I’m Back In “Business”

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Sorry to have let things slide for the past several months.  I have been otherwise occupied. Thank you all so much for the nice comments.   My mother (born in 1919) who lived in town (Columbia, MO) near me died in August after several difficult months.  From the experience,which kept me very busy, I learned a number of things that I thought I had already known about caring for patients with chronic diseases.  That’s going to be the subject of my first entry, which I promise to post in the next day or so.  Then we’ll get back to endocrine things, first with a tribute to James Tanner who died a few months ago (if the name doesn’t ring a bell with you,  he is the Tanner who developed Tanner staging for sexual development, a very important tool for pediatric endocrinologists).

What To Do When The Thyroid Test Results Don’t Make Sense

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I apologize for not having an endocrinology-based entry for quite a while.  I do appreciate the many nice comments I have received on past entries.  I will try to write something interesting and useful on a more regular basis.  Anyway, on to the business at hand.  The past few months I have had  a number of e-mails from physicians asking my advice about interpreting what seem to be bizarre thyroid test results. The most common situation is a mildly elevated thyroid-stimulating hormone (TSH) level and a high end of normal or even elevated free thyroxine (FT4) level.  The second most common scenario is a low TSH level coupled with a low or normal FT4 level.  In past entries I have touched on these types of apparently discrepant thyroid test results, but I think it is worth discussing them again and in more detail.

Regulation of thyroid hormone levels

The thyroid gland synthesizes mostly tetraiodothyronine or T4 which is converted peripherally (mostly in the liver) to the “real” thyroid hormone, triiodothyronine, or T3 (also synthesized in the thyroid gland but most T3 is derived from T4).  Both T4 and T3 are part of a classic negative feedback system in which these hormones ( the “free” or non-protein bound hormones) bind to sites in the hypothalamus and in the pituitary gland, regulating their own synthesis by effects on thyrotropin-releasing hormone (TRH) and thyrotropin ( aka,  thyroid-stimulating hormone or TSH.   Normally the negative feedback system results in normal levels of TSH and T4.  If for whatever reason, the T4 level decreases,  release of TRH and then TSH are triggered which results in increased synthesis of T4 until the serum level is back to normal, assuming the thyroid gland is capable of responding appropriately.   Conversely, if the T4 level is elevated, this normally leads to low levels of TRH and TSH, in an effort to decrease the T4 level.  Of course, if the elevated T4 level is from a tumor secreting thyroid hormone or the result of  taking too much thyroid hormone, the feedback system corrections won’t help the situation.  So, what might result in either elevated TSH and FT4/T4 levels or low TSH and low or normal  FT4/T4 levels?  And, what, if anything can we do to fix the problem?

Case History # 1

The patient is a 9 year old female with a history of congenital hypothyroidism, diagnosed in the newborn period.  The initial laboratory studies at one week of age showed markedly elevated serum TSH (350 microunits/mL) and low serum T4 (1.5 micrograms/dL) and FT4 (0.3ng/dL).  The patient has been treated with L-thyroxine since about age 10 days (current dosage is 75 micrograms/d).  She has been generally health.  Height and weight have been consistently at about 50%.  She is a straight A student.   Thyroid laboratory studies over the years have consistently shown slightly elevated TSH levels (e.g., 6-7 microunits/mL) but high normal FT4 levels (e.g., 1.3-1.4 ng/dL).  Efforts to normalize the TSH level by increasing the dosage of L-thyroxine have resulted in high FT4  levels and symptoms and signs consistent with hyperthyroidism.

The differential diagnosis

So, what’s going on here?  In most instances when a patient’s thyroid test results show  elevated TSH and low or normal FT4 levels, it is safe to assume that the patient has either compensated hypothyroidism (if the FT4 is in the normal range) or frank hypothyroidism.  But, it would be unusual to find only a minimally elevated TSH level with a low FT4- that set of results would suggest secondary or tertiary hypothyroidism.  Thus if  a patient’s FT4 level is low on the basis of primary hypothyroidism, I would expect to find a very elevated TSH level (i.e., >25 microunits/mL).  So, things only get strange is when the TSH is slightly elevated yet the FT4 is high normal or even above the upper limit of normal for the laboratory.

What are the possibilities?  First, it could always be a laboratory error (more likely an error in transcribing the report than in the actual assay).  It could also be the result of an incorrect normal reference interval for either the TSH or the FT4 test.  More likely is the possibility of a high set-point for TSH.  This means that for whatever reason, the pituitary gland does not sense that the FT4 level is in the normal range until the TSH level is a bit higher than normal.  This situation is seen in about 10% of children with congenital hypothyroidism and I can’t tell you why it happens but it does.  The solution to the “problem” is to do nothing as long as the TSH level remains only mildly elevated AND the FT4 level remains in the normal range (just to be sure I prefer to keep the FT4 level at the high end of normal).

There are other possibilities to consider before assuming it’s just another one of those high set-point patients.  The laboratory findings could be a sign of a TSH-secreting pituitary tumor.  This disorder is rare during childhood but should be considered in patients with signs and symptoms suggesting hyperthyroidism, elevated thyroid hormone levels and normal or elevated TSH levels.  Most of these patients have  symptoms suggesting central nervous system disease.  Another possibility is thyroid hormone resistance.  This disorder is the result of genetic defects in the intracellular thyroid hormone receptors.  Most reported cases have shown autosomal dominant inheritance.  Clinical presentation varies considerably from no signs or symptoms to frank hyper or hypothyroidism.  In about 20% of reported  cases, patients have deafness,  while 50% have hyperkinetic behavior and are often diagnosed as having attention-deficit hyperactivity disorder.  In this condition, the pituitary gland has to work harder than usual in an effort to achieve normal intracellular signaling from thyroid hormone.  Typically, the TSH level is normal or slightly elevated while the T4 AND FT4 levels are above normal (remember that an elevated T4 could be merely the result of increased thyroid-binding proteins.  That is why measurement of FT4 is very important since that test is not generally affected by alterations in thyroid-binding proteins).  If I ever had a patient with both a high TSH set-point and thyroid resistance syndrome, I’m not sure how I’d figure it all out.

Case History # 2

The patient is a 16 year old female with chronic lymphocytic thyroiditis diagnosed several years earlier.  The patient had presented with swelling of the neck.  Evaluation revealed diffuse enlargement of the thyroid gland and a Delphian node present just above and to the left of the isthmus (as discussed in earlier entries, presence of a Delphian node  means it’s chronic lymphocytic thyroiditis until proven otherwise).  Laboratory studies showed slightly elevated TSH (8.5 microunits/mL), normal FT4, and sky high thyroid antiperoxidase antibodies.  The patient was treated with L-thyroxine.  The thyroid gland decreased somewhat in size.  Follow-up laboratory tests showed slightly low TSH and high-end normal FT4 (1.5 ng/dL).  The patient was clinically euthyroid.

The differential diagnosis

Here the question is whether the patient’s thyroid hormone dosage is a bit on the high side.  The patient’s FT4 is in the normal range and she shows no signs or symptoms of hyperthyroidism.  In this situation, I would tend to have faith in the negative feed-back system and lower the thyroid hormone dosage a bit but not bother to recheck labs for a while (i.e., 6 months or so).

There are some situations where a low TSH and a normal FT4 suggest other possibilities.   For example, maybe the patient has mild secondary (pituitary) or tertiary (hypothalamic) hypothyroidism?  Another fairly common situation is in patients with autoimmune hyperthyroidism who have received radioactive iodine ablation therapy.  Laboratory studies, particularly in the first few months after radioactive iodine treatment, may show low or normal TSH and low FT4 levels.  Here the answer lies in the T3 level which is typically normal or slightly elevated.  That clinical situation is one of the few in which I routinely monitor T3 levels in addition to TSH and FT4.

Is thyroid disease really as complicated as it seems?

Do not despair.  Diagnosis and treatment of thyroid disorders is generally very straightforward.  Once in a while, though, things can get a bit tricky.  But, one nice thing about clinical endocrinology is that if one understands the basic physiology, it is usually fairly to easy sort things out.

Health Care Reform: The New “High-Risk” Insurance Pools

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For people who have so-called” preexisting” medical conditions,  finding affordable health insurance can be mission impossible.  Most if not all states in the U.S. already have so-called “high risk” pools for people with a variety of medical conditions.  Unfortunately, the premium costs for these pools are far above what most people can afford.  In the near future that situation may change for the better.  Under the recently enacted health care reform legislation, on July 1, 2010, all states must offer health insurance through new high-risk pools with rates no higher than those available to a healthy person.   This provision of the new law is apparently supposed to offer help until the new health insurance exchanges begin in 2014.  It is unclear how helpful this temporary fix will be.  The rules require that a person must be without health insurance for at least 6 months and the pool of money set aside by Congress to fund the program is unlikely to to be enough for more than a year or two.  Anyway, there is a nice article in today’s New York Times (26 June 2010) summarizing these new insurance pools and how one can get up-to-date information on the high-risk pool in his or her own state.

Treating Children With Growth Hormone: Moral, Ethical, And Other Considerations

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I want to call your attention to two recent articles in the New York Times that might just be of interest to you if you are a physician who cares for short children, if you are a parent of a short child or if you are short or just want to be taller.  Both articles were written by Jane E. Brody.  The first appeared in the Science Times section of the newspaper, Tuesday May 10, 2010 and was entitled “A Plus Side for Human Growth Hormone.”  As an aside, that section of the newspaper had several other very interesting articles including one on mammoth hemoglobin (here I don’t mean big hemoglobin but hemoglobin in prehistoric animals) and another on efforts to teach physicians about health care costs.  The other article was published Tuesday May 11, 2010 and was entitled “Short?  No Worries: Just Ask this Texan.

The first article is an excellent review on the current status of growth hormone therapy in children.  The newspaper article was based on a medical article published in April 2010 by Judith L Ross in the medical journal Pediatrics.  The newspaper article more or less summarizes the medical journal article and, in my opinion, provides an excellent and concise overview of the current status of growth hormone use in short children.  Ms. Brody and Dr. Ross  both danced around the somewhat contentious issue of using growth hormone injections to make normal but short children taller but who is to blame them?

The second article is basically a summary of a recently published book by John Schwartz entitled “Short: Walking tall When You’re Not tall at All.”  The book was published by Roaring Brook Press and, according to Ms. Brody, was written primarily for short teenagers.  I have not read the book yet but I will.  Based on the newspaper article, I think the book (or the newspaper article if you have lots of things “on your plate” at the moment) would be worthwhile reading not only for short teens but also their parents, friends, and physicians.

The Issues

In 1985, The U.S. Food and Drug Administration (FDA) approved the use of biosynthetically derived human growth hormone for children with growth hormone deficiency.  Since then, use of growth hormone has been a major growth industry; world-wide, annual sales of growth hormone are well into the billions of dollars.  The uses for growth hormone, legal and illegal, have expanded dramatically.  At present, only a small percentage of people taking growth hormone injections actually have growth hormone deficiency, as originally defined- some physicians and many pharmaceutical companies believe that growth hormone testing fails to identify many people (children and adults) who would benefit from treatment with the hormone.  I do not want to get into the issues here except to say that the question of whether to treat a person with growth hormone has become a very complicated one, with moral, ethical, and economic factors to consider.

There is no question that most short children who have no demonstrable medical condition responsible for the short stature can be made taller by several inches over their genetic potential (whatever that means these days) if they take enough growth hormone for long enough before their bone growth centers close.  The questions are whether the potential adult height benefit, whatever that might or might not be is worth it with respect to costs and complication risks.  I believe that reading both of the Jane Brody newspaper articles will give you a pretty good foundation for understanding the issues.  I’m not picking sides (at least in this entry) but one important consideration not really addressed in the articles is that whenever an insured patient is treated for whatever and the insurer “covers” the costs, all people covered by that insurer share in the costs.  Is it “fair” to make many people pay to enable a person to gain a few inches in height when the person does not have an demonstrable medical condition responsible for the short stature?   In my view, that’s an interesting question.  We cannot expect companies who sell growth hormone to give us an unbiased answer to the question.  Likewise, we cannot expect a physician who  benefits financially from a relationship with the company, to give an unbiased answer to the question.  Very interesting stuff.  I think I should have taken more philosophy courses in college rather than focusing on pre-med ones. How was I to know?

Are Health Insurance Discounts For Healthy Behaviors/Outcomes Fair?

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FYI: There was an interesting article in the New York Times on April 12, 2010.  The article was entitled “Could Health Overhaul Incentives Hurt Some?” and was written by Roni Rabin.  The article reviewed the potential impact of some provisions in the new health care legislation that focus on financial incentives for good health care outcomes (e.g., weight loss, smoking cessation).  The idea is that it is not fair for healthy people to share the cost of health care expenditures that are the result of  certain unhealthy lifestyles.  It’s sort of like good driver discounts for automobile insurance.

In my opinion, this is a very tricky issue.  For example, as I have discussed in previous entries, for many people who are overweight genetics plays a very important role; their obesity is not just the result of willful unhealthy behaviors.  As employers and insurers pursue the idea of promoting desirable behaviors, they need to be very careful not to place an unreasonable burden on people whose health problems are more the result of “bad” genes and bad luck than bad behaviors.

FYI: What About Health Care Reform?

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I want to call to your attention a series of very interesting and important articles published in the New York Times Science Times Section yesterday (Tuesday, March 30, 2010).  The articles do a pretty good job of summarizing what’s what about the new health care bill passed by Congress.  I would particularly recommend two of the articles.  The first is entitled “What you need to know in the first year” and was written by Tara Parker-Pope.  The second is entitled “Law may do little to help curb unnecessary care” and was written by Gina Kolata.  Some of the other article titles include:  “No matter what, we pay for others’ bad habits,” “Overhaul will lower the costs of being a woman,” and “What the health care overhaul could mean for you: do you have health insurance now?”  I think the various articles provide a fairly good overview of what the new law is likely to do and not do.  I will offer no opinions on the subject except to say that I hope the new health care legislation is “a work in progress.”  What I mean is that if the new health care bill was a college course exam, the grade would be “incomplete.”  It is interesting, however, that so far every patient I have talked to has  told me the new law would help them out.  We’ll see.

A TV Show about School Food in West Virginia, a New York Times Story on Workplace Efforts to Improve Health, and an Article in the New England Journal of Medicine Article on the Prevelance of Diabetes in China: What do They Have in Common?

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I just want to give you a heads-up on 3 very interesting media pieces that address a common theme: why are people in the U.S. (and now elsewhere) so unhealthy and what can be done about it?  The first is on ABC-TV and called Jamie Oliver’s Food Revolution.  It is a series of shows on every Friday evening but I don’t know for how long.  I saw the first show on Hulu.com last evening.  Even if you hate TV except for the NCAA basketball tournament, this is “must see” TV.  Don’t take my word for it.  Check out Marion Nestle’s blog today on Huffingtonpost.com.  In summary, the show is about Jamie Oliver’s efforts to improve school lunches in Huntington, WVA.

The second media piece was in the Business section, page 5 of the New York Times, Sunday March 26, 2010.  The piece is entitled “Carrots, Sticks and Lower Premiums” written by Steve Lohr.   The article addresses the mostly unspoken truth that health care reform in the U.S. would benefit in an extraordinary way if all of us lived healthier lives.  Data do show that 50-70% of our nation’s health care costs are preventable, mostly attributable to treatment for chronic complications that mostly related to unhealthy behaviors.  The article is about how employers are beginning to wake up to the fact that it is good business to have healthy employees.  Read the article.

The third piece is an article that appeared the other day in the New England Journal of Medicine (March 25, 2010).  The title of the article was “Prevalence of Diabetes among Men and Women in China” and written by Wenying Yang and colleagues.  The investigators studied whether the rapid change in lifestyle in China has increased diabetes prevalence.  The study population included 46,239 adults, 20 years of age or older, from 14 provinces and municipalities tested between June 2007 and May 2008. The results were astonishing.  China is catching up with the U.S., and I’m not talking about their economy.   The age-standardized prevalences of total diabetes (previously undiagnosed and previously diagnosed diabetes)  were 10.6% in men and 9.7% in women.  For prediabetes (abnormal blood glucose levels but not diagnostic for diabetes), the prevalences were 16.1% in men and 14.9% in women.  The data showed a sharp and steady increase in the national prevalence of diabetes from surveys conducted in 1980, 1994, and 2001 (e.g., prevalence in 1994 was 2.5%).  Not surprisingly , the prevalence was considerably higher in urban residents than among rural residents.  The investigators concluded the following: “that diabetes has become a major public health problem in China and that strategies aimed at the prevention and treatment of diabetes are needed.”

So?

I don’t think I really need to explain how the 3 media pieces relate to one another.  The prevalence of diabetes in China is now just about the same as the prevalence in the U.S. (prevalence of 9.6% based on the National Health and Nutrition Examination Survey 2003-2006).  It’s the price we now pay globally for our economic advances coupled with our genetic predisposition to obesity and diabetes (check out some of my old entries if you have forgotten).   Jamie Oliver knows what do do about the problem in both the U.S. and China and so do employers trying to get their employees healthier, and so do you.

A Guest Entry: Benefits of Exercise in Patients with Type 2 Diabetes

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With this entry I want to try something new- a guest blogger.  I hope you like the article and the idea of having guest articles from time to time.  If you have comments, let me know or contact the guest blogger directly.  I should mention that the opinions in guest articles are not necessarily how I might think about things but I think it’s good to get different points of view.

What Everybody Ought to Know About the Benefits of being fit if You Have Diabetes: Effects of Exercise on Blood Glucose Levels

Written by Sue Rollins

Did you know that you can more easily manage your diabetes just by engaging in regular exercise?  Exercise generally has a very beneficial effect on blood  glucose levels in people with type 2 diabetes. When you engage in exercise, you expend a lot of energy.  This first comes from the glucose stored in your liver and your muscles.  At first, the body simply uses up the stored glucose (in the form of glycogen).   Thus, engaging in exercise does not mean your blood glucose levels will necessarily fall to dangerously low levels.   The situation is somewhat different in people with type 1 diabetes and in people with type 2 diabetes who take medications that can cause hypoglycemia.  Often these people need to take snacks at regular intervals during exercise to avoid hypoglycemia.  The body is very clever and has a number of mechanisms to prevent the blood glucose level from falling too low.  For example, with exercise and also if the blood glucose level drops below normal, glucagon, a hormone stored in the pancreas gets released.  This hormone promotes further release of glucose stored in the liver.  The same is true of the hormone epinephrine, stored in the adrenal cortex.  If one does enough exercise to use up most of the stored glucose, the body can make “new” glucose from the breakdown of proteins.  Also, breakdown of fats will occur, providing an alternative source of  energy, thereby “sparing” glucose stores.  In addition, regular exercise actually increases a person’s insulin sensitivity, making the insulin they produce (or take), more effective in controlling blood glucose levels.

Why is the effect of exercise on glucose levels important to those with type 2 diabetes?

Exercise indeed has a good effect on a patient’s glucose level. This is good news for people who have type 2 diabetes. A lot of research indicates that patients of diabetes gain more control over their diabetes as soon as they get into to a regular exercise program.  Since exercise improves your insulin sensitivity, you may need less medication in order to control the diabetes.

Should patients with type 2 diabetes exercise more often or differently than otherwise healthy people?

Experts recommend that people who have type 2 diabetes should exercise about 30-60 minutes (usually only moderate aerobic activity) at least 3 days a week.   Any amount of exercise is better than no exercise.

What type of exercise is best for patients with type 2 diabetes?

Most experts believe the frequency of the exercise routine is more important that the specific kind of exercise one engages in. Ideally, the exercise program will include aerobic activities and include some weight training.

When should patients be discouraged from exercising?

Some patients have a higher risk of developing injuries from the stress of an intense exercise program. Such patients include those with preexisting diabetes eye disease, hypertension and other cardiovascular risks.  Obviously, those who have been  leading sedentary lifestyles. need to take it slow and easy.  All patients should be thoroughly evaluated by their physicians before beginning a new exercise program.

About the Author – Su Rollins writes for <a
href=”http://www.hypoglycemicdiet.org”>reactive hypoglycemic diet</a> ,
her personal hobby blog focused on tips to prevent and cure hypoglycemia
using the right diet and nutrition.

To Test Or Not To Test, That Is The Question: A Patient With Enlargement Of The Thyroid?

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The Question

The other day I got into a discussion with a primary care physician (PCP) about a hypothetical patient.  We had been discussing a case history for an upcoming medical student examination.  The patient was a 40 year old female with a medical history suggesting hypothyroidism.  The physical examination revealed an enlarged thyroid gland.  The question was as follows: what thyroid function studies should be ordered?

The Answer

The PCP said that he would order total thyroxine (TT4), free thyroxine FT4), and thyroid-stimulating hormone (TSH).  I was a bit surprised by his answer and asked if he didn’t also want to order thyroid peroxidase (TPO) antibodies?  He replied something to the effect that in the “real world” docs don’t mess with that kind of stuff.  I became even more surprised and then asked him whether he thought it was important to know what one was treating.  He got a bit hostile and replied that if the TSH were high and the FT4 and TT4 levels low, he would have a diagnosis, primary hypothyroidism.  He explained that the cost of the TPO antibodies (about $50-$80) depending on the laboratory) was not worth the benefit.  My response was “hmmmm.”

What did I really think?

I did not agree with the PCP’s approach to the hypothetical patient but I did not go ballistic since there was some merit to his argument.  On the other hand, it is my opinion that testing for TPO antibodies in the patient described above is worth the modest extra expense.  First of all, as a general principle it is important to know what one is treating.  While primary hypothyroidism is a diagnosis, there are many different causes for the condition and the approach to treatment might well be dictated by the specific etiology.  In those parts of the world where iodine deficiency is not endemic, the most common reason by far for primary hypothyroidism is chronic lymphocytic thyroiditis (CLT) or Hashimoto’s thyroiditis as it is commonly called.  This is an autoimmune disorder which is highly prevalent in females, particularly those over 40 years of age.  As I have discussed in previous entries, the physical examination often offers clues to the diagnosis; in my experience, careful examination of the thyroid gland will reveal a small lymph node on the left, just above the thyroid isthmus.  This node is called a delphian node and its presence means the patient has either CLT or autoimmune hyperthyroidism or Graves disease.  I can’t remember if I have ever had a patient with a delphian node who did not have positive thyroid antibodies.

Anyway, the differential diagnosis of primary hypothyroidism includes CLT, goitrogens (mostly iodine-containing products), familial inborn errors of metabolism (genetic abnormalities of the various steps to synthesis of thyroid hormones or their degradation), gland dysplasia (e.g., hemithyroids), and other rather uncommon entities.  I find thyroid antibodies most helpful when the TSH and FT4 come back normal (I can’t think of any reason to order TT4 but that’s a topic for another time).  The question becomes why is the gland enlarged (here we are assuming that the physician is skilled at telling when a thyroid gland is enlarged rather than there just being a prominent fat ring around the neck)?  It is still likely that the patient has CLT or possibly a so-called simple colloid goiter an entity I don’t understand; I don’t even know if the disorder exists even though almost all textbooks that cover thyroid disorders list it in the differential diagnosis of goiters (a goiter is just another way of describing an enlarged thyroid gland).  If the patient has CLT and enlargement of the thyroid, many endocrinologists will recommend treatment with replacement doses of L-thyroxine to “put the gland at rest.”  There are some data suggesting that such treatment can prevent progressive destruction of the gland which can occur; a number of studies have shown that TPO antibodies are cytotoxic even though most of the inflammation in CLT is lymphocyte-mediated.

So, it’s not so simple deciding what laboratory tests to order or not to order.   I will return to my original argument that whenever possible it’s good to know what specific disorder is being treated with medications, or  maybe, even if the treatment is just observation.  But I can sort of see the PCP’s point of view, sort of.

Health Care Reform: Status Report

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As those of you who have been reading my various entries over the past 18 months may have noticed, I have been a bit heavy on the U.S. health care debate and light on the endocrine issues.  I apologize to those of you who are weary of hearing anything more about health care , but for me as an endocrinologist who cares for many patients with chronic medical conditions, particularly those with diabetes, having a first rate health care system is important; it doesn’t matter how brilliant a physician I might be if my patients can’t afford to get the services they need or to buy the medications they need.   Anyway, I wanted those of you who may be skeptics about the  benefits of health care reform as proposed by President Obama to check out an op-ed piece that deserves attention.  The article was written by Paul Krugman, the Nobel Prize-winning economist and entitled “Health Care Reform Myths,” and published in the New York Times March 11, 2010. I agree with most of what Dr. Krugman wrote and I liked the fact that he kept the rhetoric reasonably apolitical.

My Westminster College Lecture

As long as I’m writing about health care, I might as well tell you that the other day, I gave a lecture at Westminster College in Fulton, Missouri.  Fulton is only about 25 miles from my home town, Columbia, Missouri, and the county seat of Callaway County, named for James Callaway,the grandson of Daniel Boone.  Fulton (population 13,000) is  known mostly for having 2 excellent colleges, Westminster and William Woods, and for the Winston Churchill Memorial and Library(WCML).  The WCML is located on the campus of Westminster College and is the site of Churchill’s famous “Iron Curtain” speech.  Many world leaders have visited the site and have given important speeches, including the one by then Soviet President Mikhail Gorbachev who announced the end of the Cold War and the fall of the “Iron Curtain.”  My not yet famous speech in Fulton was entitled “Chaos theory in action: The U.S. health care system.”

I spoke to a class of about 35 students in a course that examined a wide range of controversial contemporary issues.  I have no idea why the course director, Professor Margot McMillen thought U.S. health care might be a controversial issue.  Anyway, I tried my best to provide the students with a framework for understanding the current U.S. health care reform debates rather than focusing on my opinion on how to fix the problems.  I tried to keep the discussion apolitical which, I have learned, is the best way to get people on both sides of the debate to listen.  I focused primarily on describing the cost-generating components of the system.  I divided those components into 2 large categories, government and non-government.  On the government side was Medicare, Medicaid, U.S. Public Health Service (Indian Health, Etc.), Veteran’s Administration, Military (active duty members and their families), and miscellaneous (e.g., Community Health Centers).  On the other side was private insurance and self-pay (this included out-of-pocket health care expenses for even people with insurance or Medicare or Medicaid).

For each  component I tried to describe its history and current status, including costs and my take on its weaknesses (e.g., difficulties that many people on Medicaid have in finding physicians willing to see them).  I then tried to address what most experts feel are the 2 most important problems with the current U.S. health care system, lack of access and high and ever increasing costs.   By the end of the hour, I think most of the students understood enough about the issues to critically critique the various health care proposals that  bombard us if we read newspapers, watch television, or listen to the radio.  Apparently, each student will be required to write a paper about the lecture.  If Professor McMillen will give me permission, I want to read the students’ papers.  Did I actually teach them anything or do I need to “go back to the drawing board” to find a better way to educate people about the U.S. health care system?  Maybe, as the title of my lecture suggested, I should just give up trying to bring order to chaos?