As anyone who reads this blog ought to know, I love Texas. I used to have the bumper sticker that said that I wasn't born here but I got here as fast as I could. I don't know if it'll happen, but I'd greatly like for my wife and I to settle down in Texas. If my fondness for Texas were any less, though, I would have told the whole state that it can go to Hell courtesy of its medical board.

As it stands right now we're going to be in Austin for at least a year longer than initially planned. I'm not complaining, mind you, but we're largely doing it because my wife was passed up on a couple fellowships out of state. It's possible that she would have been passed up anyway, but she had the huge strike against her that she would not have been able to start on their start date. Why? Because she will be finishing her tour here a month late. Why? Because of the Texas Medical Board that honestly didn't seem to care if my wife set herself up in Texas or somewhere else.

Texas has an impending shortage of doctors and you would think that they would be chomping at the bit to get doctors accredited as quickly as possible (barring legitimate reason for concern) to prevent that from happening. At the very least you would think that they would avoid being antagonistic towards the doctors that want to set up practice in this state. But instead, Texas has the reputation for being a difficult state for licensure and a headache for would-be Texas doctors.

It would be one thing if the purpose of this was to root out bad doctors, but as far as I know Texas's approval rate for doctors seeking licensure is no lower than other states. But they still drag doctors seeking licensure in front of hostile panels over issues where no crimes have occurred, no one has been hurt, and no AMA or state regulations have been skirted. Eric Scheffey ruined bodies and lives for years and they couldn't find a way to do anything about it until 2003, but they nonetheless have a new would-be doctor track down her medical records dating back ten years (from a dozen doctors in three states) and more-or-less strip her of her medical confidentiality (it's all in her file now) for having the nerve to want to practice medicine in Texas with a less-than-pristine medical history of her own back in Oklahoma, a decade ago.

Again, we're talking about things that have affected patient care in the three years she was a resident in Idaho or when she was a medical student making the rounds in Louisiana. All of this for a physician-in-training license wherein even now that she has it she couldn't practice without another doctor's supervision (she's more than a resident, but less than a fully licensed doc).

Since we're going to be staying in Texas, though, she's going to have to do some temp work (also known as "locum tenens") to try to bide time to try again for another fellowship. To do so she's going to have to apply for full medical licensure. As it turns out the Chronicle had an unusually worthwhile article on the subject and how it pertains to Texas's shortage of doctors in general.

Dr. Kimberly Bingaman, a pediatric neurosurgeon at San Antonio's Christus Santa Rosa, tells a different temping tale.

The 39-year-old mother of three moved to San Antonio from Augusta, Ga., last May, expecting to begin working in June. The license she applied for in February, however, did not arrive until October.

"I have licenses in nine other states, so I started traveling" to places like Missouri and Minnesota in order to support her family, she said.

A month before Bingaman began working at Santa Rosa, she read a news article about a shortage of neurosurgeons in San Antonio.

"Meantime, here I was, ready, willing and able to work and traveling all over the country, essentially, providing coverage when people in San Antonio couldn't get treated here," she said. "It was very ironic."

Some states are promoting a fast-track process for temporary licensure, though of course Texas isn't one of them. The powers-that-be say that they just hadn't thought about it. Fair enough, as who would expect the Texas Medical Association to try to think of ways to address the doctor shortage?

The fact that a doctor who wants to work a temp job in Texas has to have a Texas license in hand or go through the long approval process, just like a doctor seeking permanent posts, is such an "inhibiting factor" that Staff Care has mostly given up trying to get out-of-state doctors licensed in Texas, Miller said in an interview.

Of the some 200,000 doctor days Staff Care filled in 2006, assignments in Texas account for 18,000 days, he said.

If the licensure turnaround in Texas were 90 days, like it is in many states, Staff Care estimates it would have twice the number of doctors working in Texas than it does now — which would lead to roughly twice as many days filled per year, Miller said. [...]

Texas ranked 42nd out of 51 in the American Medical Association's 2005 measurement of patient-care doctors per capita, said Marcia Collins, director of the medical education department at the Texas Medical Association. The ranking includes the District of Columbia.

Mike's post on KFC and transfats reminded me of a discussion over at Halfsigma involving a propose New York City law that would require restaurants to post nutritional content on their menus.

In short, I think it's a good idea. My chief complaint with the law is that it is not stringent enough.

I don't see why it would be a huge burden on restaurants and it's not aimed at regulating the food, but disclosing to the customer what is in it. It's amazing the differences that can exist on the same plates from one restaurant to the next.

Dominos complained that they have too many variations to keep track of. This may be true, to an extent, and the law should be somewhat flexible when it comes to extra ingredients. Subway right now puts the health content of some of their stuff on napkins. It doesn't include cheese or condiments, so those are listed separately. I don't see why there couldn't be a provision for Dominos to put a pizza topping chart on the back.

I am presently watching my fat and caloric intake very closely. Having actual numbers makes a big difference and I'm starting to lose weight. This may not last, but so far it has been at least very illuminating. It has me eating things I otherwise wouldn't consider and avoiding things I used to eat all the time. If this diet fails, it will not be because I am dissatisfied with what I am eating it will be because I am tried of keeping track and will drift towards the more convenient, less healthy foods. Right now the biggest barrier I have is trying to figure out the health content of restaurants that won't tell me.

This whole strategy would be nigh impossible if it wasn't for government regulation on supermarket items. Laws like these help people help themselves, which is a very good thing.

Reports come in today that KFC's eliminating trans fats from their recipes as fast as they can; chicken will be done soon, biscuits will be slightly longer as they figure out a replacement.

Ironically, the article gets it right on how they got there in the first place:

Ironically, many big fast food companies only became dependent on hydrogenated oil a decade and a half ago when they were pressured by health groups to do something about saturated fat.

McDonald's emptied its french fryers of beef tallow in 1990 and filled them with what was then thought to be "heart healthy" partially hydrogenated vegetable oil.

"They did so in all innocence, trying to do the right thing," said Michael Jacobson of the Center for Science in the Public Interest. "Everybody thought it was safe. We thought it was safe."

Some restaurants were still completing the changeover when the first major study appeared indicating that the hydrogenated oils were just as bad for you, if not worse.

So... in the course of trying to do the right thing (under public pressure), they wound up doing the wrong thing.

The same can be said for other chemicals. One of the big problems in modern American diets is an overabundance of sodium, because junk-science "studies" led some rather crazed types to rail against monosodium glutamate (also known as MSG). Truthfully, MSG's a wonderful thing (see IFIC's resource page on the additive). MSG has 13% sodium content (as opposed to table salt's 40%), and gives the same flavor-enhancing effect to foods with an application of much less MSG; their suggestions indicate that MSG can replace a good portion of the table salt in a given recipe for anywhere between 20% to 40% sodium reduction.

But instead, when I go to a restaurant, especially a chinese one, I see "no MSG added" on their foods. Then I ask to see the data sheets on how much salt it took to replace the MSG in the recipe. Scary thought.

Newsweek has this ominous title:
Medicine's Racial Gap - Two new studies find that, when it comes to health care, minorities just don't fare as well as whites

Then you get to the guts of it:

But why should that be, if the overall quality of medical care is improving, as shown in the earlier study? There are many possible reasons. More often than whites, African-Americans find they cannot afford expensive medications, such as cholesterol-lowering statins. Their communities tend to have more limited options for exercising and eating right. Those problems don’t lend themselves to quick fixes. [...]

The findings apparently weren’t due to explicit racism. Everyone in the minority-dominated neighborhoods—white, black, Hispanic and Asian—tended to give their health lower marks. “It relates to the poverty level, the quality of food, the quality of life, the quality of health care,” says Borrell. “In poorer areas, there are fewer green spaces to play in, fewer shops selling fresh fruits and vegetables, more cigarette ads. We’re not blaming the victim. We’re blaming the social structure.”

So... minorities... no wait... people in minority neighborhoods are getting substandard health care... no wait... they're getting the same health care (that was one of the controls of the study).

The issue here is not only not really about minorities, it's not even about health care as we understand it -- it's about self-care. The issue is how capable they are of taking care of themselves and whether society should give them more health care than their wealthier counterparts to compensate for other structural limitations.

But I guess that's not as juice as suggesting that they're getting less.

A couple weeks ago, Sammler used GoogleNews to illustrate a point:

This persistent idea that the socialized systems of Europe offer superior healthcare is simply an ahistorical folly. On a day of your choice, just search GoogleNews for "NHS" to taste the fate of those dependent on government care. I chose today, and found...

I said that I would do it the next week, but I fell asleep at the wheel so he did it again.

This time I made sure not to forget, so here I go. In the interest of fairness, I am going to highlight the first nine* articles, whether they are positive or negative (in cases where there are "related" articles I will take the first one before moving on to the next big headline):

1. Top chiefs discuss debt-ridden NHS (The Scotsman) "The extent of measures being taken by debt-ridden NHS trusts in efforts to balance their books was disclosed in a poll of NHS chief executives."


2. Hospitals on critical list as NHS cash crisis spirals (Times of London) "THE full scale of the crisis facing the NHS was laid bare last night by ministers who admitted that up to 50 trusts had lost control of their finances."


3. NHS trust is blasted for £35,000 PR exercise (The Scotsman) "THE debt-crippled NHS Lanarkshire trust has been labelled an "absolute disgrace" after spending almost £35,000 on spin doctors to soften the blow of a casualty unit's closure."


4. New Hospital a Step Closer, Say Bosses (Hemel Today) "Health chiefs have signed an agreement setting out the terms on which land will be bought for a new hospital in Hatfield."


5. Minister reveals new NHS research strategy (Financial Times) "A new research strategy for the National Health Service was launched by the government yesterday. It includes a "radical shake-up of the way research is funded" and measures to "tackle the increasing red-tape that is stifling research"."


6. NHS figures show wait times fall (BBC) "The latest NHS figures released by the Welsh Assembly Government have shown a fall in waiting times. The figures show that in the past month, the number of people waiting more than 12 months for inpatient or day-care treatment fell by 29%."


7. Patients 'failed' as six hundred beds blocked every day, say Tories (icWales) "THE Welsh Assembly Government has been accused of failing patients as it emerged more than 600 hospital beds are unavailable on any given day."


8. KPMG slams NHS managers (Financial Director) "KPMG has found that NHS managers' capabilities were 'inadequate' to turn around the dire financial situations of their organisation, according to the latest report from Department of Health finance director Richard Douglas."


9. City to get new health services (BBC) "New GP surgeries, health centres and clinics are to open in Wolverhampton. The city is one of only six areas in the country to benefit from millions of pounds of government investment."

* - It was originally going to be ten, but the tenth was a press release from the opposition Conservative Party, which does not qualify as "news" in my book. Neither does the nurse staffing come-on that was next. Besides... NHS Nine has a ring to it.

The UK is considering a measure to end Last Call and allow round-the-clock drinking. As one might predict, this has met with some opposition. It also has unfortunately has to combat a report hyping an increase in alcohol-related deaths:

The figures, from the Office for National Statistics, showed a North-South differential: in Yorkshire and the Humber, alcohol-related deaths rose by 46.5 per cent, and in the North East the figure was 28.4 per cent; in the East of England, the rise was 12 per cent — and in London drinking-related deaths have fallen 4.2 per cent since 2000. Rates of alcoholrelated death per head of population also reflect a geographical divide. Rates are the highest in the North East and North West of England, and the lowest across the South.

Charities that are campaigning against the licensing changes said that they expected more alcohol-related health problems when the drinking laws are relaxed in November. Alcohol Concern said: “The increase in alcohol-related deaths is deeply worrying but not surprising. Alcohol consumption has been rising over the past fifty years, and currently around eight million people drink above safe levels each year.”

I can't say that I care too much either way since it's the UK. As far as doing such a thing in the US, I have a couple of observations:

1. There are a total of three nights in my life that I do not remember due to inebriation. The first was my first time to ever get plastered and I didn't really know my limitations. The other two times, however, were almost explicitly due to "racing the clock," by which I mean that after a certain period of time I would not be able to drink anymore The first time I was actually racing against Last Call. We got to the bar late and I was slamming shots of Gold Schlauger (14 shots in all). The other was at a convention. I didn't want to mooch booze at some of the parties that I intended to go to, so I downed well over ten fluid ounces of straight vodka. While I'm open to being proven otherwise, I'm not sure that ending Last Call will lead to more alcohol-related deaths.

2. On the other hand, standardization has its advantages, too. Particularly in US outside of New England. Police interested in patrolling the streets have a clear window to start picking up likely drunk drivers (an hour till and hour after Last Call). That would not be the case if we had round-the-clock drinking. On the other hand, a bar that doesn't close doesn't have to push drunk drivers out the door.

Cromulent Pete puts up his perspective and is a bit surprisingly more skeptical of the perpetual bar than I am. He points to the Bourbon Street, though in my mind that may be the same as Last Call: Bourbon Street attracts chaos not only because of its relative chaos, but also because of the relative restrictions of other places. If you could get drunk 24 hours everywhere, Bourbon Street may not be quite the hub anymore. Then again maybe I've read one too many libertarian tracts.

As I was eating ramen for breakfast today, the thought crossed my mind: a ten-cent meal would have to be pretty bad to still be bad when you consider that it only cost ten cents.

In the mentality of some, I guess, something only tastes better if more time or money is put in to it. But ten cent pasta is ten cent pasta.

And better for me than the McDonald's fare I was getting into the habit of eating!

In case you ever find yourself wondering "Can I eat lukewarm canned turkey chili straight out of its can using only a knife?" I can officially tell you:

It is possible.

It is not advisable.

I got a letter today from my insurance provider, placed a phone call, and learned something new:

If you go to the doctor because you're having monster headaches, my insurance company will pick up the tab for the visit with the exception of the $40 co-pay.

But if you go to the doctor because you're having monster headaches because you've made the very health-wise decision to quit smoking, the headaches are considered "self-induced" and visits to the clinic for such are not covered (and do not count towards any deductable).

Sure makes me feel better about the money I'm going to be saving my health insurance provider in the long run.

Learning lessons is good. Lessons costing in the neighborhood of $400 (for two visits!!) not so good.

The South Florida Sun-Sentinel reports that health care costs for the uninsured are causing everyone's rates to go up:

About 45 million Americans lacked health-care coverage in 2003, according to the U.S. Census Bureau. Washington-based Families USA said people without insurance pay about a third of their health-care costs, leaving doctors and hospitals this year with more than $43 billion in unpaid bills. Providers raise prices for other patients to make up the difference, the report said.

"When the uninsured get care in an emergency room, someone has to pay for it," Families USA Executive Director Ron Pollack said.

What I find interesting about this is the prospect that a number of people will read it and believe that if they were insured these costs would somehow evaporate. Or that someone else would pay for them becuase the employers that are cutting benefits in the first place would never pass on the costs of mandated coverage to the rest of the company's employees and/or their consumers.

Now granted, use of the emergency room for non-emergency room issues is a serious issue, but it's not one limited to the uninsured. A number of people don't want to wait for appointments and know that the emergency room will see them right away. All they're paying is the deductable, so why not, right? A bigger issue in this picture is that people can't afford $100 to go see a doctor (or don't want to wait until normal clinic hours or an appointment), so they'll deal with the creditors over a $500 ER bill that they frequently will not ultimately have to pay. Insurance will knock that $100 to $20-40, which may be more digestable, but (a) to whatever extent that they take more out of the system than putting in to it (the costs on the provider end don't go down just because the patient is paying less) someone else is paying for it anyway (causing a different form of the lament we feel when we read this article), and (b) after the deductable is met it could easily encourage more rather than less unnecessary ER visits. The doctors may not have to recoup their expenses with the rest of us, but the insurance companies will.

The bottom line is that healthcare is expensive. This is not because of evil pharmaceutical companies, greedy doctors, mean capitalism, or tightfisted employers. It's because a doctor's education costs run six-digits high, drug innovation isn't cheap, and consequences of error are high and therefore so are jury awards in malpractice cases. No matter how we handle our healthcare, these things will remain somewhat constant. The best that we can do is provide the best incentives for responsible use of our resources. Does the current system do that? No, and that's probably the only thing I agree with the nationalize health care crowd. But since each of us are likely to find the current system preferable to what the other has in mind, the stalemate will likely stand.

ADD-ON: An interesting perspective in the WSJ's Opinion Journal comparing experiences with the American and British health care systems:

There is something seriously out of whack about 10 therapy sessions [in America] that cost more than a month's worth of hospital bills in England. Still, while costs in U.S. hospitals might well have become exorbitant because of too few incentives to keep costs down, the British system has simply lost sight of costs and incentives altogether. (The exception would appear to be the few remaining private clinics in Britain. The heart procedure done in the private clinic in London cost about $20,000.)

"Free health care" is a mantra that one hears all the time from advocates of the British system. But British health care is not "free." I mentioned the cost of living in London, which is twice as high for almost any good or service as prices in Manhattan. Folks like to blame an overvalued pound (or undervalued dollar). But that only explains about 30% of the extra cost. A far larger part of those extra costs come in the hidden value-added taxes--which can add up to 40% when you combine costs to consumers and producers. And with salaries tending to be about 20% lower in England than they are here, the purchasing power of Brits must be close to what we would define as the poverty level. The enormous costs of socialized medicine explain at least some of this disparity in the standard of living.

As for the quality of British health care, advocates of socialized medicine point out that while the British system may not be as rich as U.S. heath care, no patient is turned away. To which I would respond that my wife's one roommate at Cornell University Hospital in New York was an uninsured homeless woman, who shared the same spectacular view of the East River and was receiving about the same quality of health care as my wife. Uninsured Americans are not left on the street to die.