Is smoking an illness or a collective activity?
As we approach a new year filled with fresh possibilities, countless people will try to quit smoking. Everyone has their reasons to butt out: to improve their health, to eliminate the costs of tobacco products or to avoid spreading secondhand smoke.
Yet should smoking be considered an individual disease or is it a behaviour that is shaped by social conditions?
If smoking is a disease it requires medical treatment. If lighting up is a social behaviour it is shaped by norms, attitudes and environmental influences. So, is smoking an illness or a collective activity?
Medical definitions have reinforced the idea that smoking is indeed a disease. For instance, tobacco dependence was included as a psychiatric condition by the American Psychiatric Association (APA) in 1980. Eight years later, the U.S. Surgeon General's Report declared smoking to be an addiction. Since then, the majority of doctors have treated smoking as a disease requiring medical attention.
Once smoking was labeled a disease, research into its causes and effects increased and advanced our understanding of tobacco addiction. Scientists consequently developed medical treatments such as nicotine replacement patches, gums, sprays and even vaccines. Each treatment is based on the premise that smoking is addictive and leads to compulsive drug seeking.
But to treat smoking uniquely as a disease is not the best option since in doing so we can only help people quit - prevention is left out of the equation. To see smoking as a disease alone is to miss the collective and social nature of this health epidemic.
Since the 1980s, the social nature of such health-related behaviours was exposed by Geoffrey Rose. The British physician and public health leader claimed that health behaviours are shaped by our environment and affect us as a group. A case in point? Some cities are more tolerant and open to smoking than others - think Montreal versus Vancouver. According to Canadian Statistics, Montrealers are known for their love of lighting up, with Quebeckers being among the biggest smokers in this country. Vancouverites, on the other hand, disrespect even the thought of smoking. It is environmental factors, such as public permissiveness, that have shaped these differences - not medical treatment.
To decrease smoking rates across the nation, health experts have targeted the environmental conditions that shape smoking. In 1986, the Canadian government adopted a comprehensive tobacco control policy that included policy development, legislation and regulations, enforcement, mass media campaigns, community action, public education and taxation. This strategy involved programs and policies to alter how society relates to cigarettes.
The focus of these policies was to make smoking abnormal, less acceptable, less desirable and less common as a social behaviour. By depicting smoking as a social anomaly the goal was to increase the number of people who would attempt to quit while decreasing the number of folks who take up the habit.
Empirical research has demonstrated that these campaigns have been effective in reducing Canadians' smoking. And general attitudes towards smoking have changed too. While it's impossible to claim that these anti-smoking programs alone helped in the dramatic drop in smokers, according to Health Canada only 19 percent of people aged 15 years and older smoke today. Compare that lowered rate to a high of 33 percent in 1986.
Yet Canada's tobacco control strategy has stalled. Smoking rates have stagnated and the habit remains high mostly in certain segments of our society. Canadians with less income, for instance, are experiencing slower rates of decline and higher rates of uptake in smoking than their wealthier counterparts.
Geoffrey Rose provided the original answer: shared conditions affect shared behaviors. In this case, Canadians who still smoke may be affected by social conditions different from their fellow citizens but common in their communities.
We need to investigate why some groups are at a greater risk to begin and continue this life-threatening habit. As we begin 2009, novel interventions and increased research are needed to inhibit the social triggers that keep smoking a health concern.
Vitamin and Mineral Supplements - Friend Or Foe?
Dietitians of Canada has reviewed the scientific literature and weighs in on the benefits and risks of supplemental vitamins and minerals. The research grant which provided the evidence for this document was provided by the Canadian Foundation for Dietetic Research (CFDR).
"Our aim is to raise awareness on the benefits and risks of high doses of vitamins and minerals” says Susan J. Whiting, PhD, author of the review, “Our understanding of the function of nutrients now goes beyond just prevention of classical deficiency diseases to possible prevention of disease. For those people for whom vitamin and mineral supplements are needed, we want to assure them that the benefit out-weighs the risk."
The review describes the recent evidence that shows how certain supplemental vitamins and minerals have benefits to health with respect to prevention of diet-related chronic disease. And it also addresses recent evidence showing large intakes of certain vitamins and minerals can negatively impact health. For instance, supplemental folic acid or vitamin E show both benefit and harm.
Preventing Anemia Is Important To Kidney Disease Patients' Quality Of Life
Maintaining sufficient red blood cell levels is important to the physical and mental health of patients with chronic kidney disease (CKD), according to a study appearing in the January 2009 issue of the Clinical Journal of the American Society Nephrology (CJASN). The findings indicate that preventing anemia in kidney disease patients should be an integral part of their care.
Fredric Finkelstein, MD, of the Hospital of St. Raphael and Yale University in New Haven, CT, and his colleagues studied the relationship between hemoglobin levels and health-related quality of life (which includes both mental and physical components) in patients with CKD.
A total of 1,186 patients with stage three to stage five CKD participated in this study, and they were grouped into categories based on their hemoglobin levels (<11 gm/dl, 11 to <12 gm/dl, 12 to <13 gm/dl, and ≥13 gm/dl). The investigators noted that as hemoglobin levels increased from <11 gm/dl to ≥13 gm/dl, there were significant improvements in a variety of quality of life domains. These included symptom problems, burden of kidney disease, physical functioning, pain, energy/fatigue, and others.
The study's findings suggest that maintaining hemoglobin levels is important to the health and well-being of patients with CKD. More work also is needed to determine when treatment should be initiated and what the hemoglobin target level should be. "The impact of the answers to these questions for the health-related quality of life of chronic kidney disease patients may well be substantial," the authors wrote.
Bicycle Seat Design Can Directly Affect a Man's Sexual Function
Long suspected by the 5 million recreational bike riders and sexual medicine experts, bicycle seat design-shorter noseless seats versus the standard protruding nose extended seat-can directly affect a man's sexual function, based on the nation's first prospective study of healthy policemen riding bikes on the job. The study is published in the current issue of the Journal of Sexual Medicine.
Dr. Irwin Goldstein, director, Sexual Medicine Program at the San Diego-based Alvarado Hospital and editor-in-chief of the Journal of Sexual Medicine, wrote an accompanying editorial entitled "The A, B, C's of The Journal of Sexual Medicine: Awareness, Bicycle Seats, and Choices."
"For the first time, we have a prospective study of healthy policemen riding bikes on the job, using wider, no-nose bike saddles for six months. Not only did their sensation improve, their erectile function also improved. Changing saddles changed physiology. This is a landmark study for our field that that is important for future riders, and modification of lifestyle showing improvement without any active treatment," he said.
Ninety bicycling police officers from five metropolitan regions in the United States (Northwest, Southern, Desert West, Midwest, and Southeast) using traditional saddles were evaluated prior to changing saddles and then again after six months of using the noseless bicycle saddle.
The findings show that use of the noseless saddle resulted in a reduction in saddle contact pressure in the perineal region. There was a significant improvement in penile tactile sensation, and the number of men indicating they had not experienced genital numbness while cycling for the preceding six months rose from 27% to 82% using no-nose saddles.
Use of the noseless saddle also resulted in significant increases in erectile function as assessed by the initial evaluation, but there were no significant changes noted in Rigiscan® measures, a method used to record penile rigidity while the subject sleeps. With few exceptions, bicycle police officers were able to effectively use no-nose saddles in their police work and 97% of officers completing the study continued to use the no-nose saddle afterward.
Jokes
Patient: Doctor, Doctor, You’ve got to help me - I just can not stop my hands shaking!''.
Doctor: Did you drink a lot?
Patient: ''Not really - most of it spilled out!'
Patient: Doctor, 'Whenever I drink coffee, I have this sharp, excruciating pain.
Doctor: ''Try to remember to remove the spoon from the cup before drinking”
The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship
If you are like most primary care physicians, you probably have had enough of third parties injecting themselves into the front lines of medical care in ways that offer marginal value and drive up costs. Pre-authorization requirements, productivity benchmarks, competing clinical guidelines and pay-for-performance initiatives are just a few of the challenges we face as primary care physicians.
What can we do to return the locus of control to our practices and ensure adequate compensation for our work? We have to redesign our practices to optimize efficiency and show that we can not only deliver superb care but also lower the total cost of health care. The "ideal medical practice" model can move us closer to this goal.
This article shares what we have learned to date as part of a national collaborative project designed to demonstrate the viability of the ideal medical practice model. It also launches a series of articles that will delve more deeply into the essential components of ideal medical practices.
What is an ideal medical practice?
What do you get when you mix low overhead with high technology and wrap it around an excellent physician-patient relationship? You get an ideal medical practice - a practice model designed to enhance doctor-patient relationships, increase face-to-face time between doctors and patients, reduce physician workloads, instill patients with a sense of responsibility for their health and cut wasted dollars from the entire system.
The model encompasses the ideal micro practice model, which focuses on optimizing the smallest functional work unit capable of delivering excellent care: the solo doctor, even without any staff. The key principles ideal medical practices pursue are high-quality, patient-centered, collaborative care; unfettered access and continuity; and extreme efficiency.
AVERAGE MONTHLY REVENUE AND EXPENSES FOR 12 ONE DOCTOR
IDEAL MEDICAL PRACTICES
When reviewing the financial data for these 12 micro practices, it is important to acknowledge that although the model is financially sustainable for many, it is challenging in certain environments because of immense variation in payers' payment rates and policies, malpractice rates and cost of living. For example, average local payment for a 99214 visit can range from as little as $62 in one region of the United States to more than $140 in another. Similarly, a doctor in Eugene, Ore., may pay $1,000 per year for malpractice insurance while another in Chicago may pay $35,000 (neither including OB or special procedures).
The financial picture of these practices is further complicated by the fact that the majority of them have been open fewer than five years and have yet to reach financial maturity.
