. Maybe he is a good example of compensatory adaptation, where obstacles lead to success.

If you are interested in natural bodybuilding, and/or the biology behind it, this book is highly recommended!

Healthy Skeptic Podcast and Reader Questions

Chris Kresser, Danny Roddy and I just finished recording the podcast that will be released on May 24th.  It went really well, and we think you'll find it informative and maybe even practical!

Unfortunately, we only got around to answering three of the questions I had selected:

1. How does one lose fat?
2. What do I (Stephan) eat?
3. Why do many people gain fat with age, especially postmenopausal women?

I feel guilty about that, so I'm going to answer three more right now.

Read more »

Fiscal responsibility means a dividend in patient care

By John Aldis
Vice-President Corporate and Post-Acute Services,
Chief Financial Officer

As we close the books on our successful three-year Deficit Elimination Plan (DEP), I’m pleased to report that the hospital continues to optimize spending of public funds on quality patient care.
The plan ended officially on March 31, 2011, and has set the foundation for the hospital to start making meaningful reinvestments in patient programs and services, continuous quality improvements, and new equipment that benefits our patients and staff.

Years of not balancing its books had put Rouge Valley Health System (RVHS) in a situation where it could not afford to maintain and renew its facilities and equipment. The hospital was essentially bankrupt. We had no surplus cash, we covered payroll through our line of credit, and the bank would not lend us any more money. Three years later, our collective efforts have paid off for patients and the hospital.

Our plan was not just about a financial turnaround. It was about balancing financial responsibility with access to services and quality improvement. We have maintained our DEP commitment by providing the same or greater access to quality care for our patients and community. In fact, we now see more patients than we did in 2007–08 before the DEP started.

Our success has truly been a team victory for the patients of our communities in east Toronto and west Durham. Staff, managers, physicians, and volunteers across our organization have pulled together to do more and better with less. We started by comparing ourselves to how the best hospitals were providing quality care with lower infection rates, lower return rates, and shorter wait times. They were doing all this and spending less per patient. Three years later, Rouge Valley is among the leaders in our peer group for quality and fiscal responsibility. We are delivering higher quality care, as measured by the province, while making the most of our funds for our patients.

We also embarked on a long-term transformation journey using a Lean management philosophy and teamwork after a platform for success had been established by our DEP.

Now, after years of chronic deficits, we have been spending within our means since 2008–09 generating surpluses, and becoming more efficient and effective each year. While our operating results for 2010–11 are not yet finalized, we have surpassed our budgeted bottom line of $5.2 million. This means we have money to allocate to operational priorities (e.g., programs and services such as pharmacy services, a short stay unit, and critical care staff training) and invest in new equipment (e.g., equipment for cardiac catheterization, surgery, and patient mobility) and maintenance for our hospital campus buildings, which were built in 1967 (Rouge Valley Centenary) and 1964 (Rouge Valley Ajax and Pickering). With our improved cash flow, we can also borrow for big ticket items that we have been unable to tackle for years.

The ongoing maintenance needs include rather unexciting, but crucial things such as a new boiler, new roofing systems, as well as fire, electrical and water system upgrades. We can’t go out and fundraise for these items. It just isn’t something people would be attracted to in a campaign. We also have major capital equipment needs like catheterization labs, central patient monitoring systems, and information technology. 

Being fiscally responsible and generating surpluses is the best way to ensure we have the facilities and equipment to be the best at what we do. Joint capital planning with the RVHS Foundation over the last three years is also helping focus the Foundation’s fundraising efforts on the hospital’s priorities such as an MRI scanner for our Rouge Valley Ajax and Pickering campus, diagnostic equipment, and new medical beds at our Rouge Valley Centenary campus.

Our DEP was just the beginning. A new three-year financial plan is being developed to support our recently refreshed Strategic Plan On-A-Page. I look forward to sharing this plan with you in the summer and continuing to build on our success over the next three years. 

I congratulate all staff, management, physicians, board members and volunteers for this outstanding achievement. We are reinvesting in the future for our patients and communities thanks to you.

Seeing Complexity and Humanity, by blogger of the month Sarah Meyers

 I was planning to blog about my trip to Petra, but us MSIH students are so good at blogging about our travels (and we are awfully well located for travelling) that I didn’t want to give the impression that we never learn anything.  So instead, I am going to write about my Anthropology final project. 

The Anthropology class that MSIH students are required to take has had its ups and downs.  There have been some fascinating, eye-opening discussions, some lectures that students left many students frustrated, and an unexpected change in professors part way through. But as the Professor explained our final assignment to read and review an ethnographic account, I found myself getting quite excited.  There was a book, called Tally’s Corner, by Dr. Elliot Leibow, that  I had been itching to read for years, since a physician I worked with recommended it, and I was pretty sure it was an ethnography.  About ten minutes later, I realized that I had missed a particular detail that the book had to be an ethnography of the body, or relating to how a different culture views issues relating to bodies.  After a few minutes of disappointment, I decided to ask the teacher to make an exception. 

After class, I stayed behind to speak with the professor about this book.  I told her how I had come across this book.  While talking with Dr. H., who was spending his retirement providing free primary care for the homeless, the topic came up of how sometimes it was difficult to understand where our patients were coming from.  Being fresh out of college, an awful lot of what I knew came (and probably still comes) from lectures and books, so I described how I thought a book I had once been assigned called “Tell Them Who I Am: The Lives of Homeless Women,” by Dr. Elliot Leibow, had given me insight into some of the forces at work that lead to one becoming homeless, and make homelessness particularly hard to escape.  One point that stayed with me was his observation that while homelessness was often caused by substance abuse and/or mental illness, it was also common for homelessness to cause these things.  

I tried to imagine what it would be like have my life fall apart until I was living in a shelter or sleeping in the streets, and it was hard to imagine not becoming paralyzingly depressed and anxious from such an experience.  More and more I felt a deep respect for the patients who could cheerfully come into the clinic and wish everyone a”blessed day,” and empathy for those who came in and were cantankerous or combative.

When Dr. H borrowed that book from me, he returned it with the recommendation that I read “Tally’s Corner: A Study of Negro Streetcorner Men” by the same author.  While a bit dated, he said, the book provided insight into the lives of poor men working jobs that paid well below a living wage, which was a population that had large overlap with our homeless patients.

So what do two books describing people’s relationships with their families, their jobs, their friendships, where they live and how they pass their days, have to do with Medicine?

That was what I discussed, albeit in less detail, with the anthropology professor. (As you may have guessed, she allowed me to use the book for my final paper.)  It gave insight into why one woman, at high risk for cervical cancer, could not be reached for a reminder to get a Pap smear: her cell phone service had lapsed, and under the two listings for emergency contacts, she had heart-breakingly filled out “no one” each time.  His description of how some might have a well founded belief that their life would not improve, leading them to blow any money they saved, or casually quit a job, gave context to the patient who had a job but could not afford the co-payments for their medications.

But while the above lessons were useful, they are not the main value in Leibow’s work.  Leibow’s style is to give voice to peoples’ stories, and in doing so, the caricatures and stereotypes fall away, unveiling people who are often flawed, often generous, and trying to do the best they can in a difficult world.  I believe that no matter how compassionate and open-minded a doctor is, having a starting point for understanding the complexity and humanity of a patient will lead to a more empathetic relationship with the patient, greater trust in the doctor, and more appropriate care.

A criticism sometimes levelled at Leibow’s work is that as an outsider, there is only so much he could really know about the lives of the people in his book.  Yet, John Kelly from the Washington Post reported that when Leibow died of cancer in 1994, “[h]is funeral was attended by people he had written about in both books.” (27 Feb 2011.)  While a white Jewish man with a post-graduate education may by definition be an outsider in the communities he studies, the relationships he build through the course of his research were strong enough to last for decades.  So here’s to hoping that we, as future doctors, develop a fraction of that rapport with our patients. 

Highly recommended:

Tally’s Corner: A study of Streercorner Negro Men.  by Elliot Leibow

Tell Them Who I Am: The Lives of Homeless Women.  by Elliot Leibow. 

P.S. Going to Petra, Jordan, is also highly recommended. - blogger of the month, Sarah Meyers

New study: Dog bites account for 1/3 of homeowners insurance liability claims

The Insurance Information Institute, an industry-funded research group, has released a study saying that dog bites account for more than one third of all homeowners insurance liability claims last year.

The total: nearly $413 million, which averages out to more than $26,000 per claim.

The number of claims dropped slightly in recent years, although the cost of the claims rose.

According to the III, there were 15,770 dog bite claims filed last year. According to the federal Centers for Disease Control and Prevention, 4.5 million Americans are bitten by dogs each year, with one in five of those bites needing medical care.

Update: Also, here's a summary of Washington's dog bite liability laws from, yes, the website dogbitelaw.com. (Thanks to Fritz for passing that along, and all these links come with our usual disclaimer: linking ≠ endorsement.)

A moment to remember, by May blogger of the month Sarah Meyers

The siren caught me by surprise.  I was walking around downtown Eilat with three of my friends and classmates, looking for a place to have dinner, when the siren began to wail, a softer, more plaintive sound than the sirens we heard when rockets were coming.  People around us stopped walking and bowed their heads.  My friends and I realized was was happening, and also stopped walking and stood in silence.

The sun had gone down, marking the beginning of Yom HaZikaron, Israel’s memorial day.  I was on my way to a vacation in Petra Jordan with my friends. (I highly recommend Talie Lewis’s excellent recent posts on both the similarly-observed Holocaust Remebrance Day, and MSIH students’ tendency to travel.)  Yom HaZikaron remembers both fallen soldiers and victims of terror attacks, and not being Israeli, I had not expected to have much to remember.

But as I stood there silently, memories began to come back.  I volunteered with Magen David Adom in Jerusalem back in 2004, when terror attacks were ever-present.  I stood and remembered the patients I had tried to help, and those who had been beyond help.  I did not know their names and could not remember their faces.  One man, I later learned, was a journalist, fighting against the culture of silence that surrounded the abuse of children in his religious community.  Another was the seventeen-year old son of a woman I knew, on his way to school. 

This moment of silence brought to mind another day of memorial that I had once observed.  While working at a clinic for the homeless in Washington, DC, the staff held a ceremony on the day on the winter solstice and the longest night of the year, to remember the people who had died while homeless in the previous year.  The doctors and nurses took turns reading the list of names for the homeless in DC.  After each ten names, the reader said “for these we pray” or “these we remember” and we sat there in silence for a moment.  Occasionally there was a gasp of surprise as someone learned for the first time that a patient of theirs had passed away.

Both within the context of our healer’s art elective, and outside of it, conversations have taken place here at MSIH about the idea that doctors should maintain a professional distance or detachment from their patients, so as to avoid burn-out.

My thought is that there is strength in caring, strength in mourning, and strength in these ceremonies.  They reinforce our empathy and our compassion. They touch on what makes us humans rather than automotons.  And so, as I study here at MSIH to become a doctor, I hope to continue to care for, to remember, and to mourn, the patients whose lives touch mine, even if only briefly.

May their memories be a blessing.  - May blogger of the month Sarah Meyers

Administrative Note

My blog is being mercilessly ripped off by cheesy feed aggregators that are using my material for commercial gain, often without attribution.  I was able to ignore them when there were only one or two, and when they appeared far down the list on Google searches.  But at this point, there are 20+ rip-off sites that ride my coattails under questionable circumstances, and are getting decent Google rankings, so I've had enough.  I'm changing my feed settings so that I only partially syndicate my posts, and I'm adding a short plagiarism warning to each post.

What that means is that if you're using an RSS reader, you'll have to click through to my blog to read my material in full.  I apologize for the inconvenience, but I don't see any other solution.

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A Spontaneous, Hungarian-flavored excursion, by blogger of the month Talie Lewis

The King's Hotel lobby

Our group leaves the subway station

This past Friday, five classmates and I decided to book a 6-day Eastern European excursion for this week. Therefore, this post is actually being written in a hotel lobby in Budapest. We arrived this morning around 11 am after spending the night in Ben Gurion Airport and taking a 7:30 am flight to Hungary. Now you may be wondering how it is possible for us to take 6 days off of school. Well, it turns out we have a pseudo-five day break. Other than completing an anthropology take-home final, which we plan to write in an internet cafe tomorrow, we have no other academic obligations this week. This is a nice break that marks the end of our finals period, which, aside from out anthropology exam, came to an end yesterday following our epidemiology final. 

Now that I have hopefully clarified for any readers that we are not totally irresponsible, I will use this opportunity to tell you a bit about the connection between MSIH students and traveling. This shouldn't come as a surprise but many of my classmates love to travel. And it turns out there are a lot of really great package deals offered with Israel as a starting point. So when it comes to traveling, Israel is a pretty great place to be. Therefore, over the course of the year, people have gone to Turkey, Egypt, Greece, Italy, Switzerland, Austria, Romania, Spain, Hungary, some other exciting places, and of course, all over Israel.

While I have spent the previous breaks this year visiting family and friends around Israel, this break, I guess I caught the traveling bug. And after the first day of this change of pace, I must say, it's been great!    

At the airport this morning, we were greeted by a lovely man from the travel company through which we booked our trip. He gave us directions to board a bus with a whole group of Israeli tourists, and then we arrived out The King's Hotel, our home base until next Saturday night. The hotel is actually quite nice and we were pleasantly surprised. After dropping our bags off, we decided to take a self-guided walking tour through Budapest and hit some expected and unexpected sights along the way, including some a profoundly metaphoric monument, a lonely statue that just need some love, a body of water filled with pieces of modern art and a beer circus. Much of what we saw on the tour was quite intriguing and I think we all came out of it with an appreciation for the beauty of this vibrant, rich city.

Something else that seems notable is the Hungarian currency, which is the forint; 175 forints are equivalent to one dollar. So that means, when you buy a cup of coffee, it may cost 500 forints. That takes a little getting used to.

Well... tonight we discussed our plans for the rest of the week and they include what I am anticipating to be some exciting adventures. - blogger of the month, Talie Lewis