U.S. Surgeon General Richard Carmona released today a major review of the scientific evidence on secondhand smoke: The Health Consequences of Involuntary Exposure to Tobacco Smoke. This subject was last reviewed by the Surgeon General’s office twenty years ago, under Dr. C. Everett Koop.

The comprehensive study examined the link between secondhand smoke and a large number of diseases to determine if the evidence demonstrated a causal link between secondhand smoke and each disease. It also studied the extent to which nonsmokers were exposed to secondhand smoke in public places where smoking occurred.

The major conclusions of the studies are:

• Secondhand smoke causes premature death and disease in children and in adults who do not smoke.
• Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome, acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children.
• Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer.
• The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.
• Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces despite substantial progress in tobacco control.
• Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.

This is a major contribution to public awareness about secondhand smoke and will very likely inform and encourage the drive to ban smoking in public buildings. I hope it will also persuade smokers who are parents to quit.

About a month ago I attended the annual conference of the Society for Innovative Medical Practice Design (SIMPD), a national organization of physicians like me who have decided to stop working for insurance companies, and start working for our patients. The conference was very inspirational. We heard distinguished speakers including Tommy Thompson, former Secretary of the Department of Health and Human Services, Regina Herzlinger, Professor of Business Administration at the Harvard Business School, and Connie Mariano, M.D., who was White House physician to three sitting American Presidents. Their presentations had a common theme: American medical care is in serious trouble. We heard that health care is increasingly expensive, physicians are increasingly overworked and demoralized, and patients are increasingly frustrated by the inadequate time, attention and education they receive. The solution will not come from government or from insurance companies. After all, they created the problem. The solution will come from empowering patients to spend more of their healthcare dollars directly, and giving them increasing options of how to spend them. In this context, physicians who sever their relationships with insurance companies and work only for their patients will be an important part of the solution. We will revitalize patient expectations, provide examples of a fulfilling career to the next generation of medical students, and remove ourselves from the diminishing stream of insurance reimbursements. In short, we will be good for patients, good for other doctors, and good for the nation.

Hearing the speakers was very interesting, but even more enjoyable was meeting the other physicians who attended the conference. I was impressed by what an idealistic (and fairly young) bunch we were. The doctors I met had very similar stories. Many were frustrated at having to see 30 patients a day. Some were on the verge of dropping out of medicine entirely before discovering this new practice model. Some were motivated by extra time to spend with family, some by the nagging realization that they were not delivering good care in their high-volume practice, some by the desire to abandon the complexities of insurance billing. I almost never heard income mentioned as a motivation. These doctors aren’t in it for the money. They’re trying to reclaim their profession.

A question that I frequently heard asked by the doctors was “What should we call this kind of practice?” Small patient-focused medical practices have been called “concierge medicine” or “boutique medicine” but neither of those terms was very popular with the doctors. “Retainer-based medicine” has also been used in media articles about such practices. SIMPD uses the phrase “patient financed medical care” which is more descriptive, but is too long and hasn’t caught on either. Business and policy articles have begun using the phrase “consumer-driven health care”. For example, the National Center for Policy Analysis, a free market think tank, recently released their analysis paper “Consumer-Driven Health Care Spurs Innovation in Physician Services”.

Eventually I think it will be patients who settle on a name for this kind of practice which is patient centered and patient financed. I’m honestly curious what you think of the various names, or whether you have a name that you think is better. Please email me your thoughts. Since you’ll be responsible for fixing American healthcare; you might as well decide what to call the solution.

This issue of Annals of Internal Medicine has the most relevant medical study I’ve read in a long time. We’ve all been in the scary situation of driving late at night while sleepy and struggling to stay awake. This study asked the important question: Does drinking coffee or taking a nap improve driving late at night?

The study design involved having volunteer drivers each take 90 minute drives on different weeks under four different conditions. One drive was during the day, as a control. The other three drives were from 2:00 a.m. to 3:30 a.m. One night time drive was 30 minutes after drinking 125 ml (about a half a cup) of coffee containing 200 mg of caffeine. Another drive was 30 minutes after drinking the same amount of decaffeinated coffee (containing 15 mg of caffeine). Another drive was 30 minutes after awakening from a 30 minute nap which was taken at a highway rest area with the participant sleeping in the car with the driver seat reclined. The participants didn’t know if they were drinking coffee or decaf.

Driving quality was measured by videotaping the road from the car and counting inappropriate crossings of the painted lines that separate lanes. A driving instructor accompanied the driver and was prepared to take over control of the car. (So don’t try this at home!)

The results were interesting. The drivers drinking decaf did much worse (i.e. had more line crossings) than they did in their daytime drives. Both after napping and after drinking real coffee drivers did better on average than after drinking decaf, but not as well as during the daytime drive. The improvements due to a nap and due to coffee were about the same.

The authors conclude

Of interest, some participants respond very well to caffeine but do not improve greatly after a nap, while others benefit more from a short sleep than from caffeine. Both [coffee and napping] should be proposed and promoted to decrease the risk for accidents at night. Both countermeasures are about equally efficient in reducing line crossings, and we have no preference of one over the other… Participants should choose according to their own physiologic response.

The moral of this study is to try to avoid driving late at night. If you have to drive when sleepy, it’s better to first take a nap and drink some coffee, but that still won’t make you as safe as you are when driving during the day.

Gastroesophageal reflux disease (GERD), in which acid from the stomach rises into the esophagus causing heartburn, is a very common and uncomfortable problem. A connection between GERD and increased weight has long been suspected.

This recent study in The New England Journal of Medicine makes a fascinating connection between being overweight and having symptoms of GERD in women. The study looked at over ten thousand women in the Nurses’ Health Study, one of the largest studies of American women that followed a large group of women and tracked multiple aspects of their health. The study gave the women a questionnaire to grade the severity and frequency of heartburn and acid regurgitation. They compared the results of the questionnaires to the women’s body mass index (BMI).

The BMI is a way to adjust a person’s weight for her height and allows us a rough guideline by which to decide if a person’s weight is too high. You can calculate your BMI with the CDC’s BMI calculator.

The results of the study were surprisingly strong. Not only was there a strong correlation between BMI and heartburn, the correlation persisted even in the normal BMI ranges. That means that even in women of normal weight, a few pounds of weight gain resulted in a higher risk of heartburn. Women who had recently lost weight were also less likely to have heartburn than women who had gained weight.

This was a purely observational study, so this can only show that weight and heartburn are associated. It can not prove that one causes the other. I would love to see an experiment in which patients with heartburn are randomized to two groups, one which receives antacids, and a second who receives antacids plus diet and exercise aimed at weight loss. If the second group lost more weight and had less heartburn, this would prove that weight is partially responsible for heartburn symptoms.

There are already lots of other good reasons to keep our weights down: lower blood pressure, lower cholesterol, and better control of diabetes. It’s possible that less frequent heartburn should be added to that list.