H1N1 Update and ABC News 10 Sacramento

Streaming live on ABC 10 today with Sharon Ito about questions regarding H1N1 vaccine.

Sharon's summary of today's discussion.

SACRAMENTO, CA - On Monday's Live_Online at 11 a.m., we talked with frequent contributor Dr. Davis Liu, a family physician with Kaiser.

Liu said Kaiser, along with other health providers, are still awaiting additional shipments of the H1N1 vaccine. He said Kaiser closed its flu shot clinics a couple of weeks ago after running out of the vaccine, but he expects the vaccinations to resume shortly. Liu said the vaccine's manufacturers were overly optimistic when initially projecting the distribution of the vaccine.

Liu told viewers he can't understand why some doctors and nurses around the country have refused to get the H1N1 vaccine, especially when they're seeing sick patients and their potential exposure to the virus can infect other people.

Liu told viewers the manufacture of the H1N1 vaccine is similar to the production of other flu vaccines, and he said those methods have proven safe.

You can reach Live_Online at: LiveOnline@news10.net

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Watch the entire interview here.

Secrets to Weight Loss -- Part Two -- The Body Doesn't Lie

Now a couple days after Thankgiving, an important concept to remember is the following:


The body doesn't lie.


We've all eaten a little too much. If we've done any exercise, then it is likely standing in line during Black Friday (or clicking the mouse on Cyber Monday). We should not be shocked about some weight gain. Although my patients find it hard to believe, the body doesn't lie and are stunned that they continue to gain weight in subsequent office visits. It can't be due to anything they are doing.


It must be due to a medical problem. Aside from hypothyroidism, low thyroid levels which can be determined by a simple blood test, or other even less common illnesses like Cushing's disease, the reality is that the vast majority of individuals I see who are overweight or obese simply due to their dietary and caloric intake. Simply put, they eat more than they burn.


It isn't necessarily due to a lack of willpower. The majority of patients who are obese (body mass index or BMI of 30 or greater) report to me that they were normal weight at the end of high school. Decrease activity, disability, and pregnancy are some reasons patients are heavier than years past. Many not only are surprised about their weight gain, but also on how difficult it is to lose.


Why is it more difficult to lose? Caloric intake or eaten exceeds that which is expended or burned off. It doesn't take much.


A typical American is supposed to take in only 2000 calories per day. Sounds like a lot, but it isn't. An In and Out cheeseburger with cheese, fries, and a soda is 1100 calories. A Subway 6" cold cut combo, mayonnaise, soda, and chocolate cookie will add another 950 calories. Eat one for lunch and the other for breakfast and one has already exceeded the 2000 calorie daily limit. Not a lot of food.


Many of my patients who work construction don't realize how many calories they eat when going out to lunch. A typical Burger King double whopper with cheese, large fries, and large regular soda equals 1890 calories! Yet, they don't feel like they overeat. Nevertheless, the body doesn't lie and neither does the scale (although many of my patients swear that our office scale isn't accurate).


Portion sizes have increased over the past couple of decades. Despite well meaning public initiatives like having nutritional and calorie information available on menus, it is doubtful that alone will help change behavior. What is needed isn't the calories, but how much physical activity one needs to do to burn off the extra calories.


Image if a slice of pizza came with the disclaimer, each slice requires a 30 minute walk. With activity listed rather than calories, individuals would begin asking themselves whether second helpings, supersizing meals, or even finishing the entire meal (rather than taking it home) would be a good idea.


Since it only takes 3500 calories to equal a pound. Any calories left unused the body dutifully begins storing for a rainy day (which doesn't occur as much industrialized countries as it does other places around the world). Since the rainy day never comes, your increased fat stores result in a heavier weight.


Unless the food and restaurant industry voluntarily decreases portion sizes, then expect more Americans to be heavier and less healthy. Cases of obesity and type 2 diabetes are occurring at an alarming rate. It is expected that children born since 2000, will be the first generation of Americans not to live as long as their parents. While type 2 diabetes affects about 1 in 4 adults over age 65, for children born at the beginning of this century the rate will be 1 in 3.


Is it the food and restaurant industries fault for the obesity epidemic? Regardless of what you believe, it is unlikely that significant changes in health will be the result of those organizations making substantial changes. Americans demand cheap food that is quick and convenient.


So the world is against you in maintaining a healthy weight (or losing weight if you are overweight or obese).


What can you do? Some simple ideas:

• Purchase some frozen lunches / dinners with the Weight Watchers, Healthy Choice, South Beach labeling. Save the containers and use those as your new plates. Don't pack in the food. Don't go for seconds.
• Switch to diet sodas or zero calorie drinks like water or tea.
• If drinking fruit juices, consider diluting the amount with water.
• Never ever supersize anything. Consider having children sized meals or smaller versions.
• Avoid packaged foods like chips, cookies, candies etc., and opt for fruits.
• Hold off on second helpings (and don't simply double the size of the first helping).

Learn more about calories and more importantly how much activity you must do to burn off the calories to maintain or lose weight by reviewing the Portion Distortion quiz by the National Heart, Lung, and Blood Institute and other information by the U.S. Department of Human and Health Services.


Remember, the body doesn't lie.


Check with your doctor if you have special dietary needs or diabetes whether the above dietary adjustments are safe to do. Make the changes permanent. It's a lifestyle change. Don't expect friends or family necessarily to follow suit. It really is building a system that you can do consistently daily in response to a society which encourages more food and calories.


Any other helpful tips or ideas?

e-Patients, Dr. Google, Your Doctor, and You

A recent article by NPR confirmed what many patients and doctors already know. The internet is leveling the playing field and allows individuals to access information easier and more quickly. Research by Pew Internet and American Life Project found:

• 61 percent of adults say they look online for health information - known as e-patients
• 20 percent of e-patients go to Internet and social-networking sites where they can talk to medical experts and other patients
• 39 percent of e-patients already use a social-networking site like Facebook
  

Yet as individuals embrace new technology, the New England Journal of Medicine found earlier this year that only 17 percent of doctors use electronic medical records. To say doctors are conservative and slow in adapting to new ways of communicating and accessing information would be an understatement. An article in TIME magazine proclaimed "Email Your Doctor" which graced newsstands in 1998! Email communications with doctors is still the exception rather than the rule.

Many doctors actually are very concerned about patients using the internet to research information. Stories of physicians being inundated with printouts or patients insistent that they have a certain diagnosis based on a description abound. Doctors don't always appreciate patients googling their medical information.

Why?

Because although information gathering is far easier than a decade ago, the problem is data overload. How does one filter out all of the different diagnoses with similar symptoms? How does one use judgment when theirs is based on little experience? Medical students commonly come down with medical illnesses after studying a subject. It's the power of suggestion. Fever and a little neck stiffness? Meningitis. Intermittent numbness in the arm? Multiple sclerosis. Circular rash? Lyme disease.

Only through experience and actually caring for patients diagnosed by more seasoned colleagues do medical students see the textbook descriptions come to life. Patients diagnosed with meningitis, multiple sclerosis, and Lyme disease and their associated symptoms and signs are seared into students' memories. Words in the textbook now have far different meanings. Reading and book learning while important only provides the foundation to build upon. It's seeing and doing that matter.

Doctors can't know everything. So it can be helpful if you research information and bring in some ideas or questions that you have about a particular diagnosis. I know patients are more empowered with more information, but realize there is still value in clinical expertise. Have a frank discussion with your doctor whether the information obtained by Dr. Google is accurate or relevant to your concerns. Keep an open mind. Don't be anchored by what you read. I certainly learn from my patients. My patients learn from me. It's a win-win.

While the internet can make anyone more knowledgeable, it doesn't make someone an expert. The good news is that the survey found in the end that the source people still trust the most is their doctor. So go ahead research, but find reputable sources like the Mayo Clinic or Medline Plus. Talk to your doctor and perhaps email him. Gain from both knowledge tempered with expertise.

As we all gather around for Thanksgiving, savor the time with family and friends. While I would never be mistaken for a chef, let alone a good cook, I will be making a delicious butternut squash soup which is a new Thanksgiving tradition. The recipe? Courtesy of the internet and Wolfgang Puck. How hard could it be? I finished organic chemistry.

Breast Cancer Screening with Mammograms at age 40? 50? Who is the USPSTF?

When the U.S. Preventive Services Task Force (USPSTF) updated their recommendations and were against routine mammography for women aged 40 to 49, it certainly got a lot of attention. These guidelines are far different than those advocated by the American Cancer Society (ACS) which recommends screening starting at age 40 with annual mammograms.

• Who is the USPSTF?
• What does their recommendations mean for women?
• Why is there conflicting recommendations?

Who is the USPSTF?

The U.S. Preventive Services Task Force (USPSTF) is an independent committee of primary care and preventive physicians that periodically reviews the latest medical research and recommends tests and screening methods that have scientifically been shown to make a difference. As a result, its recommendations are the most conservative of any national organization.

The USPSTF’s recommendations are considered the “gold standard” for determining which clinical services are preventive. They review and look at various screening tests and preventive medications to determine whether there’s proof these interventions work and that the benefits they provide outweigh the potential harm. USPSTF indicates how strongly it recommends a particular method with a letter grade designation (A, B, C, D, and I). An A recommendation means that USPSTF strongly recommends that doctors provide a particular service to eligible patients. A B rating is simply a recommendation. A C means the task force recommends against routinely providing the service, but leaves the decision to the discretion of the individual doctor and patient. A D rating means the group recommends against providing for a particular intervention. An I recommendation indicates that there is not enough evidence to determine whether to recommend for or against a particular procedure.

The USPSTF recommendations tend to be the most conservative of any national organization, because they look for interventions that have proven benefits backed by research. Therefore, promising new technologies and tests that are yet unproven (and at times remain unproven or shown to be no better than existing tests) will not be recommended. As a result, the USPSTF’s guidelines may lag behind those of other organizations. But because they set such a high standard before recommending a particular treatment, insurers should cover the tests and procedures rated A and B.

From the November 2009 update on breast cancer screening update, the USPSTF recommended:

• Against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.
  

• Recommended biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.
  

• Against teaching breast self-examination (BSE). Grade: D recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement.
  

• Insufficient evidence to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

What does this mean for women?

First, that there is some evidence that screening between ages 40 to 49 for breast cancer among women with average risk may not be as beneficial as we previously thought. There has been evidence from other countries, like Canada, which have suggested that. However, it is highly unlikely that the American Cancer Society (ACS), being an advocacy group for cancer awareness will change their stance. They said as much with the following:

The USPSTF says that screening 1,339 women in their 50s to save one life makes screening worthwhile in that age group. Yet USPSTF also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms. Surveys of women show that they are aware of these limitations, and also place high value on detecting breast cancer early.

The American Cancer Society neglects to mention the potential number of extra women harmed with the extra screening between age 40 to 49. An additional 565 women need to be screened above and beyond the 1,339 women to save one life. Within this additional group, many women will have abnormal mammograms and require breast biopsies only to discover that the results were normal. The mammogram was a false-positive.

The USPSTF found in a study in the Annals of Internal Medicine, funded by the National Cancer Institute, that screening every other year achieved over 80 percent of the benefit of screening annually while cutting the false-positive result by nearly half. While every other year screening from age 50 to 69 years resulted in about a median 16.5% (range, 15% to 23%) decrease in breast cancer deaths compared to no screening, starting mammogram at age 40 decrease the death rate further by 3 percent, but increased the costs as more false-positive cases occurred. This article helped influence their recent decision.

Realistically for women, since ACS will not change their recommendation, is that mammograms will still be a covered benefit for any woman who desires to have a mammogram as early as age 40 and can be repeated annually.

What does this mean for you? If you are worried about breast cancer, consider getting screened starting at age 40, however, the benefit of screening may not be as good as we first thought. Certainly if there is a family history of breast cancer, you should discuss with your doctor whether mammography is enough or whether a breast MRI is needed.

Why are there conflicting information?

This won't be the first time USPSTF will have different recommendations than groups like ACS or other professional medical associations. Reasonable doctors and researchers can look at the same data and have different results. It speaks to the problem of screening for cancers and the tools that we currently have. The amount of precision that we would like as patients and doctors in identifying which group of individuals truly need a screening intervention and who does not have yet to be discovered. USPSTF and ACS disagree a bit on colon cancer screening as well. For example, when it comes to colon cancer screening USPSTF gives a grade A recommendation and suggests that:

Using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods may vary.

Yet, ACS also recommends virtual colonoscopy or stool DNA testing as reasonable alternatives even though there is no proof they save lives.

Stay tuned. Medical science continues to evolve and recommendations continue to change. The the mean time, exercise regularly, don't smoke, eat five servings of fruits and vegetables daily, and you might extend your life by an additional 14 years!

Your most crucial and trusted relationship is between you and your doctor. Questions? Speak up and ask. Don't be scared. Be informed.

Secrets To Weight Loss - Part One

It's disturbing that in the United States, two-thirds of Americans are either overweight or obese. As a doctor, it is one of the most common problems I address, even if a patient doesn't ask me to. Got a cold? Feeling stressed? Want a physical? Rolled your ankle?

Has anyone ever discussed your weight? Are you concerned about your weight? What have you tried for weight loss? What did you find successful?

In this series, I'll reviewed my discussions with patients so you understand what it will take to lose weight and keep it off.

Losing weight is hard work and frankly can be a difficult and lonely experience since the majority of Americans are overweight or obese. The problem of heaviness in this country is only becoming worse.

First some basic concepts. Overweight is defined as a body mass index or BMI greater than 25 and less then 30. Obesity is a BMI greater than 30. Morbid obesity is a BMI greater than 40. Calculate your BMI. Although BMI isn't perfect, unless you are a high performing athlete (not a weekend warrior) and have significant muscle mass, BMI is a reasonable way of determining which category you fit into.

Second, the body does not lie. Unless you have some sort of medical problem like a low functioning thyroid (hypothyroidism) or other less common hormone problem, your body does not lie. If you eat exactly the same amount as you burn, then you will not lose or gain weight. Eating less and burning more consistently will cause weight loss. Eating more and burning less will result in weight gain. Simple concept. What goes in must equal what goes out to maintain weight. Any alteration in this simple equation causes weight loss or weight gain. The body does not lie.

Third, I don't think you overeat to the degree you think I do. Patients invariably tell me that they eat very little and certainly a lot less than their friends or family. While I know individuals aren't eating a Thanksgiving dinner or eating an entire large pizza for lunch daily, weight loss requires a caloric intake less than the output. Note the previous point the body does not lie. If a person did eat a lot, he would continue to gain weight, not maintain.

Fourth, you need to understand basic math. Know this number. 3500. An addition of 3500 calories equals one pound. If your body has 3500 calories left over, then you gain a pound. Burning 3500 calories, then you lose a pound. Sounds like a lot of calories, doesn't it? But it's not. If you drank a can of regular soda daily (and yes, diet doesn't count as it has zero calories), then that is an extra 130 calories per day. In 27 days less than one month you would gain a pound (3500 / 130 = 27). In one year you would be 12 pounds heavier.

Fifth, think of calories as money and your weight as a savings account. Your savings account goes up or down depending on how much you save. Put more into the bank and withdraw less? More in your savings account. Taking out more than you put in, the amount in the savings account falls. Your bank doesn't care if you deposit $100 in pennies or in a crisp C-note. Skipping the discussion of nutritional value, your body doesn't care if the 2000 calories you are supposed to ingest comes all via salad greens or the equivalent of a box of chocolates. Money is money. Calories are calories regardless of how you get them.

Sixth, your body is built for survival and isn't stupid. Go back to the previous point. Your weight is a savings account and to keep it level what goes in equals what goes out. If all of a sudden, your income gets cut then to make ends meet you must take withdrawals from your bank account. If the income doesn't return to previous levels, then the savings account continues to get smaller.

Faced with this situation of being unable to restore deposits to previous levels, would you continue to spend as much? Of course not. To avoid bankruptcy you would make hard choices like downsizing your expenses and making adjustments. As a result you slow down the outflow of money so that eventually the amount that you spend is equal to the new decreased amount coming in.

Your body is built for survival and isn't stupid either. Faced with a budget crisis, that is a diet where calories coming in is less than what is burned, initially the body hasn't had adequate time to make adjustments. It depletes its savings resulting in weight loss. But since it is built for survival, it will make adjustments necessary to that its expenditures exactly made your diet. You no longer lose weight. Your body doesn't know whether it is on a desert island or living in the United States where food is plentiful, but all it knows is that its caloric budget was cut. It needs to keep you alive until it can find its next meal. Adjustments are made. Weight loss stops. Naturally, it will deplete fat first, then muscle. So don't worry about that being a reason not to being weight loss.

Seventh, the vast majority of patients I see weren't overweight or obese to being with. Weight gain typically occurred after high school or college, job change which was less physically demanding, after pregnancy, and as they got older. Sadly this isn't the case today where children are increasingly obese and will be the first generation of Americans not to live as long as their patients because of weight related medical problems.

Finally, the success to long term weight loss is permanent reduction in calories and increase in physical activity. It's not a diet but a lifestyle change. You can lose weight in the short-term with fewer calories, which is the reason why gastric bypass works. However, long-term weight loss requires physical activity.

Union Behavior Might Be Obstacles in Transforming American Healthcare

Some interesting articles in USA Today regarding union positions about the H1N1 vaccine which suggest that transforming American medicine so that it is higher quality, improved access, and even more affordable will be extremely difficult if not impossible.

Some hospitals, healthcare organizations, and the state of New York attempted to have staff required to get the seasonal and H1N1 vaccines. Even though, Infectious Diseases Society of America recommended all healthcare workers get flu shots, the Service Employees International Union (SEIU) opposed this and won.

Although patients are lining up demanding flu shots, doctors and the Centers for Disease Control want those at risk, SEIU indicates that the issue is education, rather than attaining compliance by fiat. To be completely fair, too many doctors don't get vaccinated either which is equally as disturbing. In healthcare, we make too many exceptions rather than require that the right thing gets done at all times.

While I was troubled by the behavior of SEIU, I can understand while disagree with their opposition to mandatory vaccination. It seems more of a political decision rather than scientific.

Yet, later that week SEIU was again in the news. This time upset about the distribution of flu vaccine to companies that have employed in-house doctors and clinics. Specifically, the union had a problem with companies like Goldman Sachs which received vaccinations from the City of New York in a equitable system where only those at highest risk (chronic illnesses or pregnancy) were to be immunized and the original distribution was reserved for pediatricians and obstetricians who requested vaccine. Sadly only about half of the pediatricians in New York City wanted it. As a result, the city moved on to give vaccines to those doctors caring for adults, which included the physicians working at Goldman Sachs as well as the Federal Reserve Bank, Columbia hospital, and Time. From the article:

"Wall Street banks have already taken so much from us. They've taken trillions of our tax dollars. They've taken away people's homes who are struggling to pay the bills," union official John VanDeventer wrote on the Service Employees International Union website. "But they should not be allowed to take away our health and well-being."

The union has about 2 million members, including health care workers.

Um, so wait. Healthcare workers are considered a high-risk group as defined by CDC. Naturally healthcare workers should be among the first in line to get the vaccine. If you had agreed to a mandatory vaccination program for those in the union who are healthcare workers, wouldn't that mean those in your union therefore are vaccinated and kept healthy? Getting the vaccine, which is in short supply wouldn't be a take away, but a benefit!

Having mandatory vaccinations in really only a small issue in a much larger problem. How can employers and unions get together and transform American healthcare?

To be clear, I'm not opposed to unions. One of the most successful organizations ever is Southwest Airlines, which to the surprise of many who don't know, is among the most unionized airline in the country.

I'm troubled because companies like General Motors failed because unions and employers were unable to see eye to eye. As a result, it failed because it was unable to compete with foreign competitors. Unlike the auto business, there foreign national healthcare organizations wishing to take over the US marketplace.

What it does mean, however, that making healthcare better and cheaper won't happen. Result? Government takeover or increasingly more Americans uninsured, worsening healthcare quality, and increased costs.

An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All

A fascinating article and equally disturbing is a fantastic article from Wired magazine. An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All is an objective look at the two different camps regarding vaccinations and the concern whether they are the cause of autism.

Both camps want to keep children safe. Both have very different ideas on what that means. For doctors and the medical profession, the science has been drowned out by a very effective media savvy campaign which has resulted in significant decreases in immunization rates resulting in the return of previously contained childhood illnesses like measles and pertussis.

As the internet connects more of us and removes obstacles for acquiring knowledge, it has instead reinforced and caused polarization not only in politics, but even more so in medicine.

Find out the truth on how to stay healthy and well by asking questions, listening to opposing points of view, and then making your own decision. I learn from patients. Patients learn from me.

As the article rightly notes, choosing not to have a child vaccinated isn't risk free, but rather a different set of risks occur. While I may disagree with patient's decisions, I do respect them as long as I feel they are informed about the pros and cons. I only hope that they choose based on rational thinking rather than emotional fear.

Can Doctors Provide Rational Care or Cave In? H1N1 Experience with Public Health Indicates Latter

As the country discusses providing everyone with health insurance, an even more important conversation is how to slow the rise of healthcare costs. Many studies and research point to the ability of doctors to remove waste by not performing unnecessary tests or procedures and not prescribing the latest medications which are proven to be no better than generic versions. There is a belief that much of this additional cost is due to the fee for service reimbursement system where doctors get paid more to do more.

For example, spending 30 minutes on nutritional counseling, weight loss, and exercise for one patient with hypertension doesn't pay as much as prescribing blood pressure medication for three patients in 10 minutes. In the fee for service environment, volume is key, not necessarily providing the right care or the most rational care. A recent Newsweek opinion piece by an emergency doctor showed how he evaluated a patient appropriately for a recent head injury, discussed the plan with the family, and arranged follow-up with the pediatrician all without getting a CT scan of the head. Result? Patient did fine. No radiation exposure to the brain. No additional cost to the healthcare system, insurer, or family. Everyone benefited.

While the example isn't rare, it also isn't common. Some 30 percent of tests or procedures performed in this country have been suggested to be unnecessary and added no value to improving patients' quality of life or outcomes.

In other words, if we removed the fee for service reimbursement system, then doctors would prescribe only the right care. Not too much or too little, but just right.

Or would they?

Recent articles should make us think twice. The H1N1 virus which has been demonstrated to affect those under age 25 years old and pregnant women disproportionately than the general population now has a vaccine available, albeit in short supply. This limited supply has been given to individuals not deemed at high-risk for adverse outcomes by CDC.

While the issue might be that some public county clinics received more vaccine than others (a systems or distribution problem), the bigger question is whether public county officials and doctors are willing to have honest and frank discussions about a person's need for the vaccine. Unlike doctors in the fee for service environment, these providers don't get paid more to do more. Since compensation isn't an issue, then can they talk through the fear that people have and provide the appropriate care?

Answer? Unfortunately no. Public health officials don't want to be the police and determine who should justifiably get the vaccine and who should be turned away.

In other words, if people want it, then they will get it. If public health officials can't say no appropriately, then can we expect much better for doctors in the future? Even if the fee for service reimbursement structure is removed, unclear if that will ever happen, will doctors provide rational care and advice or cave in when patients demand prescriptions based on television ads or care recommended by celebrities?

As I received my vaccine at a flu clinic, there were nurses asking each individual in line what vaccine did they want. The nurses appropriately advised those not in the high-risk groups that they would only receive the seasonal flu vaccine and not the H1N1 vaccine. There were no fights, outbursts, or fear. Patients understood that they were getting the right care. Not too much and not too little, but just right.

If America is going to solve the affordability issue of healthcare, then doctors will need to lead the way.

Based on the public clinic officials' performance, I'm even less optimistic about the medical profession's ability as a whole. While I have great confidence in my fellow medical school alumni from the University of Connecticut School of Medicine, the colleagues I work with at the Permanente Medical Group as well as the many medical bloggers I've encountered (many who follow me via Facebook or Twitter - thanks everyone!) , I have real concern about many doctors nationwide and specifically on their ability to provide rational care and not to cave in and take the easy way out when making decisions about medical care.

What does this ultimately mean? Without doctors leading the way, the only choice left is government run healthcare. If doctors can't say no based on scientific and medical evidence, then Uncle Sam will say no. Don't say I didn't warn you.