Thursday, October 28, 2004

Bridge Blogging

There's less than a week to the election, and I'm burned out from checking the polls at Real Clear Politics every 15 minutes. So, to relieve the stress, relax the body and clarify the mind, it's time for some bridge blogging.

Say what?

Bridge blogging. It just so happens that I live near an engineering marvel in progress: the new Tacoma Narrows bridge. Most folks have heard of the Tacoma Narrows bridge - or at least the first one, "Galloping Gertie", which catastrophically failed during a windstorm in November 1940.


Built at the cost of $6.6 million dollars, designed by world-famous bridge architect Leon S. Moisseiff (who also designed the Golden Gate bridge), it embraced the light, elegant design principles in vogue at the time - and was designed with complete ignorance of the aerodynamic effects of high winds on bridges. Moisseiff had inadvertently created a mile-wide airplane wing, with its light-weight narrow deck and plate-girder sides. It survived only 4 months after completion. In a strong-but-typical November windstorm, the wave-like undulations were severe enough to unseat a cable from its saddle on the West tower, creating a corkscrew torsional motion which ripped the bridge to shreds. The only casualty, surprisingly, was Tubby the three-legged dog. May he rest in peace.


The fallen span of the bridge remains at the bottom of the Tacoma Narrows, and has been designated a National Register of Historic Places to prevent salvage. It is one of the world's largest artificial reefs, and home to a plethora of marine life, as well as the world's largest octopuses. The remainder was disassembled and sold for scrap during WWII. The caissons and anchors (for the cables, on either bank) were used, largely unmodified, to support the towers and cables of the second Narrows Bridge.


The second - and current - Narrows bridge was begun in 1948, and completed October 14, 1950, 29 months after construction began, at a cost of $14 million. It was one of the most highly researched bridge engineering projects in history, and greatly advanced the understanding of aerodynamics in suspension bridge construction. A 1/72 replica of both the original and the new bridge were built in a wind tunnel and thoroughly tested for several years prior to design completion.


Designed to carry 60,000 cars per day, the current bridge ferries over 90,000, and has become a major chokepoint for traffic in the rapidly growing South Puget Sound area. These transportation pressures have given rise to the new Tacoma Narrows Bridge project.

The Tacoma Narrows is a formidable natural barrier. Carved out by ancient glaciers, over a mile wide and 260 feet deep, with steep, unstable banks on either side, it is a hostile environment for a suspension bridge. Wild tidal currents rip through the Narrows twice daily, through the sole portal between the Pacific Ocean and the entire South Puget Sound. High winds and fog are common. The Puget Sound area is also prone to major earthquakes.

The new Narrows Bridge project is the largest engineering endeavor in the U.S. in the last 30 years. Construction began in late 2002, after approval of an $800 million public-private financing package. The new caissons underwent initial construction in the Port of Tacoma, and were towed to their location in the Narrows, where they were secured in place on the surface with a series of anchor cables radiating circumferentially. These cables, and flotation tanks in the caissons, where used to control the descent of these floating concrete islands, as layers of concrete were added to the top.


The task was akin to building a 25-story building from the roof down, all the while holding its precise position in the alternating rip tides of the Narrows. The bottom of the caissons is configured to be a mammoth cookie cutter, with a sharp steel knife edge to cut through sediments to reach bedrock 50 feet beneath the bottom.

On the east and west banks are the anchors - enormous concrete fortresses designed to secure the cables with their huge tractive forces to the sandy glacial till on either side of the Narrows.



Over the past several months, the towers have begun to rise from the caissons, and now are nearly at the deck level of the current bridge.


The new bridge is scheduled to be completed in 2006, and renovations to the existing bridge made after this. The final project is scheduled for completion in 2007. You, my faithful readers, will see history unfold on this very blog, with regular updates until then.

Wednesday, October 20, 2004

Faith and Reality


Ron Suskind's article in the NY Times Magazine, Without a Doubt, addressing the issue of the faith of George W. Bush, begins as follows:

Bruce Bartlett, a domestic policy adviser to Ronald Reagan and a treasury official for the first President Bush, told me recently that ''if Bush wins, there will be a civil war in the Republican Party starting on Nov. 3.'' The nature of that conflict, as Bartlett sees it? Essentially, the same as the one raging across much of the world: a battle between modernists and fundamentalists, pragmatists and true believers, reason and religion.

''Just in the past few months,'' Bartlett said, ''I think a light has gone off for people who've spent time up close to Bush: that this instinct he's always talking about is this sort of weird, Messianic idea of what he thinks God has told him to do.'' Bartlett, a 53-year-old columnist and self-described libertarian Republican who has lately been a champion for traditional Republicans concerned about Bush's governance, went on to say: ''This is why George W. Bush is so clear-eyed about Al Qaeda and the Islamic fundamentalist enemy. He believes you have to kill them all. They can't be persuaded, that they're extremists, driven by a dark vision. He understands them, because he's just like them. . . .

''This is why he dispenses with people who confront him with inconvenient facts,'' Bartlett went on to say. ''He truly believes he's on a mission from God. Absolute faith like that overwhelms a need for analysis. The whole thing about faith is to believe things for which there is no empirical evidence.'' Bartlett paused, then said, ''But you can't run the world on faith.''

There is much to address and analyze in this lengthy article, and no doubt others better versed on the credibility of its sources, the speciousness of its evidence, and its use of unconfirmed hearsay and biased sources will rise to the debate. But I was particularly struck by one line which I believe embodies the heart of the article's core thesis:
He truly believes he's on a mission from God. Absolute faith like that overwhelms a need for analysis. The whole thing about faith is to believe things for which there is no empirical evidence.

Listening to the secular fundamentalists at the NY Times expound on the mind and heart of a man of the Christian faith is akin to a man blind from birth describing a rose: you are far more likely to hear about the thorns than the subtle coloration and beauty of its petals.

"The whole thing about faith is to believe things for which there is no empirical evidence."


The tension between faith and reason (or "reality", as Suskind calls it) is hardly a new issue, reaching back centuries to such philosophers and theologians as Augustine, Thomas Aquinas, and even Plato and Aristotle. Aquinas has the most fully developed exposition on the seeming dichotomy between that which is discernible to the senses or by logical deduction, and that which is revelation and mystery. Far greater minds than ours have taken - and mastered - this challenge.

There is a name for someone who believes things for which there is no discernible evidence: a fool. And I suspect most journalists for the NY Times would find this an apt assessment of President Bush - and by inference, his religious supporters, lumped together under the tattered banner of the "religious right". As a believing Christian, therefore, I am a proxy target for this accusation. And as a blogger, it is my sworn duty to reply.

So, is this thing I call faith really a fantasy, a trust and hope in some unseen, unprovable philosophy or myth? Most definitely not. There are, from my perspective, quite a few objective reality-based foundations for that which I believe. Among these are:

bulletHistorical: The Christian faith is a historical faith. It is based on an individual, Jesus Christ, who lived in history, verified as real not only by His followers (and enemies) but by detached historians with no agenda to promote. The core convictions of this faith are easily demonstrable, not only in its sacred texts, the Scripture, but in writings and teachings of men from many cultures and times, from the earliest years following the death of Christ continuously to the present. The accuracy of its ancient sacred texts is nothing short of stunning, supported by an exponentially greater volume of manuscripts and archeological evidence than any other ancient writings. If the Old and New Testament were not religious texts, there would be no academic dispute about their veracity and reliability. They are challenged because they shine a light on the darkness of the human heart, and make uncomfortable demands on human behavior and belief. If you can prove the judge is a corrupt impersonator, you dodge the sentence for your crimes; if he is unimpeachable, you're busted.

bulletRelational: There are several aspects to the relational nature of Christianity which serve as evidence for its reality. People do not arrive at Christian conviction by lightning bolt or holy vision, but rather by their relationship with others who hold the faith. We witness the effects of Christianity on the lives of others, and are led to consider it not only because of what they say, but far more by what we observe. Few of us would buy a car without talking to other car owners, reading reviews, and taking it for a drive. While not a guarantee of a good car, we consider such information valuable evidence in making our decision. While such evidence can be misleading - people are often seduced into cults by an appealing but deceptive attractiveness, for example - it is nevertheless evidence of the veracity of faith when carefully considered and weighed against other facts and observations.

The evidence of Christianity is also revealed in its ability to transform relationships. Many Christians can testify to the healing and restoration of relationships with spouses, children, employers, between races, class and ethnic groups. Are all Christians so transformed? Not by any means, unfortunately. But the evidence of those who have been - often resolving seemingly hopeless situations and personal divisions - should not be dismissed outright because of the incompleteness of its scope. Do we do abandon chemotherapy because not all survive?

bulletExperiential: Christianity is both doctrinal and experiential: it is comprised of a series of assertions to truth, but is not simply a belief system; it affects - often profoundly - the lives, convictions and experiences of those who follow it. While this is easy to challenge with claims of a purely emotional or psychological basis for such experience, in reality it is not so lightly dismissed. While short-term behavioral change can occur as a result of emotional experiences, and delusional thinking in mental illness can result in bizarre behavior, the vast majority of practicing Christians do not fit this mold. When people from all walks of life - responsible, sane citizens whose behavior is ordinary in every other way - profess their ability to overcome profound personal shortcomings, relationship disasters, personal tragedy or devastating misfortune with a peace and inner strength not available to them apart from their faith, is it not reasonable to conclude that something profound has happened, not attributable to the impotency of pop psychology? Might there not be a plausible explanation involving a Being greater, wiser, and more gracious and loving than ourselves from which such resources come? Scientific proof, no, but certainly evidence not to be dismissed out of hand.

John Edwards is right: there are two Americas - just not the two he imagines. The divide places secular and liberal religious (often no more than thinly-guised socialism, with little connection to historical Judeo-Christian belief) on one side, and people of faith on the other, with lives quietly transformed by God and a vision expanded beyond the tight constraints of materialistic or political thinking. For the secular, religion is like borrowing a sports coat at a fancy restaurant when you've forgotten yours: you use it to get your meal and drink wine with your friends, then shed the ill-fitting garment at the earliest possible time. There is a deep discomfort with and mistrust among the secular of anyone who claims such superficial window dressing could actually guide, direct or empower the lives of others.

I cannot presume to speak for the mind or spirit of President Bush. But many of us who have experienced the inner transformation which faith alone brings, sense in the man a like mind and heart, which despite sometimes strong differences in policy or politics gives us confidence in his inner compass and core principles. Such conviction in our experience leads to discernment, rejecting well-intentioned but misguided advice, and pursuing goals judged to be noble and right despite the high costs of doing so. Faith does not overwhelm analysis; it sharpens and directs it. This is something that political speeches in churches or talk of boyhood alter boy service can imitate, but cannot replicate. The jacket just doesn't fit the man.

Sunday, October 17, 2004

The Dangers of High Testosterone

Moose Life can be stranger than fiction.

Much has been written - and considerable media attention given - to the benefits and risks of estrogen replacement therapy, but considerably less attention has been directed at testosterone replacement. Yet androgen replacement therapy is becoming increasingly common, as improved delivery systems have been developed.

Low testosterone is common in aging men, although there is not a uniform sharp decline as seen in women at menopause. The symptoms are variable, but include fatigue, decreased libido, difficulty with erections, weight gain and loss of muscle mass.

Testosterone replacement has been available for many years, but was limited by less-than-ideal delivery systems. Oral replacement is easy and convenient, but most of the testosterone is metabolized by the liver on its way out of the intestine, resulting in low blood levels and higher risk of liver function abnormalities. Injectable testosterone bypasses the liver and achieves good blood levels, but requires frequent injections, typically every 1-3 weeks. Skin patches were developed in the early nineties, but have been plagued by a high incidence of skin irritation and the need (with some systems) to apply the patch to the scrotal area - not a crowd-pleaser, to be sure. The recent development of topical gels - Androgel and Testim - have revolutionized androgen replacement, providing excellent blood levels with very low risk of skin irritation or other side effects.

Testosterone replacement in men with low serum levels provides many benefits, including improved energy, strength, and libido. Preservation of bone mass and muscle mass are also seen. The downside risks appear to be modest, and include weight gain, sleep apnea, and an increased red blood cell count. There is also much concern about long-term effects on the prostate, including an acceleration of benign enlargement or an increased risk of prostate cancer. To date, however, studies indicate that prostate-related risks do not appear to be of great concern, although long-term monitoring will continue.

One other risk is of great concern to researchers, however: the risk that high testosterone levels may cause recipients to become high-strung. Consider the following report from Alaska:

In one of those only-in-Alaska stories that will shock even the sourest of sourdoughs, a trophy-sized bull moose was accidentally strung up in a power line under construction to the Teck Pogo gold mine southeast of Fairbanks. The moose apparently got its antlers tangled in electrical wire before workers farther down the line pulled the line tight about two weeks ago.

The moose was suspended 50 feet in the air when workers, recognizing something was wrong, backtracked and found it...

The prevailing theory is that the moose came across the sagging and swaying wires and, in a testosterone-filled moment, decided to challenge the power line to a fight, as bull moose are known to do during the rut, or mating season.

"My guess is he was in full rut and probably seen that line moving out there," and decided to fight, said Marvin Pickens, line construction manager for City Electric in Anchorage.

I am now counseling my patients to avoid high tension electrical wires at the initiatiation of testosterone replacement therapy. I know I will be sleeping better since informing patients of this risk.

Friday, October 15, 2004

The Chips Are Down

DaffodilThe FDA this week approved the use of the Applied Digital 4Verisign implantable chip in humans. The chip has been in use for some time in animals, to identify pets and livestock. The technology is straightforward: the chip is implanted under the skin, in the subcutaneous tissue, ideally in the right upper arm near the triceps, and contains RFID transmitter which is activated by a hand-held scanner. Contrary to some media reports, the chip stores no medical data, but only a a unique 16 digit identifying number. This number is used to securely access an online database and retrieve information specific to the patient.

The dream of centralized patient information is hardly new. Current medical record technology is little removed from the 19th century - often handwritten and illegible, decentralized, and paper-based. EMR's are gaining acceptance, but are costly, and standards for data structure, communication protocols, and interchange between different vendors and applications are incomplete and not uniformly implemented. My EMR cannot get or send patient information to yours, nor can it easily obtain from, or relay information to, hospitals, pharmacies, insurance companies, or emergency rooms. Even laboratory data - the most widely implemented medical electronic data exchange - varies from one laboratory to the next, and is only partially standardized.

The long-term solution to such standards and interface barriers would appear to be secure database access over the internet, as is currently done in banking and e-commerce. The Verisign chip is being touted as a first step toward just such a system. But color me very, very skeptical about the likelihood of ever seeing a system of this nature in practice. The obstacles seem insurmountable.

A myriad of problems present themselves when addressing online patient medical databases. Some of these include:

bullet Security and Privacy Issues: From start to finish, many of the hurdles to such a system lie in the securty and privacy realm. Who enters a patient in the system? How do we know you are who you say you are? A quick look at the driver license, SSN, and voter registration systems should give one considerable pause. Fraudulant and duplicate entries would be common, and could pose enormous problems and risks. Imagine you get added to the database under someone else's name, to fraudulently obtain health insurance coverage, or are a duplicate name and date of birth with another person. You are severely allergic to penicillin, and your alias or name clone is not, and you end up dead from an anaphylactic reaction, after receiving it while unconcious in an emergency room. Who's responsible? And could hackers or terrorists wreak health havoc by gaining entry to the system? If the Pentagon and banking system can be hacked, the health care databases will be no less vulnerable to cyberterrorism.

And who gets to access your personal health information - a treating doctor, presumably, but let's say you just fired him or her and don't want him accessing your information any longer - can you block access to specific providers? Insurance companies? Hospitals? Lawyers? Government agencies, such as Medicare, Medicaid, workman's compensation?

Then consider the problem of partial information access - for example, information about substance abuse or mental health issues. Such information is generally held to a higher standard of privacy than general medical information in many states. Can you allow the doctor at your company to know about your diabetes, while not revealing your history of bipolar disorder, or substance abuse? The complexities of who gets access to which information are daunting, so say the least.

bullet Database Updates and Accuracy: Who gets to add, edit and delete information from your medical history database? Can your naturopath make an entry about weak adrenals or body toxins? How about your dentist, or pharmacist, or massage therapist? Anyone who has taken a medical history knows that a patient history can be devilishly difficult to obtain with accuracy: prior surgeries and their dates, medications and dosages, allergies, family history - can vary wildly from one provider to another, or from alternative sources such as family or old medical records. What about medical differences of opinion? Dr Jones thinks you have chronic fatigue syndrome, while Dr. Smith is convinced you're a neurotic hypochondriac. And Dr. Johnson understood you to say you had a history of uterine cancer, when you actually had fibroids. But the cancer diagnosis is now in you database. Who is authorized to change that information?

bullet Database Currency: How up-to-date is the information in the centralized database? To maintain patient medical data currency, the system would have to be universally accessible and ubiquitous in utilization. Ol' Doc Watson, who still writes his chart notes in longhand and doesn't own a computer, isn't likely to enter your severe reaction to his prescribed medication, or log the highly-contagious disease you've acquired, onto the database servers at the Health Information Agency. And, by the way, who will manage this database - government? private companies? insurance carriers? Microsoft? Will it be as reliable as, say, Windows?

The downsides of such centralization of medical information vastly outweight the benefits, in my opinion. And is universal access to medical information really needed? The vast majority of health information is communicated at the local level, within the community where the patient lives, or occasionally to nearby regional medical centers. Rather than compromise privacy and information integrity with a massive centralized medical database and implanted patient RFID chips, it would be far more useful to focus efforts on standardization of information management at the local levels, with policies to encourage the use of standard terminology, communication technologies and protocols (such as XML web services and SOAP), while maintaining the flexibility, security, and privacy of the current decentralized medical information system.

Monday, October 11, 2004

Debating Federal Tort Reform

Day Lily

In the second presidential debate between John Kerry and George Bush, the topic of medical malpractice reform was raised. Here's the exchange:

LAURENT: Senator Kerry, you've stated your concern for the rising cost of health care, yet you chose a vice presidential candidate who has made millions of dollars successfully suing medical professionals. How do you reconcile this with the voters?

KERRY: Very easily. John Edwards is the author of the Patients' Bill of Rights. He wanted to give people rights. John Edwards and I support tort reform. We both believe that, as lawyers — I'm a lawyer, too. And I believe that we will be able to get a fix that has alluded everybody else because we know how to do it...

Now, ladies and gentlemen, important to understand, the president and his friends try to make a big deal out of it. Is it a problem? Yes, it's a problem. Do we need to fix it, particularly for OGBYNs (sic) and for brain surgeons and others? Yes.

But it's less than 1 percent of the total cost of health care.

First of all, the mention of John Edwards' sponsorship (with Ted Kennedy and John McCain) of the Patients' Bill of Rights is a non-sequitur to the issue of the growing malpractice crisis: the Patients Bill of Rights addressed a patient's right to sue their HMO for denial of care, and also allows wronged patients to receive unlimited punitive damages in state court and awards in federal court of up to $5 million. As such, this bill is highly favorable to trial attorneys, and worsens the overall liability crisis. And it has nothing to do with medical malpractice. When the trial attorneys start talking "patients' rights", it's time to hold on to your wallet if you're in the health care industry. "And I believe that we will be able to get a fix that has alluded everybody else because we know how to do it". Hmmm, the fox knows how to solve the chicken-killing spree, because he knows how foxes get into the hen house. Somehow I'm not feeling reassured about this.

It would be interesting to see the origin of Kerry's "1 percent of the total cost of health care" figure. The John Kerry website white paper on malpractice reform does not mention this statistic, or give any references in support of it. I suspect this figure is inaccurate, and very low. And I'm not sure it's relevant anyway - as I'll detail below.

In the MedPAC report on medical liability costs, released in March 2002, physicians' medical malpractice premium costs were estimated to be 3.2% of revenue in 2001. The past 3 years have seen double-digit percentage increases in malpractice premiums for all physicians, along with reductions in revenue, making even the 3.2% figure woefully outdated.

In my practice - a relatively low-premium surgical subspecialty - malpractice premiums represent 10% of my expenses - exceeded only by rent and salaries - and about 6% of revenue. So in my practice, and that of many physicians, malpractice premiums are not yet devastating, although their inexorable and exponential rise adds substantially to the financial vise grip of growing expenses and dropping reimbursements. But rising expenses and declining income for physicians is not really the main problem, at least in the short term; the real problem is patient access.

The reason for this is twofold. First of all, malpractice premiums are not evenly distributed, but disproportionately affect some specialties far more than others. So talk of "average malpractice costs" is meaningless. Most affected are OB-GYN (not "OG-BYN", as Kerry said) and neurosurgery, and certain other high risk specialties. They are the canaries in the medical malpractice mineshaft. They are most affected not because they have the most negligent physicians - indeed, they often are the most skilled and highly trained of physicians. They are adversely affected because adverse outcomes in such specialties may have devastating long-term consequences, or perhaps more important, are most easily sold to juries as due to negligence. It is much easier to convince a jury that a bad baby is due to obstetrician error than it is to convince them that a cardiac event after coronary bypass surgery is surgeon incompetence. The average non-medical lay person expects delivery of a healthy baby to be the norm - don't women deliver at home with a midwife? - but an uneventful recovery from open heart surgery is considered to be something of a miracle. So the crisis strikes first at the high-liability-risk specialists, forcing them to curtail services, relocate to more favorable states, or leave practice altogether. This is already taking place in many areas, is well-known, and is highly detrimental to health care in such areas as critical services go lacking.

The less widely appreciated problem with malpractice costs and access affects far more physicians and patients. For many years, the federal programs of Medicare and Medicaid have contained a hidden tax: they have not paid their way, reimbursing at or below the cost of providing care. For years, health care providers - and patients - have paid this tax by offsetting these losses with reimbursements from private payers. This option is no longer viable, as rising health insurance premiums and dropping third party reimbursements eliminate this income redistribution. As a result, physician practices, with their viability as businesses threatened, are reevaluating their willingness or ability to see such patients - not out of greed, but out of necessity.

A recent WSMA physician survey showed that 57 percent of doctors polled said they were limiting their Medicare patients or no longer seeing any at all. In Bellingham WA, Family Care Network, which has 11 locations and provides about half the primary care for its area, is typical of the dilemma many practices face:

"In every case, when we got above a certain percentage (about 25 percent) of Medicare and Medicaid patients, it was impossible to operate the office in a way that it would pay for itself," said Dr. David Lynch, who directs clinic operations for the 45-doctor group. "And that's before we paid our doctors anything. We realized we would go out of business if we didn't do something." In 2000, Family Care Network lost an average of $4 every time one of its physicians saw a Medicare patient.

The overhead expenses increased by spiraling malpractice premiums make the break point at which medical practices can afford to see low-reimbursement federal health care patients lower each year. Finding a primary care or GYN physician in my area who will accept a new Medicare patient in referral is extraordinarily difficult. Of the 10 practices in my specialty in my area, only 1 will accept new Medicaid patients - and that number is capped. My former group practice, which accepted Medicaid, saw Medicaid patients who would drive 2-3 hours to see us, who could not find a specialist who would take them any closer to home. Coordinating care in such situations - scheduling x-rays or diagnostic studies, or meeting with families - was almost overwhelmingly difficult.

Our malpractice lottery is causing severe disruptions in access to care, as well as eliminating access to certain specialties altogether. This is not merely about preserving physician incomes. The solution requires a radical rethinking of the approach to adverse events in medicine - one which, unfortunately, neither presidential candidate is likely to endorse - especially those who have profited greatly from the current system.

Wednesday, October 06, 2004

Drugs from Canada

ButterflyIn the Vice Presidential debate last night, John Edwards detailed the Kerry-Edwards health care plan, stressing, among other points, their intention to allow drug importation from Canada:

They've blocked allowing prescription drugs into this country from Canada. We're going to allow it.

Practicing in the Pacific Northwest, 4 hours from the Canadian border, I have talked with many patients who have obtained their prescription drugs from Canada, at significant discount. I also have a few patients who have purchased drugs cheaply in Mexico. The appeal is obvious, and the logic can be hard to refute. Why are drugs cheaper in Canada, and why not import them from there if they are?

The reasons for less expensive Canadian drugs are severalfold. Prescription drugs still on patent are price-controlled in Canada at the wholesale level by the Patented Medicine Prices Review Board (PMPRB), which sets the price of all new patented medications. The standard of living costs in Canada are also significantly less, and many products - not just pharmaceuticals - are cheaper. Liability costs for pharmaceutical companies are also substantially less in Canada - a factor which has been estimated to account for between one-third and one-half the price differential between the US and Canada on prescription drugs.

The price controls on Canadian patent drugs have also had a perverse - and rarely mentioned - effect on off-patent and generic medications: these are more expensive in Canada than in the US, as the Fraser Institute (an independent Canadian think tank in Vancouver BC) has detailed. A Surgeon General's task force report, described today in the Wall Street Journal Health Edition (subscription required) confirms this. Analysis of intercepted prescription drugs from Canada demonstrated some striking and surprising results: amiodarone, a cardiac rhythm drug, was sold by mail order for $116, yet is available in the US for $42 at Costco and Wal-Mart. Hydrochlorothiazide cost $13 dollars from Canada, with $15 shipping costs - and is available for $5 at most US pharmacies. Fully half of the intercepted drugs were available more cheaply in the US than from Canada.

Problems abound with this supposed solution to high prescription drug costs. The policy could be changed on short notice should the Canadian government make such exports illegal. Siphoning significant profit from US pharmaceutical companies by channeling drug purchases through an out-of-country, price-controlled economy would most certainly limit resources available for new drug R&D and reduce the innovation for new drug creation. And then there is the problem of quality control and potential fraud.

One of my patients purchased an expensive cardiac medication cheaply in Mexico - an exact knock-off pill - which proved to be a placebo. Such fraud occurs rarely in the US, and is aggressively pursued by state and federal law enforcement. Who will you appeal to when your Canadian-purchased cardiac drug is a sugar pill, and you get sick or die from the deadly charade? Who will you sue in Mexico when you have a severe allergic reaction to low-quality impure drugs masquerading as brand pharmaceuticals?

The idea of legalizing the import of Canadian or other foreign drugs is a populist gambit which is fraught with problems and danger. It is a prescription for our health care best avoided.